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. 2021 May 13;11(5):408.
doi: 10.3390/jpm11050408.

Recommendations for a Combined Laparoscopic and Transanal Approach in Treating Deep Endometriosis of the Lower Rectum-The Rouen Technique

Şerban Nastasia  1 , Anca Angela Simionescu  2 , Jean Jacques Tuech  3 , Horace Roman  4
Affiliations

Recommendations for a Combined Laparoscopic and Transanal Approach in Treating Deep Endometriosis of the Lower Rectum-The Rouen Technique

Şerban Nastasia et al. J Pers Med. .

Abstract

The complete excision of low rectovaginal deep endometriosis is a demanding surgery associated with an increased risk of intra- and postoperative complications, which can impact the quality of life. Given the choices of optimal surgery procedures available, we would like to emphasize that a minimally invasive approach with plasma medicine and a transanal disc excision could significantly improve surgery for deep endometriosis, avoiding the lateral thermal damage of vascular and parasympathetic fibers of roots S2-S5 in the pelvic plexus. The management of low rectal deep endometriosis is distinct from other gastrointestinal-tract endometriosis nodules. Suggestions and explanations are presented for this minimal approach. These contribute to individualized medical care for deep endometriosis. In brief, a laparoscopic transanal disc excision (LTADE; Rouen technique) was performed through a laparoscopic deep rectal dissection, combined with plasma energy shaving, and followed by a transanal disc excision of the low and mid-rectal deep endometriotic nodules, with the use of a semi-circular stapler. LTADE is indicated as the first-line surgical treatment for low and mid-rectal deep endometriotic nodule excisions, because it can preserve rectal length and innervation. This technique requires a multidisciplinary team with surgical colorectal training.

Keywords: Rouen technique; laparoscopic-transanal disc excision; low rectovaginal deep endometriosis; plasma energy shaving; surgical education.

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Conflict of interest statement

Professor Horace Roman and Professor Jean-Jacques Tuech received personal fees from Ethicon Endo-Surgery, Inc. for their involvement in masterclasses and training on the Rouen technique. Şerban Nastasia and Anca Angela Simionescu have no conflicts of interest nor financial ties to disclose.

Figures

Figure 1
Figure 1
Preoperative MRI image shows deep endometriosis involving the low rectum and vagina.
Figure 2
Figure 2
Laparoscopic view of the pelvis. (a) Inspection of the pelvic cavity and (b) identification of anterior rectal wall.
Figure 2
Figure 2
Laparoscopic view of the pelvis. (a) Inspection of the pelvic cavity and (b) identification of anterior rectal wall.
Figure 3
Figure 3
Opening the deep rectal spaces and rectovaginal septum surrounding the rectal nodule. The nodule is dissected, and the rectum is released and shaved.
Figure 4
Figure 4
Dissection and removal of the fat tissue on the left lateral rectal wall.
Figure 5
Figure 5
Dissection and removal of the fat tissue on the right rectal wall.
Figure 6
Figure 6
Excision of a vaginal patch, followed by vaginal closure.
Figure 7
Figure 7
Transanal excision of the involved rectal area. (a) Transanal placement of a suture on the shaved area; (b) laparoscopic placement of a suture on the shaved area, to assist the colorectal surgeon in identifying the rectal area to be excised; (c) introduction of the closed transanal circular stapler (the stapler opening is at the nodule level), and the stapler closing and firing; (d) stitches reinforce the stapled line.
Figure 7
Figure 7
Transanal excision of the involved rectal area. (a) Transanal placement of a suture on the shaved area; (b) laparoscopic placement of a suture on the shaved area, to assist the colorectal surgeon in identifying the rectal area to be excised; (c) introduction of the closed transanal circular stapler (the stapler opening is at the nodule level), and the stapler closing and firing; (d) stitches reinforce the stapled line.
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