Feasibility and Safety of Laparoscopic-Assisted Bowel Segmental Resection for Deep Infiltrating Endometriosis: A Retrospective Cohort Study With Description of Technique

Abstract

Study objective: To evaluate the feasibility and safety of laparoscopic segmental bowel resection for deep infiltrating endometriosis (DIE).

Design: Retrospective clinical study (Canadian Task Force classification II-3).

Setting: Endoscopica Malzoni-Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy.

Patients: A retrospective cohort of 248 patients who underwent laparoscopic segmental bowel resection between January 1, 2011, and December 31, 2014.

Intervention: Laparoscopic segmental bowel resection for DIE.

Measurements and main results: Bowel endometriosis was histologically confirmed in all 248 of the 248 patients (100%). The mean length of the resected specimens was 11.83 ± 4.56 cm. In all cases, margins were free of disease. The muscular layer was infiltrated up to the submucosal layer in all 248 patients (100%), whereas the mucosal layer showed signs of infiltration in only 4 patients (1.6%). Two nodules were found in 36 patients (14.5%), and 3 nodules were found in only 8 patients (3.2%). None of the resected bowel segments had nodules shorter than 3 cm, and the majority of lesions had a longitudinal diameter of 3 to 7 cm. In the majority of cases, resected segments involved the mid to low rectum (distance from the lower margin of resected segment from the anal verge of 4 to 12 cm), whereas in 6% of cases, ultra-low resections (≤4 cm) were performed. No intraoperative complications occurred, and conversion to laparotomy was not required for any patient. Major perioperative and early and late postoperative complications occurred in 20 patients (8.06%). Significantly reduced pain associated with disease was observed up to the 1-year follow-up irrespective of postoperative hormonal treatment. Pelvic relapse was found in up to 50% of patients, especially in patients without hormonal suppression, but only in the form of endometriomas or adherences, with no recurrent deep lesions observed.

Conclusion: This large single-center series demonstrates that laparoscopic bowel resection for DIE is a feasible technique, with low complication rates. In symptomatic patients, treating deep fibrotic endometriosis nodules by laparoscopic segmental resection is very effective in reducing pain and restoring bowel function. This surgical approach is safe but complex, requiring specific skills in laparoscopic urologic and colorectal procedures, and should be performed only in specialized high-volume centers by high-volume surgeons.

Keywords: Bowel endometriosis; Deep infiltrating endometriosis; Endometriosis; Laparoscopic bowel segmental resection; Laparoscopy.