{"paper_id":"9954498d-f22f-48c4-8846-64eda7e27ffb","body_text":"EJMCR  EJMCR  EJMCR  EJMCR  EJMCR  EJMCR  \n223\nDouble-discoid excision for deep \nbowel endometriosis – a case \nreport\nY amal Patel1 , Kennedy Malele2*, Charles \nMuriuki3, Alin Constantin4, Joseph Njagi3\nABSTRACT\nBackground: Deep infiltrating bowel endometriosis (DIE) can result in debilitating pain, dyspareunia, and infertility. Double-\ndiscoid full-thickness resection is a fertility-sparing option for selected rectal lesions.\nCase Presentation: A 35-year-old African woman presented with severe dysmenorrhea (VAS 9/10), menorrhagia, dyschezia with \nalternating constipation and bloating, deep dyspareunia, and infertility. Transvaginal ultrasound demonstrated adenomyosis, \nmyoma, and a 2.72 × 0.78 × 1.75 cm rectal nodule; Enzian classification: A3, B2/2, C2, FA. She underwent diagnostic hysteroscopy \nwith hysteroscopic myomectomy, laparoscopic resection of pelvic endometriosis nodules, adhesiolysis, and staged transanal \ndouble-discoid full-thickness excision of the rectal (lesion with a transanal circular stapler. Histopathology of the specimens \nconfirmed endometriosis of the uterosacral and rectal lesions.\nOutcome: The patient was discharged on postoperative day 2, described marked symptomatic improvement at a 10-day follow-\nup visit, had resumed a normal diet and bowel function, and was started on suppressive hormonal therapy (dienogest). No \ncomplications were encountered.\nConclusion: Double-discoid full-thickness excision of rectal endometriosis is a feasible surgical option for selected rectal DIE \nnodules <30 mm depth-invasive or when lesion geometry allows; careful patient selection and operative expertise are crucial \naspects.\nKeywords: Bowel endometriosis, full-thickness, resection, discoid excision, case report.\nBackground\nDeep infiltrating endometriosis (DIE) of the bowel is a \ncomplex clinical diagnosis affecting up to 12% of women \nwith endometriosis [1,2]. Patients often present with \nsevere dysmenorrhea, dyspareunia, dyschezia, bloating, \nand infertility, symptoms which lead to significant impair-\nment of quality of life [3-5]. Diagnostic delays can be \nproblematic due to overlapping symptoms with other gas-\ntrointestinal diseases. High-resolution transvaginal ultra -\nsound and magnetic resonance imaging can provide better \npreoperative mapping and classification [6-8]. Surgical \nmanagement for treatment in symptomatic cases is neces-\nsary when medical therapy is ineffective at rates [9]. Three \nmain surgical techniques include shaving of seromuscu-\nlar disease, discoid full-thickness resection, and segmen-\ntal bowel resection. The selected technique depends on \nthe size, depth, and circumference of the lesion [8-12]. \nUltimately, individualized treatment decisions should \ndetermine the radicality of excision weighed against the \nrisk of complications such as bowel dysfunction, fistula \nformation, or anastomotic leakage [13-15]. The discoid \nexcision approach has been widely used to treat rectal DIE \nin women with fertility-preserving desire. However, what \nis not as widely applied is the double-discoid excision \napproach. This report describes the use of a double-discoid \nfull-thickness excision performed transanally in a patient \nwith a longitudinally extensive anterior rectal deep endo-\nmetriosis lesion that could not be optimally excised with \na single stapler, yet had limited circumferential involve -\nment. The decision to complete a full-thickness excision \nwas based on the geometry of the lesion, avoidance of \nsegmental resection, and fertility-preserving desire. \nCase Presentation\nA 35-year-old African female diagnosed with long-\nstanding severe dysmenorrhea, menorrhagia, dyschezia, \nRunning Head: Patel et al.\nType of Article: CASE REPORT  Specialty: Urology\nCorrespondence to: Kennedy Malele\n*Research Department, 3rd Park Hospital, Nairobi, Kenya.\nEmail: kennedy.malele@gmail.com\nFull list of author information is available at the end of the article. \nReceived: 19 December 2025\nRevised (1): 22 March 2026\nAccepted: 10 April 2026\nEuropean Journal of Medical Case Reports\nVolume 10(7):223–228\nDOI: 10.24911/ejmcr.9-2421\nOPEN ACCESSOPEN \nACCESS\nThis is an open access article distributed in accordance \nwith the Creative Commons Attribution (CC BY 4.0) \nlicense: https://creativecommons.org/licenses/by/4.0/) \nwhich permits any use, Share — copy and redistribute \nthe material in any medium or format, Adapt — remix, \ntransform, and build upon the material for any purpose, \nas long as the authors and the original source are \nproperly cited. © The Author(s) 2026\n\nPatel et al. EJMCR. 2026;10(7):223–228.\n224\nalternating constipation and bloating, deep dyspareunia, \nand infertility. She rated her menstrual pain a 9/10 and \nalso reported intermittent non-cyclic pelvic pain. On pel-\nvic examination, she had reproducible posterior pelvic \ntenderness; no prior adnexal mass was palpated on biman-\nual exam. Transvaginal ultrasound for DIE demonstrated \nadenomyosis, uterine myoma, and a hypoechoic ante -\nrior rectal wall nodule measuring 2.72 × 0.78 × 1.75 cm \n(Figure 1). #Enzian(u): A3, B2/2, C2, FA; intraoperative \nEnzian(s): T2/2, A2, B2/2, C3, FA. The preoperative and \nintraoperative evaluation indicated a single anterior rectal \nDIE nodule with full-thickness muscularis involvement, \n<50% circumferential involvement, and longitudinal \nspread greater than the diameter of the staple disc. The \ndepth of the lesion could not allow for complete excision \nby rectal shaving. Bowel resection was unnecessary, given \nthe absence of disease multifocality, limited circumferen-\ntial involvement, and rectosigmoid stenosis. Therefore, \na staged transanal double-discoid full-thickness excision \nwas considered to achieve complete lesion clearance while \nproviding preservation of fertility and bowel continuity. \nDifferential diagnoses considered included colorectal \nneoplasm and inflammatory bowel disease, but imaging \nand operative findings supported DIE. Histopathology \nconfirmed endometriosis in rectal and uterosacral speci-\nmens. No history of prior medical therapy for endometri -\nosis was provided.\nSurgical approach (step-by-step)\nUnder laparoscopic guidance, extensive pelvic adhesi-\nolysis, hysteroscopic myomectomy, and laparoscopic \nshaving of uterosacral nodules were performed. The rec-\ntal lesion was mobilized and shaved (Figure 2); angle \nsutures and two Prolene traction sutures were placed. A \ntransanal circular end-to-end stapler was used for the first \nfull-thickness discoid excision. Due to the longitudinal \nlength of the lesion Figure 4 exceeding the capture capa-\nbility of a single circular stapler disc, the staged discoid \nexcision provided complete full thickness resection of \nthe DIE lesion while maintaining the integrity of the \nstaple line and bowel continuity (Figure 3). On-table \nrectoscopy showed the staple line was intact. Two-angle \nsutures were placed to augment the anastomosis. There \nwere no intraoperative complications. Post-operative \nanalgesics and antibiotics were provided prophylacti-\ncally as per institutional protocol; no post-operative ther -\napeutic antibiotics were required. \nThe patient was started on suppressive hormonal ther -\napy with dienogest (2 mg). She was vitally stable, tolerated \ndiet well, and passed stool and urine without complica -\ntion. At the initial clinic review day 10, the patient stated \nher symptoms of dyschezia and ≤bloating had almost \nsignificantly resolved; she had a significant decrease in \nher dysmenorrhea (before surgery, her Visual Analogue \nScale (V AS) score was 9); and she had normalized bowel \nfunction. There were no immediate adverse or unexpected \nevents documented. She was continued on suppressive \nhormonal therapy with dienogest. Postoperative pain \nimprovement was evaluated based on the patient-reported \noutcome on a V AS scale. No specific validated quali -\nty-of-life assessment instrument was used. \nPrior to presentation, the patient described a multiple-year \nhistory of progressively worsening cyclical pelvic pain \nand bowel symptoms. Diagnostic transvaginal ultrasound \nfor DIE mapping was performed, followed by surgical \nintervention after multidisciplinary discussion. Surgery \nconsisted of a simultaneous laparoscopic and transanal \ndouble-discoid excision. The patient was discharged \n2 days postoperatively, with a follow up appointment \nat 10 days, and began suppressive hormonal therapy \n(Dienogest) after that date Figure 5.\nFigure 1. A 2D Sonographic imaging showing the hypoechoic, irregularly con-\ntoured rectal nodule measuring 2.72 × 0.8 × 1 .75 cm, located in the anterior rectal \nwall. The lesion appears infiltrative with posterior shadowing, consistent with deep \nendometriosis.\n\n\nPatel et al. EJMCR. 2026;10(7):223–228.\n225\nDiscussion\nThis case demonstrates that double-discoid full-thickness \nexcision can be a safe and efficacious fertility-sparing \napproach to bowel DIE. It highlights the application of a \nstaged double-discoid excision for rectal DIE lesions with \nunique longitudinal geometry. While discoid excisions \nhave been performed before, this case expands the under-\nstanding of the applicability of double-discoid excisions, \nwhere a discoid excision or a segmental resection can be \nundertaken, given the length of the lesion involved. The \ndouble-discoid excision in this case preserved continuity \nof the bowel and the fertility potential of a young woman \nwho was infertile. The patient’s fertility outcomes will \ncontinue to be tracked during the patient’s ongoing clini-\ncal follow-up; however, there are no pregnancy outcomes \navailable at this time.\nThe patient had presented with severe cyclical pain \nand bowel symptoms, which improved significantly after \nsurgery, with bowel function normalizing and no immedi-\nate complications. Current literature supports some form \nof surgical approach for rectal DIE, including shaving, \ndiscoid excision, and segmental resections, noting that \nthe type of surgery is dependent on the size of the lesion, \ndepth of lesion, as well as circumferential involvement \nof the lesion [1-4]. Segmental bowel resection was an \noption in pre-operative planning, but was unsuitable due \nto the absence of bowel stenosis, limited circumferen-\ntial involvement, and the fertility-preserving goal. Wide \nsegmental resection is usually reserved for multiple \nlesions involving >50% of the circumference or consid-\nerable bowel-compromising luminal issues. A double \ndiscoid technique offers complete excision of extensive \nlongitudinal lesions with less morbidity associated, in \ncomparison, and is recommended for nodules less than \n3 cm and with less than 50% circumferential involve-\nment of the rectum, as in this case [5,6]. Comparatively, \nFigure 2. Laparoscopic rectal shaving to excise DIE tissue. The dissection is \nundertaken carefully down to the anterior rectal wall in the muscularis layer to \nallow for maximal excision of fibrotic and infiltrative disease while maintaining \nrectal viability. This is an important step before full thickness rectal disc excision \nfor deeper infiltration.\nFigure 3. Rectal shaved area caught between the anvil and the shoulder of the \ntransanal circular stapler, which is progressively closed under laparoscopic control.\n\nPatel et al. EJMCR. 2026;10(7):223–228.\n226\ngeneral data suggests that long-term pain relief is com-\nparable between discoid and segmental resection; how-\never, discoid approaches offer less morbidity and better \nfunctional outcomes than segmental resections [7-9]. \nDouble-discoid approaches provide an option for excis-\ning a nodule longer than the reach of a single stapler disc \nto allow for adequate excision while maintaining some \ndegree of bowel continuity [14,15]. The double-discoid \nexcision technique is generally associated with fewer \noccurrences of anastomotic leak, post-operative bowel \ndysfunction, and long-term stenosis when performed in \npatients selected appropriately, when compared to seg-\nmental colorectal resection. Segmental resections may \nbe necessary for extensive or circumferential disease, \nbut the technique has a greater risk of disrupting conti-\nnuity of the bowel and nerve injury. The double-discoid \napproach appears to provide a balance between disease \nexcision and a lower incidence of complications associ-\nated with the surgery [7-9,14,15].\nThis case illustrates technical feasibility, multidis-\nciplinary surgical consideration, and documents early \nsymptomatic resolution. The case asserts that dou-\nble-discoid excision is an acceptable and fertility-spar -\ning approach in selected patients, specifically those with \nrectal DIE. Good outcomes depend on careful patient \nselection, advanced laparoscopic skills, and an optimal \nsurgical and medical management approach. The use of \ndienogest post-operatively is also consistent with the \nliterature that supports medical suppression of disease \n[12,13]. A significant limitation includes a significantly \nshort duration of follow up; thus, no long-term functional \n(reproductive) or recurrence outcomes can be assessed \nat present. The consideration for the preservation of fer -\ntility was an influence on the surgical decision-making \nprocess; however, pregnancy outcomes were still not \navailable at the time of this report.\nConclusion\nThe double-discoid excision technique is a feasible oper -\native approach for the treatment of bowel DIE. It allows \nfull excision of endometriotic lesions while preserving \nbowel continuity in symptomatically troubled patients. \nThis case report provided an example of successful dou-\nble disc excision in a patient with DIE, with satisfactory \npost-operative results and improvement in the patient’s \nsymptomatology. The importance of patient selection, sur-\ngical experience to perform the surgery, and a multidisci-\nplinary working relationship will ensure the best possible \noutcomes for the patient.\nFigure 4. Intraoperative images showing the gross appearance \nof the resected rectal nodule, with a firm, irregular, fibrotic mass \ninvading the muscularis propria of the anterior rectal wall, con-\nsistent with DIE. The surface is nodular and heterogenous and \nshows signs of fibrosis, and possibly glandular components.\nTimeline\nFigure 5. Timeline of the patient’s endometriosis management pathway.\n\nPatel et al. EJMCR. 2026;10(7):223–228.\n227\nWhat is new?\nDIE of the bowel is a complicated condition that causes \ndebilitating pelvic pain, bowel symptoms, and can lead to \ninfertility; treatment options include shaving, discoid exci-\nsion, or segmental resection, depending on the lesion char -\nacteristics. Discoid full-thickness excision is a fertility-sparing \napproach for small rectal nodules. This paper details a new \nadaptation of a double-discoid (or double-disc) full-thick -\nness excision for rectal DIE. The authors describe the techni-\ncal feasibility, safety, and good short-term outcomes. Careful \npatient selection and multidisciplinary surgical planning are \ncrucial aspects.\nList  of Abbreviations\nDIE Deep infiltrating endometriosis \nVAS Visual Analogue Scale\nConflicts of interest \nThe authors declare that they have no conflict of interest \nregarding the publication of this case report.\nFunding\nNo funding was received from the public, commercial, or not-\nfor-profit sector.\nConsent for publication\nWritten informed consent was obtained from the patient for \npublication of this case report and any accompanying images. A \ncopy of the written consent is available for review by the Editor-\nin-Chief of this journal.\nEthical  approval\nEthical approval for this case report was obtained from \nKenyatta University Ethics Review Committee (KUERC Ref. No.: \nPKU/3389/14110) dated on:11th November 2025.\nAvailability of data and material\nThe data supporting the findings of this case report are not pub-\nlicly available due to privacy and ethical considerations. \nAuthor contributions\nAll authors contributed to conception, data collection, manu -\nscript drafting, and final approval of the submitted version.\nAuthor details\nYamal Patel 1, Kennedy Malele 2, Charles Muriuki 3, Alin \nConstantin4, Joseph Njagi3\n1.  Consultant Obstetrician and Gynaecologist, Hysteroscopic \nand Laparoscopic Surgeon, 3rd Park Hospital, Nairobi, Kenya\n2.  Research Department, 3rd Park Hospital, Nairobi, Kenya\n3.  Consultant Obstetrician, Gynaecologist and Laparoscopic \nSurgeon, 3rd Park Hospital, Nairobi, Kenya\n4.  Alin Constantin, Department of Gynecology, Obstetrics \nand Reproductive Medicine, Saarland University Hospital, \nHomburg, Germany\nReferences\n1. 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EJMCR. 2026;10(7):223–228.\n228\n14. Pinho Oliveira MA, Crispi CP , Oliveira FM, Reis PS, \nRaymundo TS, Pereira TD. Double circular stapler, or lap-\naroscopic double discoid resection with a circular stapler. \nJ Minim Invasive Gynecol. 2016;23(5):844. https://doi.\norg/10.1016/j.jmig.2016.01.031 \n15. Kondo W, Ribeiro R, Zomer MT, Hayashi R. Laparoscopic \ndouble discoid resection with a circular stapler for bowel \nendometriosis. J Minim Invasive Gynecol. 2015;22(6):929–\n31. https://doi.org/10.1016/j.jmig.2015.04.021\nSummary of case\n1 Patient (gender, age) 35 years, female\n2 Final diagnosis Deep infiltrating rectal endometriosis\n3 Symptoms Severe dysmenorrhea (VAS 9/10), menorrhagia, dyschezia, constipation and bloating, deep \ndyspareunia, and infertility\n4 Medications Postoperative suppressive hormonal therapy - dienogest (2 mg daily); perioperative analgesics \nand antibiotics\n5 Clinical procedure Laparoscopic + transanal double-disc full-thickness excision of endometriosis\n6 Specialty Obstetrics and gynaecology – minimally invasive / laparoscopic surgery","source_license":"CC0","license_restricted":false}