Roman Horace, Abo Carole, Huet Emmanuel, Tuech Jean-Jacques
Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France.
Research Group EA 4308 'Spermatogenesis and Male Gamete Quality', Rouen University Hospital, Rouen, France.
Surg Endosc. 2016 Jun;30(6):2626-7. doi: 10.1007/s00464-015-4528-8. Epub 2015 Sep 30.
Colorectal resection is performed in a majority of patients presenting with large endometriosis of mid and lower rectum; however, it may negatively and irreversibly impact postoperative rectal function. To avoid such unfavourable outcomes, we propose an original technique combining laparoscopic deep rectal shaving and transanal disc excision using a semi-circular stapler.
The video presents the procedure performed in a 29-year-old nullipara referred with a large endometriotic nodule infiltrating the lower rectum on more than 30 mm length. The first step is laparoscopic and involves deep rectal shaving performed using exclusively the plasma energy. Then, transanal excision of shaved area is performed, by placing traction parachute sutures in the middle and outside the shaved area. Their traction induces the prolapse of shaved area that is resected using a semicircular stapler. Insufflating the rectum with air checks the integrity of the staple line.
Operative time was 210 min. Immediate postoperative outcomes were uneventful, and bowel movements were normal beginning with day 6. Our technique is suitable in large rectal nodules located up to 10 cm above the anus, infiltrating the rectum on up to 6 cm length, and these parameters are preoperatively assessed using MRI and computed tomography. To date, it was successfully carried out in 29 women with large deep endometriosis of the mid and lower rectum. Rectovaginal fistula was recorded in one patient (3.6 %) and transitory bladder dysfunction in seven patients (25 %). Digestive function assessment using standardized questionnaires revealed an overall improvement, without de novo anal continence troubles. Postoperative pregnancy rate was 78 % with a majority of patients having conceived spontaneously.
Based on our experience, we believe that our conservative technique is feasible and reproducible in large mid and lower rectal endometriosis and might avoid the risk of unfavourable outcomes related to low colorectal resection.
大多数患有中低位直肠巨大子宫内膜异位症的患者需接受结直肠切除术；然而，这可能会对术后直肠功能产生负面且不可逆的影响。为避免此类不良后果，我们提出了一种将腹腔镜直肠深部刮除术与使用半圆形吻合器经肛门盘状切除术相结合的原创技术。
该视频展示了在一名29岁未育女性患者身上实施的手术过程，该患者患有一个巨大的子宫内膜异位结节，浸润下段直肠超过30毫米。第一步是腹腔镜手术，仅使用等离子能量进行直肠深部刮除。然后，通过在刮除区域的中部和外部放置牵引降落伞缝线，经肛门切除刮除区域。牵引这些缝线会使刮除区域脱垂，使用半圆形吻合器将其切除。向直肠内注入空气以检查吻合口的完整性。
手术时间为210分钟。术后即刻情况平稳，从第6天开始排便正常。我们的技术适用于距肛门10厘米以上、浸润直肠长度达6厘米的直肠大结节，术前使用磁共振成像（MRI）和计算机断层扫描（CT）评估这些参数。迄今为止，该技术已成功应用于29例中低位直肠巨大深部子宫内膜异位症女性患者。1例患者（3.6%）出现直肠阴道瘘，7例患者（25%）出现短暂性膀胱功能障碍。使用标准化问卷进行的消化功能评估显示总体有所改善，未出现新的肛门失禁问题。术后妊娠率为78%，大多数患者自然受孕。
基于我们的经验，我们认为我们的保守技术在中低位直肠巨大子宫内膜异位症中是可行且可重复的，并且可能避免与低位结直肠切除术相关的不良后果风险。
