{"paper_id":"00a283f7-67c9-4bba-89b4-3eddc4c4a29d","body_text":"Vol.:(0123456789)\nArchives of Gynecology and Obstetrics (2025) 312:555–561 \nhttps://doi.org/10.1007/s00404-025-08040-4\nRESEARCH\nTotally intracorporeal colorectal anastomosis (TICA) after segmental \ncolorectal resection for deep endometriosis: technical notes and case \nseries\nFrancesco Santullo1 · Alessandra De Cicco Nardone2 · Miriam Attalla El Halabieh1 · Claudio Lodoli1 · Carlo Abatini1 · \nFederica Ferracci1,2,3 · Federica Campolo2 · Greta Benvenga2 · Giovanni Scambia2,3 · Fabio Pacelli1,3 · \nManuel Maria Ianieri2\nReceived: 11 February 2025 / Accepted: 21 April 2025 / Published online: 6 May 2025 \n© The Author(s) 2025\nAbstract\nPurpose The aim of this study was to evaluate the safety and feasibility of totally intracorporeal colorectal anastomosis \n(TICA) in patients undergoing colorectal resection for the treatment of deep endometriosis (DE) affecting the bowel.\nMethods Between January 2021 and August 2024, 33 consecutive patients with DE treated with segmental colorectal resec-\ntion were enrolled. In 30 patients, TICA was performed. Demographic, operative, and postoperative data were collected \nretrospectively.\nResults The mean distance between the endometriotic nodule and the anal verge was 11.5 (7–18) cm. The mean operative \ntime was 282.83 (190–512) minutes. No major intraoperative complications occurred. Three (10%) patients developed a \nminor (Clavien‒Dindo grade I/II) postoperative complication.\nConclusion TICA is a safe and feasible technique and represents a valid alternative reconstruction method after colorectal \nresection for DE.\nKeywords Deep endometriosis · Colorectal resection · Colorectal anastomosis · Laparoscopic surgery\nIntroduction\nDeep endometriosis (DE) is an infiltrative form of endome-\ntriosis affecting the bowel, usually the rectum and sigmoid \ncolon, in 8–12% of cases [1 , 2]. Colorectal resection is the \nmost radical surgical approach in the treatment of selected \ncases of DE affecting the bowel [3]. However, mini laparot-\nomy in combination with colorectal resections is associated \nwith postoperative complications, such as wound infections, \nincisional hernias, and worse cosmetic results.\nHence, over the years, the mainstream surgical treatment \nof DE has been to reduce surgical trauma and invasiveness, \ndeveloping new anastomotic techniques, such as natural \norifice specimen extraction (NOSE) [4 , 5]. Recently, we \ndescribed a new technique of totally intracorporeal colorec-\ntal anastomosis (TICA) [6] after colorectal resection for DE, \nalso used successfully for some cases of recurrent ovarian \ncancer [7].\nThe aim of this study was to evaluate the safety and feasi-\nbility of TICA in patients with DE in terms of the short-term \noutcome.\nMaterials and methods\nThe present paper reports the results from 33 consecu-\ntive single-center colorectal resections for DE performed \nat Fondazione Policlinico Gemelli between January 2021 \nand August 2024, selected to perform TICA. All patients \nwith intestinal DE were evaluated by a multidisciplinary \nteam, including a gynecologist, a radiologist, and a general \n * Miriam Attalla El Halabieh \n miriam.attallaelhalabieh@guest.policlinicogemelli.it\n1 Surgical Unit of Peritoneum and Retroperitoneum, \nFondazione Policlinico Universitario A. Gemelli, IRCCS, \nLargo Agostino Gemelli 8, 00168 Rome, Italy\n2 Unit of Oncological Gynaecology, Women’s Children’s \nand Public Health Department, Fondazione Policlinico \nUniversitario Agostino Gemelli, IRCCS, Rome, Italy\n3 Catholic University of the Sacred Heart, Rome, Italy\n\n556 Archives of Gynecology and Obstetrics (2025) 312:555–561\nsurgeon specializing in minimally invasive colorectal sur -\ngery. We included all patients who underwent laparoscopic \nradical surgery for DE with segmental intestinal resection \nperformed with IMA preservation and pelvic nerve-sparing \ntechniques [8 ] in which the feasibility of performing the \nTICA was assessed preoperatively; if not feasible, a colorec-\ntal anastomosis was performed using the standard technique \n(Fig.  1). Segmental intestinal resection was performed in \npatients with symptoms of bowel obstruction, nodules > 3 \ncm, multiple nodules, full-thickness invasion reaching the \nmucosa and failure of conservative surgical techniques.\nData regarding history and preoperative evaluation \nwere recorded. All women were subjected to rectovaginal \nexamination, advanced transvaginal ultrasonography and \nmagnetic resonance imaging. In cases of sub-occlusive \nsymptoms, either a colonoscopy or double barium enema \nwas further required to evaluate the stenosis. The opera-\ntive and postoperative data were reviewed. Complications \nwere subdivided into minor complications, corresponding \nto Clavien‒Dindo grade I and II, and major complications, \ncorresponding to Clavien‒ Dindo grade III and IV [9 ]. \nInformed consent was obtained from all individual partici-\npants included in the study. The study was approved by the \nlocal Institutional Review Board (IRB-number of protocol \nDIPUSVSP-25-06-2156).\nPreoperative care, surgical technique \nand postoperative care\nIn preparation for surgery, all patients followed a 5-day res-\nidue-free diet and underwent mechanical bowel preparation \nconsisting of a 4-l split dose of Macrogol: 2 L 2 days before \nsurgery and 2 L the day before surgery. All patients received \nantibiotic prophylaxis 30 min preoperatively (1–2-g cefa -\nzolin iv. and 500-mg metronidazole iv.). All patients were \noperated on by a multidisciplinary surgical team widely \nexperienced in laparoscopic surgical excision of bowel endo-\nmetriosis, including a gynecologist and a colorectal surgeon. \nThe operative room setup was the same for all procedures. \nThe patient was positioned in an anti-Trendelenburg posi-\ntion. Pneumoperitoneum was established using a 12 mm \numbilical trocar, and the gynecological surgical procedures \nwere performed using three 5-mm trocars placed in the \nsuprapubic area, left iliac fossa, and right iliac fossa. Intesti-\nnal resection was performed using the same trocar positions \nexcept for a 12-mm trocar in the right iliac fossa in place \nof the 5-mm trocar and a fourth 5-mm trocar on the right \nflank (Fig. 2). The peritoneum of the mesosigma was opened \nabove the root of the inferior mesenteric artery (IMA), stay-\ning as close to the bowel wall as possible. The sigmoid ves-\nsels, which supply the bowel segment to be resected, were \nprogressively identified and selectively ligated. The dissec-\ntion was carried out until reaching the rectal wall below the \nendometriotic nodule, and then the rectum was transected \nwith a linear stapler, Echelon  Flex™   Endopath® Staplers \n(EFES) 60 mm (Ethicon, Cincinnati, OH, USA). Before \nanastomosis, the anvil of a circular stapling device  (EEA™  \ncircular stapler with Tri-Staple ™  technology, 28 mm or \n31-mm Medium/Thick, Covidien, New Haven, CT, USA) \nwas prepared with a 0 Vicryl suture, which was bound at \nthe hole of the tip. The anvil was brought into the abdominal \ncavity through the opening for the 12-mm port in the right \nabdominal flank. A colotomy was performed at the colonic \nwall just proximal to the endometriotic nodule (Fig.  3). The \nanvil was introduced into the colon through the colotomy \n(Fig.  3). The linear stapler was arranged to include the whole \nFig. 1  This flow diagram \nillustrates the total number of \npatients who underwent surgery \nfor deep endometriosis (DE) at \nour center from 2021 to 2024, \ndetailing how many of them \nunderwent segmental intestinal \nresection and the type of colo-\nrectal anastomosis performed\n\n\n557Archives of Gynecology and Obstetrics (2025) 312:555–561 \ncolotomy. The suture attached to the rod of the anvil was \nremoved from the superior border of the colotomy, keeping \nthe Vicryl suture out of the linear stapler. The colon was \nthen transected with the linear stapler (Fig.  3). The suture \nwas pulled out of the colon, allowing the rod of the anvil to \nexit the colon next to the suture line. The circular stapler was \nintroduced in the rectum, and end-to-end anastomosis was \nperformed. The specimen was extracted through the 12 mm \nport on the right flank. At the end of the procedure, an air \nleak test was performed to evaluate anastomosis integrity. \nOne drainage was left in place in the pouch of Douglas. On \nthe first postoperative day, oral fluid intake was allowed, \nFig. 2  Placement of the surgical ports during gynecological procedures (A) and TICA (B)\nFig. 3  Colotomy is performed at the colonic wall just proximal to the endometriotic nodul (A), the anvil is introduced into the colon through the \ncolotomy (B), the colon is transected with a linear stapler and the suture is pulled out of the colon (C), colorectal end-to-end anastomosis (D)\n\n558 Archives of Gynecology and Obstetrics (2025) 312:555–561\nand from the second postoperative day, patients started a \nlow-fiber diet until tolerance for solid food and passage of \nflatus and stool occurred. Postoperative pain was measured \nby VAS score, and all patients received paracetamol 1 g iv \nevery 8 h on demand and continued orally when feasible.\nResults\nPatient demographics and preoperative characteristics are \nsummarized in Table  1. Among the 33 resections, we expe-\nrienced 3 (9.1%) intraoperative complications that did not \nallow us to complete the TICA. In one case, during the \nextraction of the anvil, the tip was caught in the suture line. \nIn the other two cases, the colon was too small, so we could \nnot laparoscopically introduce the anvil. In both cases, we \nperformed a classical anastomosis with the Pfannenstiel inci-\nsion. Hence, we excluded these three patients, and we con-\nducted the subsequent analysis only on the 30 patients who \nunderwent TICA. The mean patient age was 38.83 (32–52) \nyears, and the mean patient BMI was 21.63 (18–27) kg/\nm2. The mean distance between the endometriotic nodule \nand the anal verge was 11.5 (7–18) cm. The median size \nof the intestinal endometriotic implants was 34.2 (20–40) \nmm. The mean rASRM score was 61.5. Table 2 summarizes \nthe operative and postoperative details. The mean operative \ntime was 282.83 (190–512) minutes. The mean estimated \nintraoperative blood loss was 129.16 (50–300) ml. No major \nintraoperative complications occurred, and no conversions to \nlaparotomy were necessary. Three (10%) patients developed \na minor (Clavien‒ Dindo grade I/II) postoperative compli-\ncation: two postoperative bleeding of the anastomosis that \ndid not require any surgical or endoscopic intervention and \none postoperative ileus that was medically treated. No major \n(Clavien‒Dindo grade III/IV) complications occurred. The \ncomplete operative details and postoperative complications \nare shown in Table  2. After 3 months, three patients (10%) \nwith protective ileostomy underwent rectal contrast enema \nand subsequent ostomy closure.\nDiscussion\nWe present a series of thirty consecutive colorectal resec-\ntions for deep endometriosis (DE) performed with a nerve-\nsparing technique plus IMA preservation [10] in which \nTICA was successfully performed without any modification \nof the standard practice. The 30-day complication rate is \nsimilar to that reported in the literature by other authors [11, \n12] after colorectal resections for DE, showing that TICA \nTable 1  Patient demographics and preoperative characteristics\nNominal variables are described with number of cases (n) and percent \n(%)\na Median value\nVariables N (30)\nAge (mean, SD) years 38.83 (32–52)\nBMI (mean, SD) 21.63 (18–27)\nPrevious surgery for endometriosis 8 (26.7%)\nOrmonal Therapy 3 months previous surgery 30 (100%)\nPreoperative symptoms\n Dysmenorrhea (vas) a 7.58\n Dischezia (vas) a 5.75\n Dysuria (vas) a 1.33\n Dyspareunia (vas) a 6\n Chronic pelvic pain (vas) a 6.25\n Constipation 12 (40%)\n Diarrhea 0\n Rectal bleeding 2 (6.7%)\n Symptomatic colorectal stenosis 13 (43.3%)\n STAGE rASRM 61.5\nIntestinal DE\n Intestinal lesions > 3 cm 25 (83.3%)\n Multiple intestinal lesions 5 (16.7%)\n Major nodule dimension (mean, SD) mm 34.2 (20–40)\n Nodule location\n  Sigmoid colon 13 (43.3%)\n  Rectum 17 (56.7%)\n Distance from anal verge (cm) 11.5 (7–18)\nTable 2  Intraoperative and posoperative data\nNominal variables are described with number of cases (n) and percent \n(%)\na One patient with simultaneously ureteral resection and reimplanta-\ntion, one patient with simultaneously ileocecal resection, one patient \nwith multiple comorbidities\nVariables N (30)\nIntraoperative\nBlood loss (mean, SD), ml 129.16 (50–300)\nOperative time (mean, SD) min 282.83 (190–512)\nDiverting enterostomy% 3 (10%)a\nIntraoperative complications 0\nConversion, n (%) 0\nPostoperative\nStart of postoperative diet Day 1 23 (76.7%)\nDay 2 7 (23.3%)\nTime to resume intestinal function (days) 3.5 (1–6)\nPostoperative hospital stays days 5.4 (4–10)\nPostoperative complications (Clavien–Dindo) 3 (10%)\nGrade I–II 3 (10%)\nGrade III–IV 0\nReadmission, n (%) 0\n\n559Archives of Gynecology and Obstetrics (2025) 312:555–561 \nis a safe, effective and reproducible anastomotic surgical \ntechnique.\nThe concept behind this technique’s design is that in most \ncases, only a short tract of the bowel is resected during DE \ncolorectal surgery; moreover, there is no need to resect the \nmesum as in oncologic colorectal surgery. In our experience, \nafter a typical bowel resection for DE, a large part of the \nmesum should be resected only to remove the colon from \nthe Pfannenstiel incision (Fig. 4). When performing a TICA, \nthere is no need to achieve wide mobilization; therefore, \na considerable part of the mesocolon and the surrounding \nsigmoid vessels and nerves are saved.\nConsidering this concept, a better indication for TICA \nis when intestinal DE appears as a single nodule or even \nmultiple but closely spaced nodules, and a short resection \ncan be performed. In contrast, the presence of multiple and \noutlying nodules, which require a wider resection and mobi-\nlization, makes patients less suitable for a safe application \nof this technique.\nIn the surgical approach of young women with intestinal \nDE, our anastomotic technique offers different advantages. \nFirst, by avoiding the Pfannenstiel incision, TICA provides \nbetter cosmetic results, less postoperative pain and a lower \nrisk of developing postoperative wound infection and post- \nincisional hernia. Second, there is no need to widen the dis-\ntal stump resection, as in the case of transanal extraction of \nthe specimen in which the rectal stump is left open at first to \nextract the specimen and insert the anvil and then resected \na second time. This advantage is not relevant in the case \nof a higher resection but is paramount when a resection in \nthe middle and low rectum has been performed. Moreover, \navoiding the opening of the vagina avoids injury to a healthy \norgan and reduces the risk of rectovaginal fistulas. Another \npossible advantage of TICA is that performing colorectal \nanastomosis in a totally intracorporeal way allows us to \navoid wide mobilization of the colon, which is normally \nremoved through the Pfannenstiel incision; therefore, a con-\nsiderable part of the mesocolon and the surrounding sigmoid \nvessels and nerves are preserved, further reducing the risk \nof intestinal denervation of the proximal and distal stump. \nImprovement in functional outcomes should be confirmed \nby further studies.\nOver the years, various laparoscopic techniques of intra-\ncorporeal colorectal anastomosis have been developed to \nimprove the minimally invasive approach of laparoscopic \nsurgery in DE [13–15]. The NOSE technique for segmental \ncolorectal resection in patients with DE is one of the most \ndescribed techniques in the literature due to the outstanding \ncosmetic results and with a lower risk of incisional hernia \nand postoperative infections, less postoperative pain, and \nless analgesia requirements, resulting in a shorter hospital \nstay [4]. While TICA is similar in many postoperative ben-\nefits, the NOSE technique, on the other hand, is burdened \nwith technical surgical complexity [16], leading to complica-\ntions such as a higher risk of peritoneal contamination from \nthe open bowel [17] and distal rectal stump injury [18] in \ncases of transanal specimen extraction or rectovaginal fistula \nwhen transvaginal extraction is performed [19].\nA possible technical concern of our technique is the pres-\nence of multiple intersections of staple lines on the circu-\nlar anastomotic plane. The classical Knight–Griffen dou-\nble stapling technique (DST) [20, 21] provides two lateral \nintersecting staple lines (“dog-ears”) and two intersection \npoints with the circular stapling line. Historically, these are \nconsidered weak points in DST anastomosis. In TICA, there \ncould be a possible doubling of these intersections because \nthere are two linear stapler lines (proximal colon and rectal \nstump) that could intersect the circular stapling line. There-\nfore, there could be up to 4 intersecting points compared to \nthe 2 points of the DST. To avoid this drawback, in some \nFig. 4  Shown here is the part \nof mesocolon and surround-\ning sigmoid vessels and nerves \nsaved performing a TICA\n\n\n560 Archives of Gynecology and Obstetrics (2025) 312:555–561\ncases, we used 31-mm circular staplers: the wider area of \nthe circular stapler could include one or both extremities \nof the proximal and, rarely, distal linear stapler, avoiding \ndog-ear creation. In some cases, we adopted another pre-\ncaution of an intracorporeal reinforcement suture with 3–0 \nVicryl at the intersection point. However, in our experience \nwith colorectal anastomosis with DST, “dog-ears” are not \na major risk factor for anastomotic leakage, and there was \nno case of anastomotic leakage in this case series. We have \nto report just on case of sub-clinical leakage in one of the \npatients with protective ileostomy in which the leakage was \ndiscovered three months after surgery during the contrast \nenema. Moreover, this technique involves the preserva-\ntion of the IMA and the sigmoid vessels to improve the \nvascularization of both the proximal stump and the distal \nstump. The downside is that we experienced anastomotic \nbleeding in 2 patients (6.7%); hence, attention should be \ngiven to this specific postoperative complication. The intra-\nabdominal opening of the colon is part of TICA, and this \ncan lead to possible intra-abdominal contamination, as in \nNOSE with transrectal extraction. However, in our series, \nwe did not observe an increase in intra-abdominal infections \nor abscesses. Last, it must be said that TICA is a technically \ncomplex procedure requiring advanced laparoscopic skills. \nThe most difficult part of the procedure is introducing the \nanvil into the proximal colonic stump. In fact, we report 2 \ncases (6.7%) in which we were unable to complete the pro-\ncedure, and it was due to problems in introducing the anvil \ninto the proximal stump. However, no differences were seen \nin terms of in terms of intra and postoperative complications \nbetween TICA technique and a classical technique of bowel \nresection for DE [22].\nConclusion\nOur study shows that TICA is a safe and feasible technique \nin patients who undergo laparoscopic colorectal resection for \nDE. Further studies are still required to evaluate a possible \nimprovement in functional outcomes.\nAuthor contributions Conceptualization: Francesco Santullo, Miriam \nAttalla El Halabieh, Manuel Ianieri; Methodology: Alessandra Nardone \nDe Cicco; Formal analysis and investigation: Manuel Ianeri, Federica \nCampolo, Greta Benvenga; Writing—original draft preparation: Mir -\niam Attalla El Halabieh, Claudio Lodoli; Writing—review and edit -\ning: Francesco Santullo, Carlo Abatini, Federica Ferracci; Supervision: \nFabio Pacelli, Giovanni Scambia.\nFunding Open access funding provided by Università Cattolica del \nSacro Cuore within the CRUI-CARE Agreement. The authors declare \nthat no funds, grants, or other support were received during the prepa-\nration of this manuscript.\nData availability No datasets were generated or analysed during the \ncurrent study.\nDeclarations \nConflict of interest The authors declare no competing interests.\nOpen Access This article is licensed under a Creative Commons Attri-\nbution 4.0 International License, which permits use, sharing, adapta-\ntion, distribution and reproduction in any medium or format, as long \nas you give appropriate credit to the original author(s) and the source, \nprovide a link to the Creative Commons licence, and indicate if changes \nwere made. The images or other third party material in this article are \nincluded in the article’s Creative Commons licence, unless indicated \notherwise in a credit line to the material. 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