Sugishita Hiroki, Watanabe Yuji, Yamamoto Yuji, Yoshida Motohira, Sato Koichi, Horiuchi Atushi, Kawachi Kanji
Department of Organ Regenerative Surgery, Ehime University School of Medicine, Toon, Japan.
Case Rep Gastroenterol. 2009 Nov 20;3(3):318-323. doi: 10.1159/000256617.
A 34-year-old woman presented with pain during menstruation and was diagnosed with endometriosis of the lower rectum. Despite treatment with an LH-RH agonist, she was unable to become pregnant and surgical removal of her endometriosis was recommended. Preoperative magnetic resonance imaging revealed endometriosis localized between the neck of the uterus and rectum with indentation and scuffing. Laparoscopically assisted low anterior resection was performed. Exfoliation was started from the right side of the rectum to the presacral and retrorectal space, and the rectococcygeus ligament was transected. Exfoliation of the retrorectal space was continued to the levator ani muscle and mobilization of the right side of the rectum was performed. In front of the rectum, exfoliation was started posterior to the wall of the vagina, but layers became unclear near the tumor as the tissue was solid in this region. The left hypogastric nerve close to the tumor was inflamed and it was cut. The layer of the exfoliation was connected to the right side of the rectum, the tumor was isolated from the vagina, and the lower rectum was transected at a point 1 cm distal to the tumor with a 60-mm linear stapler. Reconstruction with a 31-mm circular stapler was performed using the double stapling technique. Operative time was 520 min with a blood loss of 320 ml. On the 9th post operative day, a rectovaginal fistula occurred, and ileostomy was performed. The patient was discharged from the hospital on the 25th postoperative day, and 4 months later, stoma closure was performed.
一名34岁女性因经期疼痛就诊，被诊断为低位直肠子宫内膜异位症。尽管使用促性腺激素释放激素激动剂进行了治疗，但她仍无法怀孕，因此建议手术切除子宫内膜异位症病灶。术前磁共振成像显示子宫内膜异位症局限于子宫颈和直肠之间，伴有压痕和擦伤。遂行腹腔镜辅助下低位前切除术。从直肠右侧开始剥离至骶前和直肠后间隙，切断直肠尾骨韧带。继续在直肠后间隙向肛提肌方向剥离，并游离直肠右侧。在直肠前方，从阴道壁后方开始剥离，但在肿瘤附近层次变得不清楚，因为该区域组织质地坚硬。靠近肿瘤的左下腹神经有炎症，予以切断。剥离层面与直肠右侧相连，将肿瘤与阴道分离，使用60毫米直线切割吻合器在肿瘤远端1厘米处切断低位直肠。采用双吻合技术用31毫米圆形吻合器进行重建。手术时间为520分钟，失血量为320毫升。术后第9天发生直肠阴道瘘，遂行回肠造口术。患者于术后第25天出院，4个月后进行造口关闭术。
