Elsevier

Obstetrics & Gynecology

Volume 96, Issue 2, August 2000, Pages 304-307
Obstetrics & Gynecology

Instruments and methods
Laparoscopically assisted vaginal resection of rectovaginal endometriosis

https://doi.org/10.1016/S0029-7844(00)00839-5Get rights and content

Abstract

Background: We wanted to establish a technique of laparoscopically assisted radical vaginal surgery for deep endometriosis of the rectovaginal septum with extensive rectal involvement.

Technique: The procedure is started by vaginally excising the involved area which is left on the rectum, followed by bilateral dissection of the pararectal and retrorectal spaces. Para- and retrosigmoido-rectal spaces are developed laparoscopically along the coccygeosacral bone and medially to the pelvic splanchnic nerves toward the para- and retrorectal openings that were made transvaginally. Rectal transection is done with a laparoscopic stapling device caudal to the endometriotic lesion. Using a suprapubic minilaparotomy, the bowel is transected cranial to the lesion and reintroduced into the abdomen, and a transanal circular stapler anastomosis is done.

Experience: Thirty-four women had this procedure. The mean distance of the anastomosis was 4 cm above the anus. None required ileostomy or colostomy and no major complications were noted.

Conclusion: The combination of laparoscopic and vaginal approaches is useful for removing extensive endometriotic infiltration of the rectosigmoid; bladder and rectal function and fertility can be preserved.

Section snippets

Technique

After clinical examination under anesthesia, the posterior fornix of the vagina is exposed by two Breisky specula and the cervix is pulled ventrally by two tenacula. After infiltration of the vagina with 10 mL lidocaine hydrochloride 2% with epinephrine, an incision is made around the endometriotic nodule and the posterior cervix is dissected (Figure 1). To avoid bowel injury, the pouch of Douglas is not opened transvaginally. The vaginal resection margins must be free from endometriosis on

Experience

Thirty-four consecutive patients were operated on between December 1997 and July 1999 for endometriosis of the rectovaginal septum with large (over 2 cm in diameter) infiltration of the lower rectum (not more than 7 cm above the anus). Women were referred to our institution for radical surgery (including bowel surgery) because previous surgical and medical treatments had failed. Thirty-three had deep and extensive rectal infiltration with fixed mucosa confirmed by rectal examination. In 33

Comment

Deep endometriosis of the rectovaginal septum is a serious problem for women and physicians. Diagnosis can be established by routine vaginal examination because deep endometriosis is localized in the vagina, the pouch of Douglas, the uterosacral ligaments, or the rectovaginal space. The rectosigmoid has to be palpated to determine the extent of endometriotic infiltration. Catamenial rectal bleeding or pre- or intraoperative rectosigmoidoscopy are of limited value for judging extension of bowel

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