{"paper_id":"044d03de-bad3-4ae3-afe6-9018f981e3b0","body_text":"A peroperative analysis of\nrectal vascularization after the\nshaving technique: an\ninnovative method to\navoid fistula?\nWhatever the technique used to treat rectovaginal septal en-\ndometriotic lesions with muscular layer in filtration, the pro-\ncedure has to be considered as highly complex and it\nrequires multidisciplinary peroperative evaluation of the\nbest surgical approach. Recommendations for the surgical\ntreatment of deep endometriosis have been published recently\nby a working group of experts, concentrating on the\nperoperative management and surgical technique depending\non the location and extent of disease ( 1).\nThree surgical techniques have been described to manage\nbowel endometriosis: rectal shaving, disc excision, and\nsegmental colorectal resection. All of these procedures are\nassociated with complications such as bowel perforation\nand fistulas but their rate appears lower after rectal shaving.\nPresurgical evaluation of bowel infiltration using various im-\naging techniques is, therefore, of utmost importance to\nchoose the right technique for the patient ( 2).\nIn their preliminary study, Bourdel et al. ( 3) evaluated a\nnew laparoscopic procedure consisting of the evaluation of\nthe rectal vascularization of the treated area by using indoc-\nyanine green (ICG), named ‘‘indocyanine green in deep in fil-\ntrating endometriosis ’’ (INDIE). The authors claimed that\nrectal wall ischemia, secondary to the deep shaving, could\nbe responsible for the fistula formation and suggested that\nthe observation of a decreased vascularization of the rectal\nwall at the end of surgery could alert the surgeon. This type\nof mechanism, ischemia followed by a secondary fistula, is\nwell described in ureteral surgery and related to the tissue\ndamage caused by electrocautery. They postulated that the\nrate of postoperative complication such as fistula could\ndecrease if the rectal vascularization can be considered as\nnonaffected after the rectal shaving.\nAnalyzing the rectal wall vascularization using ICG as\nsuggested by the authors after a deep shaving is of great inter-\nest. In fact, exclusion of thermal damage using macroscopic\nevaluation of the anterior rectal wall is dif ficult, especially\nwith injuries due to monopolar electrosurgery, often not\nrecognized during the operation.\nIatrogenic perforation of the bowel during pelvic surgery\nis mainly the consequence of inadvertent thermal lesion or\nimproper use of electrosurgery, but it also occurs during adhe-\nsiolysis or excessive traction with incorrect intestinal\nhandling. In the speci fic case of rectal shaving that does not\nrequire vascular pedicle dissection or clamping, the fistula\ncan be the consequence of a misdiagnosed peroperative bowel\nmicroperforation. The latter occurs after excessive resection\nof the nodule, which thickness peroperatively was underesti-\nmated. Therefore, the rectal air test or the injection of methy-\nlene blue into the rectum at the end of the procedure may be\nused to control the absence of rectal perforation.\nIndocyanine green, detecting the neovascularization of\nendometriotic lesions, was used by De Neef at et al. ( 4), to\ndelimit intraoperatively the exact extension of the rectal\nnodule that should be resected. Therefore, under the condition\nof a correct presurgical assessment, ICG could be interesting\nto avoid iatrogenic bowel perforation by identifying the limits\nof the nodule. This also would allow physicians to shave the\nvagina rather than opening it, as we know that the vagina\nopening is a major risk factor for serious intestinal\ncomplications.\nThis emphasizes that peroperative imaging is mandatory\nto evaluate the involvement of the bowel muscularis and the\ndistance between the inferior border of the lowest bowel\nlesion and the anal verge. These parameters are expected to\nhave an impact on the type of surgery that will be performed.\nUltrasonography is one of imaging modalities for bowel\nendometriosis assessment that can identify accurately the\nextension of the muscular layer in filtration and correspond-\ning thickness in addition to nodule length and thickness ( 5).\nIn cases of rectal infiltration by endometriosis, as recently\nrecommended, the dissection of the endometriotic lesion from\nthe anterior wall of the rectum has to be obtained using blunt\ndissection or using low-thermic energy sources (e.g., CO\n2 laser\nor plasma) with minimal collateral thermal spread ( 1). In the\ntechnique of rectal shaving performed by Bourdel et al., pre-\nviously described in 2011, the monopolar electrocautery was\nused to perform the dissection of the rectal wall.\nIf monopolar electrocauterization is still used instead of\nlow-thermic energy sources (such as ultrasonically coagu-\nlating shears) or even cold scissors, the peroperative evalua-\ntion of the rectal wall vascularization probably is required\nto be aware of the possible postoperative complications\nrelated to ischemia.\nIn case of decreased rectal vascularization observed using\nINDIE at the end of the surgery, the question is if we could su-\nture only the anterior rectal wall as described in the article by\nBourdel et al. or if we should perform a diverting stoma or a\nsegmental colorectal resection according to the size of the re-\nsected nodule.\nIn conclusion, whatever the type of energy used during\nthe rectal dissection, the suggestion of Bourdel et al. of eval-\nuating the rectal vascularization with ICG after a deep rectal\nshaving is innovative. It could be applied in all cases to eval-\nuate the risk of postoperative complication and to make the\nappropriate peroperative decision. Counseling for patients\nwill have to be adapted according to the peroperative evalu-\nation of rectal in filtration.\nMichelle Nisolle, M.D., Ph.D.\nG/C19eraldine Brichant, M.D., Ph.D.\nLinda Tebache, M.D.\nDepartment of Obstetrics and Gynecology, University of\nLi/C18ege, CHR Li /C18ege, Li/C18ege, Belgium\nhttps://doi.org/10.1016/j.fertnstert.2020.04.062\nYou can discuss this article with its authors and other\nreaders at\nhttps://www.fertstertdialog.com/users/16110-fertility-\nand-sterility/posts/30361\nVOL. 114 NO. 2 / AUGUST 2020 275\n\nREFERENCES\n1. Working group of ESGE, ESHRE, and WESKeckstein J, Becker CM, Canis M,\nFeki A, Grimbizis GF, et al. Recommendations for the surgical treatment of\nendometriosis. Part 2: deep endometriosis. Hum Rep Open 2020;1:1 –25.\n2. Nisolle M, Brichant G, Tebache L. Choosing the right technique for deep\nendometriosis. Best Pract Res Clin Obstet Gynaecol 2019;59:56 –65.\n3. Bourdel N, Jaillet L, Bar-Shavit Y, Comptour A, Pereira B, Canis M, Chauvet P.\nIndocyanine Green In filtrating Endometriosis (INDIE): a preliminary feasibility\nstudy to examine vascularization after rectal shaving. Fertil Steril 2020;114:\n367–73.\n4. De Neef A, Cadi/C18ere G-B, Bourgeois P, Barbieux R, Dapri G, Fastrez M. Fluores-\ncence of deep in filtrating endometriosis during laparoscopic surgery: a pre-\nliminary report on 6 cases. Surg Innov 2018;25:450 –4.\n5. Malzoni M, Casarella L, Coppola M, Falcone F, Luzzolino D, Rasile M, et al.\nPreoperative, ultrasound indications determine excision technique for bowel\nsurgery for deep infiltrating endometriosis: a single, high-volume center. J Minim\nInvasive Gynecol 2020;https://doi.org/10.1016/j.jmig.2019.08.034,i np r e s s .\n276 VOL. 114 NO. 2 / AUGUST 2020\nREFLECTIONS","source_license":"CC0","license_restricted":false}