How to do a structured rectal mobilization in complex pelvic endometriosis

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Excerpt

Endometriosis affects 10–15% of reproductive aged women,1 with gastrointestinal involvement seen in 5–10% and the rectosigmoid involved in up to 90% of those cases.3 Complete surgical resection improves symptoms and quality of life.4 However, surgery is complicated due to the deeply infiltrating nature of the disease. We describe a structured approach to rectal dissection in these cases.
Cases are managed in a multidisciplinary setting, with patients reviewed pre‐ and post‐operatively by the colorectal surgeon and laparoscopic gynaecologist, and the operation carried out conjointly. The patient is placed in lithotomy position and a pelosi uterine retractor elevates the uterus anteriorly (Video S1). Rectal mobilization begins on the left using a spatula diathermy electrode (Fig. S1). The ureter location is identified and mobilization begins medial to this along the lateral edge of the mesorectum. Dissection begins proximal to the endometrial plaque at the pelvic brim. This tissue plane is carried inferiorly along the lateral rectum and uterosacral ligaments, down into the pouch of Douglas and below the level of the plaque, into normal rectovaginal septum. The plaque is left adherent in the midline at this stage. Lateral mobilization is then replicated on the right, again down below the level of the plaque and into normal rectovaginal septum, leaving the plaque adherent (Fig. 1).
Following bilateral and inferior dissection into normal rectovaginal septum, the plaque can be carefully dissected off the vagina commencing on the lateral aspect of the plaque bilaterally. This requires meticulous dissection in the fat plane between anterior rectum and posterior vagina. Finally, the residual medial attachment is divided. This is the area of densest attachment where endometrial tissue may invade bowel wall. Once the plaque has been freed, mobilization continues within normal rectovaginal septum to the level of the pelvic floor.
The anterior rectal wall is inspected and if there is residual invading disease a decision regarding further excision is made. Plaque size and rectal lumen distortion inform this decision. Shave excision is considered if serosal surface involvement is <1 cm. Disc excision is generally required as the plaque approaches 1 cm or greater. Plaques approaching 2 cm or larger or significant bowel lumen distortion require formal segmental resection.
Disc excision is performed by clearing all extraneous tissues circumferentially and mobilizing the mesorectum to ensure it is not incorporated into the anastomosis. A curved endoluminal stapler is inserted per rectally and opened intra‐luminally, positioning the plaque between the anvil and shoulder of the stapler. A stay suture, placed through the plaque, is used to apply downward traction on the plaque pulling it into the stapler. Downward traction is also placed on the stapler handle to avoid incorporating posterior rectum. The stapler is then closed and fired.
These patients are young, fit women with well vascularized and mobile bowel. If a formal segmental resection is required, mobilization is generally only required to the mid‐descending colon. The inferior mesenteric artery is preserved and only segmental arterial branches are divided to facilitate a short segment resection.
This mobilization technique has been used in 78 consecutive patients undergoing 80 operations from 2006 to 2016 with no inadvertent rectal injuries (File S1). If there was colonic muscle involvement, subsequent disc excision or formal bowel resection was undertaken. Care must be taken to avoid anastomotic bleeding, particularly in patients undergoing disc excisions as this involves an anastomosis in rectum without vascular division.
Pelvic dissection in complex endometriosis is among the most challenging of surgical dissections.4 Safe surgery requires multidisciplinary care and a standardized surgical approach to avoid inadvertent bowel injury. Our results, with the technique described, demonstrate that this is a safe and effective dissection technique to avoid inadvertent bowel injury.
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