Bowel Resection With Invasive Endometriosis
An anastomosis in the upper or mid-rectum has a low risk of leaking (less than 2%). Sometimes, in patients with a deep cul-de-sac, the lesion is attached to the mid-rectum and the anastomosis must be performed in the lower rectum, within a few centimeters of the anus. Low rectal anastomoses have leak rates as high as 10%. A flexible sigmoidoscopy must be performed to check for an air leak. If one is found, the anastomosis should be reconstructed or repaired. Temporary diverting ileostomy should be considered if the anastomosis is suboptimal.
An endorectal ultrasound shows endometriosis invading the muscularis propria (1 o'clock position).
Source Courtesy Dr. John J. Park
Endometriosis invades the rectal wall. The mucosa is distorted, but intact.
The inferior mesenteric artery (left) is ligated at the root of the aorta so that various collateral vessels within the marginal branches and Riolan's arch are not sacrificed. This ligation alone often will adequately free up the sigmoid colon enough for a tension-free anastomosis. If the sigmoid colon still cannot be lowered into the rectum without undue tension, the surgeon also will ligate the rectal tributary of the inferior mesenteric vein (right), one of the two main tributaries of the mesenteric vein.
The colon is being attached to the distal rectum using an end-to-end anastomosis stapler.
Source Images Courtesy Dr. John J. Park
Deeply Invasive Rectosigmoid Endometriosis
Deeply invasive rectosigmoid endometriosis can be associated with a severe – and at times incapacitating – symptom complex. This includes dysmenorrhea – both premenstrual and menstrual – deep dyspareunia, dyschezia, and rectal bleeding at time of menses. There also can be an impact on fertility as well, which can be rectified with bowel resection. In the accompanying graphic (right), a number of studies revealing pregnancy post bowel resection for rectosigmoid endometriosis are noted.
As bowel resection is generally not in the armamentarium of the gynecologic surgeon treating benign disease, the proper treatment of deep infiltrated rectosigmoid endometriosis must involve a cooperative effort with a colorectal surgeon who is capable of performing advanced minimally invasive surgery. This collaboration permits the minimally invasive gynecologist to laparoscopically excise endometriosis, lyse pelvic adhesions, resect ovarian endometriomata, and where indicated, perform ureterolysis and total laparoscopic hysterectomy. The colorectal or general surgeon can then proceed with the bowel resection via a minimally invasive approach.
For this current Master Class in Gynecologic Surgery, I have solicited the expertise of Dr. John J. Park. Dr. Park is a clinical assistant professor of surgery in the division of colorectal surgery at the University of Illinois at Chicago, as well as attending surgeon at Advocate Lutheran General Hospital, Park Ridge, Ill. Dr. Park completed his residency in general surgery at the University of Illinois and his colorectal surgery residency at Mayo Clinic, Rochester, Minn. Dr. Park is board certified in general surgery and colon and rectal surgery.
