Laparoscopic discoid anterior rectal excision with the circular stapler for rectosigmoid endometriosis, performed by the gynecologic surgeon

Abstract

Study objective: To demonstrate the technique of laparoscopic discoid anterior rectal wall resection using a circular stapler, feasible in the case of rectosigmoid endometriosis lesions measuring ≤ 3 cm.

Design: Case report (Canadian Task Force classification III).

Setting: Private practice hospital in São Paulo, Brazil.

Patient: Thirty-four-year-old woman with pelvic deep endometriosis including a 2-cm lesion in the rectosigmoid situated 11 cm proximally to the anal border. She had chronic pelvic pain, dysmenorrhea, dyspareunia, and constipation. She had undergone no previous surgical procedures.

Interventions: Standard 4-puncture laparoscopy was performed, and all visible endometriosis lesions were first removed before proceeding to rectal resection. The avascular rectovaginal space was identified, and the rectosigmoid was mobilized cranially, releasing the vagina and increasing the final distance of the bowel anastomosis to the anal border. The rectosigmoid nodule was isolated in its entire circumference and remained restricted to the anterior wall of the bowel. It was then transfixed using a 2-0 polyglycolic suture, with the healthy proximal and distal limits of the bowel included in the suture. A 33-cm endoscopic circular stapler was introduced via the anus up to the distal limit of the lesion and opened inside the bowel lumen. By pulling the edges of the suture, the rectosigmoid nodule was introduced inside of the circular stapler. It was fired to resect the anterior rectal wall, and the anastomosis was situated at the anterior and lateral walls of the bowel. Integrity of the bowel was checked via infusion of saline solution with methylene blue dye. Gynecologic surgeons performed all of the procedures.

Measurements and main results: Bowel resection took 20 minutes, and the entire surgical procedure lasted 120 minutes. The patient was discharged after 48 hours. There were no intercurrent events, either early or late postoperatively. The patient was symptom-free at 2 years of follow-up.

Conclusion: Laparoscopic discoid excision of an anterior rectal nodule using the circular stapler is an effective option for treating selected cases of rectosigmoid endometriosis. The technique might be reproducible by gynecologic surgeons after proper training.

Keywords: Bowel resection; Circular stapler; Deep endometriosis; Discoid resection; Gynecologic surgeon; Laparoscopy; Rectosigmoid endometriosis.