{"paper_id":"c57e2128-afb8-42ef-a91a-87cd849e8e52","body_text":"Annex Publishers | www.annexpublishers.com                    \n \nVolume 3 | Issue 1\nSurgery for Deep Endometriosis: Standardization of the Operating Technique\nLimberger LF1,3, Jacobsen L*1, Koshimizu RT2, Siqueira DP3 and Rosa Alves NJD3\n1Department of Obstetrics and Gynecology, Hospital Nossa Senhora da Conceição, Porto-Alegre, Brazil\n2Department of Proctology, Hospital Nossa Senhora da Conceição, Porto-Alegre, Brazil\n3Department of Obstetrics and Gynecology, Hospital Moinhos de Ventos, Porto-Alegre, Brazil\n*Corresponding author:  Jacobsen L, M.D., Department of Obstetrics and Gynecology, Hospital Nossa \nSenhora da Conceição, Praça municipal 407/201, Porto Alegre, Brazil 91040-400, Tel: +55 51 981771599, \nE-mail: leonardojacobsen@hotmail.com\nResearch Article Open Access\nCitation: Limberger LF , Jacobsen L, Koshimizu RT, Siqueira DP , Rosa Alves NJD (2018) Surgery for \nDeep Endometriosis: Standardization of the Operating Technique. J Surg Oper Care 3(2): 202. doi: \n10.15744/2455-7617.3.202\nIntroduction\nEndometriosis is defined as the presence of endometrial tissue outside the uterine cavity, resulting in a chronic inflammatory \nreaction at these sites [1]. These ectopic endometrial implants are usually located in the pelvis but may occur in any area of the \nbody [2]. Endometriosis can manifest in different ways among patients. Most patients with endometriosis have low-grade disease \nassociated with mild or moderate symptoms. Typically, these patients have implants in the ovaries, serous surfaces or superficial \nperitoneal disease [3-5]. In some cases, endometriosis manifests more aggressively with lesions that deeply infiltrate the pelvic \nstructures and organs. These patients present more severe degrees of pain and clinical manifestations, great negative impact on \nquality of life and serious complications if they are not treated [6]. Deep endometriosis is defined as the infiltrative forms of \nendometriosis that affect the fundus of the sac and the rectovaginal septum, uterosacral ligaments and vital structures such as \nintestine, bladder and ureters [7,8]. Unlike superficial forms of the disease, deep infiltrative endometriosis (DIE) is a peculiar \nform that does not respond well to drug therapy and generally requires extensive and aggressive surgery that must be performed \nby an experienced professional using specific techniques [5,9]. This study describes the cases of deep endometriosis of patients \nsurgically treated by an experienced gynecologist and multidisciplinary team in tertiary services in Porto Alegre, RS, defining the \nclinical and epidemiological profile of these patients and the affected sites and organs, surgical indications, complications and \npostoperative outcomes, proposing a standardization of the operative technique to be followed in all cases.\nAbstract\nKeywords: Deep Infiltrating Endometriosis; Laparoscopy; Surgery; Colorectal\n                        Volume 3 | Issue 2\n                    Journal of Surgery and Operative Care\nISSN: 2455-7617\nBackground and objectives: Deep endometriosis is a disease with a great negative impact on patient quality of life, requiring surgical \ntreatment in tertiary centers and surgeons highly skilled in performing complex surgeries, and is associated with high rates of morbidity \nand related complications. We evaluated all cases of deep endometriosis operated by the same surgeon since 2011 to evaluate the profiles of \npatients, sites and organs affected, surgical indications and complications and to propose a standardization of the surgical technique used \nin our service.\nMethods: Data were retrospectively collected from 54 patients diagnosed with deep endometriosis between 2011 and 2016 and included \nage, body mass index, symptoms, CA-125, affected sites, surgical route, surgical procedures performed, complications and pregnancy rate \nafter surgery.\nResult: The main complaint was pain without infertility in the majority (64%), and dysmenorrhea was the most common symptom. The \nmain sites were intestine (70.4%), vagina (14.8%), uterosacral ligament and ureter (both with 5.6%) and bladder (3.7%). Of the 54 patients, \n136 lesions of deep endometriosis were resected in 130 surgical procedures. Endometrioma was associated in 34 (63%) of the cases. Ten \npatients (18.5%) had some type of complication. Nine (60%) of the fifteen patients complaining of infertility were able to spontaneously \nbecome pregnant after surgery.\nConclusion: Surgery for deep endometriosis affects multiple structures and organs, resulting in a high degree of morbidity and high \ncomplication rates, and should be performed in tertiary centers with a multidisciplinary team and experienced surgeons, obeying standard \nsurgical techniques.\nList of abbreviations: Deep Endometriosis; Urinary Endometriosis; Bowel Endometriosis\nReceived Date: April 5, 2018 Accepted Date: June 29, 2018 Published Date: July 2, 2018\n\nAnnex Publishers | www.annexpublishers.com                    \n \nVolume 3 | Issue 2\nJournal of Surgery and Operative Care\n \n2\nMaterials and methods\nData collection through medical chart review was approved by the Ethics and Research Committee of Hospital Nossa Senhora \nda Conceição. We included all 54 patients diagnosed with DIE, operated on by gynecologist Dr. Limberger from 2011 to 2016, \nattended at the Nossa Senhora da Conceição, Ernesto Dornelles, Mãe de Deus and Moinhos de Vento hospitals, all of which are \nlocated in Porto Alegre-Rio Grande do Sul. We consider deep endometriosis to include the infiltrative forms of endometriosis that \naffect the rectovaginal septum, uterosacral ligaments, fundus of the vaginal sac and vital structures such as intestine, bladder and \nureters, confirmed by anatomopathological examination. For each patient, demographic data, such as age, number of children, \nbody mass index (BMI) and comorbidities, were collected. Previous history of hormone treatment and surgery for diagnosis or \ntreatment of endometriosis were recorded.The following symptoms were identified from the clinical chart: chronic pelvic pain \n(not related to the menstrual cycle), dysmenorrhea (pelvic pain or colic during the menstrual period), dyspareunia (pain during \nintercourse), gastrointestinal symptoms during menstruation (dyschezia, hematochezia and diarrhea or constipation) and urinary \nsymptoms also during the menstrual period (hematuria, dysuria, urinary urgency and bladder tenesmus). In view of the described \nsymptoms, we considered four main indications for surgery: pain with infertility, pain without infertility, infertility without pain or \nasymptomatic hydronephrosis. According to surgical descriptions and anatomo-pathological reports, we reviewed and classified \nendometriosis lesions located at five main sites: bladder (a lesion that infiltrates the actual bladder muscle), ureter (a lesion that \ninfiltrates the ureter wall), uterosacral ligament (a lesion that infiltrates the uterosacral ligament, either uni- or bilaterally), vagina \n(when the lesions infiltrate the fundus of the anterior rectovaginal sac, the posterior vaginal fornix or the retroperitoneal region \nbetween the anterior vaginal sac and the posterior vaginal fornix) and intestine (a lesion that infiltrates the actual intestinal muscle). \nWhen the patient had multiple locations of deep endometriosis, she was classified according to the category corresponding to \nthe most severe main lesion. According to the definition, we classified the lesions from the least severe to the most severe in the \nfollowing order: uterosacral ligament (USL), vagina, bladder, intestine, and ureter. For patients with intestinal involvement, we \ndivided the disease into the following locations: straight, rectosigmoid, sigmoid colon, ileo-cecum, appendix and small intestine. \nThe presence of associated ovarian endometrioma was also evaluated. The surgical routes used, i.e., abdominal (laparotomy) and \nvideo laparoscopic, were analyzed. Each surgical procedure specific to the different locations of deep endometriosis was recorded \naccording to the surgical description. Postoperative complications were reviewed and described, and for those patients who had \nsurgical indication for infertility, we described those that managed to become pregnant after the procedure. Because the patients \nwere treated by the same surgeon and multidisciplinary team, we were able to systematize and standardize the surgical technique \nin all cases. Our service has adopted the following routine. The patient is prepared with an enema. Under general anesthesia, \nthe patient is placed in the modified Lloyd-Davies position (lithotomy). Bladder catheterization is performed, and the uterine \nmanipulator is placed. Pneumoperitoneum is established using a Veress needle through a supra-umbilical longitudinal incision \nwith a pressure of 15 mmHg. The operation starts in the Trendelenburg position (with 20° slope), and 5-mm trocars are then \ninserted in the right iliac fossa, left iliac fossa and the middle third between the umbilicus and the pubic bone. The first step is \ndiagnosis with thorough inventory of the abdominal cavity and understanding of the problem. The second step is to re-establish \nthe anatomy by releasing the sigmoid colon, adhesions and cystic drainage, thus allowing adequate exposure of the pelvis. The \nureters are then released from the iliac vessels up to their entry into the bladder, with identification of the hypogastric nerves \nalong the uterosacral ligaments and the lower hypogastric plexus. Opening of the pararectal spaces is then performed, allowing \nthe reassessment of structures compromised by the foci of endometriosis including the bladder, ureters, intestine, uterosacral \nligaments, vagina and uterus. In patients with less than 30% of the rectum involved, the nodule is resected, respecting the depth \nof invasion, by shaving or discoid resection. When the invasion is superficial, nodule resection alone is adequate. However, when \nthe invasion is deeper or a rectal opening or an impression of residual lesions on the intestinal wall is present, continuous suturing \nof the area is performed with prolene 2-0, an endoluminal circular stapler is introduced with its payload attached via the rectum, \nthe stapler is opened, and the suture is drawn into the stapler, which is closed and fired, completing the discoid resection and \nclosing the opening in the rectum. In cases of endometriosis of the rectovaginal septum, this approach is performed via the vagina \nbecause the vagina is open for resection of the nodule. In cases of concomitant endometriosis infiltrating the sigmoid colon with \na need for incision for removal of a larger surgical specimen, a suprapubic transverse incision approximately 7 cm in length is \ncreated, followed by insertion of an Alexis® wall retractor, prepared with the glove hand and latex aspiration tube, and resection \nand manual extracorporeal sutures are performed. The ventilator test is performed, and air insufflation via the rectum and possible \nextravasation of air in the pelvis filled with saline solution is observed. At the end of surgery, the chromotube test with patent blue \nis performed in patients with infertility, followed by hemostasis, cavity lavage with saline solution and portal closure.\nResults\nDuring the analyzed period, 54 women underwent surgical treatment for deep endometriosis. The data, symptoms and previous \ntreatments undergone by the patients are summarized in (Table 1). According to the severity of the lesions, the main sites affected \nin order of frequency were intestine (70.4%), vagina (14.8%), uterosacral ligament and ureter (both with 5.6%) and bladder (3.7%). \nThese 54 women had 136 DIE lesions, confirmed by anatomopathological examination, with anatomical distribution described in \n(Table 2). As we observed in the distribution of lesions due to deep endometriosis, the main site of involvement was the intestine. \nOf the 54 patients, 38 (70.3%) had involvement of any site of the intestinal tract of the 38 patients with endometrioid lesions in \nthe intestine, 14 (36.8%) had more than one intestinal lesion. The distribution of lesions in the intestine in ascending order of \n\nAnnex Publishers | www.annexpublishers.com                    \n \nVolume 3 | Issue 2\n                            Journal of Surgery and Operative Care\n \n3\nfrequency was as follows: small intestine (n = 1, 1.6%), appendix (n = 4, 6.4%), sigmoid colon (n = 4; 6.4%), ileo-cecum (n = 7; \n11.2%), rectosigmoid (n = 15; 24.1%) and rectum (n31; 50%). Of the 54 patients with deep endometriosis, we observed that 34 \n(63%) had associated endometriomas (either uni- or bilaterally) and required oophoroplasty during the surgical procedure for \nresection of these lesions. Among the surgeries performed, the majority (n = 37; 68.5%) were performed by video laparoscopy \nand 16.7% (n = 9) by laparotomy. In 8 cases (14.8%), the surgery started using video laparoscopy but had to be complemented \nby laparotomy due to the absence of adequate surgical material in the institution. The surgical procedures performed for the \nexcision of DIE lesions are described in (Table 3). Of the 54 patients submitted to surgery, a total of 130 surgical procedures were \nperformed. In our series, we observed that 10 (18.5%) patients had complications associated with the surgical procedure, with the \nmost common being primary anastomosis dehiscence with need for protective ileus/colostomy, followed by bladder dysfunction \nwith associated urinary retention, hematoma and pelvic abscess. Of all of the patients, 3 (5.6%) had recurrence requiring a surgical \nreintervention to remove new deep lesions of endometriosis. We considered as recurrence those cases in which the patients had \nevidence on ultrasound and/or magnetic resonance imaging and underwent a new surgery with the diagnosis of endometriosis \nconfirmed in the pathology examination. The surgical indication was clinical worsening in all three cases. One patient had \nrecurrence on the colostomy scar (subcutaneously) and endometriomas bilaterally at 3 years after the first surgery. In the second \ncase, recurrence occurred 2 years after primary surgery, and a rectosigmoidectomy and appendectomy were performed, probably \ndue to permanence of endometriosis foci in the intestine due to a less aggressive surgery on the first approach. The third case was a \npatient who had undergone two previous surgeries in other hospitals for endometriosis, who was operated on by our team in 2014 \nfor resection of intestinal endometriosis and one year later underwent hysterectomy with bilateral salpingectomy for persistent \nand disabling pelvic pain. Foci of endometriosis were observed in the left fallopian tube and fragments of the left ovary. Of the \n15 patients who complained of infertility associated or not associated with pain, 9 (60%) became pregnant spontaneously after \nsurgery, and 6 (40%) were not able to conceive one year after the surgical procedure.\nPatient characteristics (n = 54)\nAge (years)a 36.4±7.0 (23-53)\nBMI (kg/m2)a 24.7±3.9 (17-37)\nNumber of prior pregnanciesa 0.6±0.8 (0-3)\nPrior treatment for Endometriosis (%)\n    Hormonal 87\n    Surgical 53\nMain complaint (%)\n    Pain without infertility 64.9\n    Pain and infertility 9.3\n    Infertility without pain 25.9\nPainful symptoms (%)\n    Chronic pelvic pain 46.3\n    Dysmenorrhea 53.7\n    Dyspareunia 20.4\n    Gastrointestinal symptoms 33.4\n    Cyclical urinary symptoms 5.6\nCA-125 (U/ml)a 55.1±70 (9-352)\nData are presented as means ± standard deviations (minima-maxima). BMI: body mass index\nTable 1: Characteristics of women with deep infiltrative endometriosis\nSite n (%)\nLR 6 (4.4)\nAUS/UVPR 11 (8)\nUSL 27 (19.8)\nVagina 25 (18.3)\nBladder 2 (1.4)\nIntestine 62 (45.5)\nUreter 3 (2.2)\nTotal 136 (100)\nLR: Round Ligament; SUA / RVPU: Anterior Uterine Serosa / Uter-\nine Vesicle Peritoneal Reflection; USL: Uterosacral Ligament;\nTable 2: Anatomical distribution of the main lesions reported in the description of the surgical procedure\n\nAnnex Publishers | www.annexpublishers.com                    \n \nVolume 3 | Issue 2\nJournal of Surgery and Operative Care\n \n4\nProcedures performed (n = 130) n\nAnterior compartment\n    Resection of the round ligament (uni- or bilateral) 6\n    Resection of the superficial uterine peritoneum 9\n    Partial cystectomy 2\n    Replacement of the ureter 3\nPosterior compartment\n     Resection of the uterosacral ligament (uni- or bilateral) 25\n     Nodule resection at the rectovaginal septum 24\n     Rectal shaving 21\n    Discoid resection at the rectum 9\n    Segment resection at the rectum 6\n    Segment resection at the rectosigmoid colon 14\n    Ileocecal resection 6\n    Segment resection at the small intestine 1\n    Appendectomy 4\nTotal 130\na Sometimes more than one procedure was performed in the same patient.\nTable 3: Surgical procedures for treatment of deep infiltrative endometriosis\nDiscussion\nOur data and data from the literature suggest that lesions of infiltrative endometriosis tend to be multifocal in most patients \nand that a large number have intestinal involvement [10-13]. We also observed that the majority (63%) of patients with DIE had \nassociated endometriomas. The main complaint of patients seeking care was pain. Although our study is retrospective and the \nevaluation of pain was not standardized as it would be in a questionnaire, the main pain symptoms were similar to those described \nin the literature, the most frequent being dysmenorrhea, acyclic pelvic pain, cyclic gastrointestinal symptoms, dyspareunia and \nurinary symptoms; most of the patients complained of more than one painful symptom [11,14]. In the distribution of patients \naccording to the most severe DIE lesions, we observed a larger number of patients with intestinal involvement (70.4%) and fewer \nwith involvement of the uterosacral ligament (5.6%) than previously reported in the literature. The percentages of patients with \nprimary lesions located in the vagina (14%), bladder (3.5%) and ureter (7.5%) were similar to those reported in other studies \n[10-13]. In the cases of endometriosis with intestinal involvement, the majority of the patients in our study had involvement \nof the rectum and rectosigmoid junction (74.1%), followed by the ileo-cecum (11.2%), sigmoid colon (6.4%), appendix (6.4%) \nand small intestine (1.6%), similar to findings from other studies [12,15]. When deep endometriosis affects the rectosigmoid, \nmultifocal intestinal lesions are observed in 40% or more patients, a number similar to the 36% found in our study [16]. Because \nthe disease involves a complex pathology that requires extensive aggressive surgeries for complete excision of its lesions, the \nrates of postoperative complications described for deep endometriosis surgery are high, varying from 10 to 15% in the literature, \nespecially when they reach the urinary and/or intestinal tract [17-20]. In our study, ten patients (18.5%) had postoperative \ncomplications, the majority (4 cases) related to anastomosis dehiscence requiring temporary protective ileus/colostomy, and 3 \nof them had reconstructed intestinal transit. Other complications were bladder dysfunction with a need for self-catheterization \nfor a limited time, pelvic hematoma and abscess. There were no intraoperative complications, and conversions performed for \nlaparotomy (n = 8; 14.8%) were due to the absence of adequate surgical material available at the institution. Conversion rates in \nthe literature range from 2-12.5% [19,21]. Recurrence rates range from 2 to 43.5% according to the literature. This variability is due \nto different definitions for recurrence and the short segment time. A longer segment time results in greater recurrence rates [22]. \nThree of the fifty-four patients (5.6%) had recurrence in our study, and the segment time ranged from 5 years for patients operated \non in 2011-2012 to 1 year or less for patients operated on in 2016. Y oung age and high BMI are risk factors for recurrence [22]. \nThe three patients who suffered recurrence were operated on before July 2013 (4 or more years of follow-up), and only one was \nobese (BMI 33). In a Cochrane systematic review, the authors concluded that laparoscopic surgery to treat endometriosis reduces \noverall pain and increases pregnancy and live birth rates [23]. Our study showed a general and subjective improvement of painful \nsymptoms among our patients after the surgery, but we were unable to investigate further due to the lack of applied questionnaires \nin this retrospective study. Of the patients complaining of infertility, 60% managed to spontaneously get pregnant after surgery for \nendometriosis, a number similar to those described in the literature, which range from 50 to 60% [17,24]. The aim of the surgical \ntreatment for deep endometriosis is the complete excision of all lesions [16]; the procedures should be performed by experienced \nsurgeons and by a multidisciplinary team [24]. In our series, all 54 patients with deep endometriosis were operated upon in a \ntertiary center by the same gynecologist, and in all cases of intestinal or urinary tract involvement, a coloproctologist or urologist \nsurgeon participated, all with extensive experience and training in video laparoscopy.\n\nAnnex Publishers | www.annexpublishers.com                    \n \nVolume 3 | Issue 2\n                            Journal of Surgery and Operative Care\n \n5\nThe choice of surgical technique should be individualized in each case according to the location, size and quantity of lesions, and \nin cases of multifocal disease, several surgical procedures should be combined [9,16,23,25]. We performed 130 surgical procedures \nfor the treatment of DIE cases in our study. Except for one patient operated on in the year 2011, the remaining 53 patients were \noperated on in a 5-year period (2012-2016), resulting in an average of 10 patients per year (7-17). The small size of our sample and \nthe fact that it is a retrospective study evaluating surgeries performed during a 5-year period are the main limitations of our study, \nalthough our results are similar to those described in the literature by several other centers in several countries around the world. \nAlthough each case requires individualized planning, we conclude that there should be standardization in the surgical approach \nof these patients. Because surgery for deep endometriosis affects multiple structures and organs, resulting in a high degree of \nmorbidity and high complication rates, it should be performed in tertiary centers with a multidisciplinary team and experienced \nsurgeons, obeying standard surgical techniques.\nConclusion\nSurgery for deep endometriosis affects multiple structures and organs, resulting in a high degree of morbidity and high complication \nrates, and should be performed in tertiary centers with a multidisciplinary team and experienced surgeons, obeying standard \nsurgical techniques.\nReferences\n1. Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, et al. (2014) ESHRE guideline: management of women with endometriosis. Hum Reprod \n29: 400-12.\n2. Markham SM, Carpenter SE, Rock JA (1989) Extrapelvic endometriosis. Obstet Gynecol Clin North Am 16: 193-219. \n3. American Society for Reproductive Medicine (1997) Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril \n67: 817-21.\n4. Nisolle M, Donnez J (1997) Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. \nFertil Steril 68: 585-96.\n5. Garry R (2004) Is insulin resistance an essential component of PCOS?: the endometriosis syndromes: a clinical classification in the presence of aetiological \nconfusion and therapeutic anarchy. Hum Reprod 19: 760-8.\n6. Garry R, Clayton R, Hawe J (2000) The effect of endometriosis and its radical laparoscopic excision on quality of life indicators. BJOG 107: 44-54.\n7. Vercellini P , Frontino G, Pietropaolo G, Gattei U, Daguati R, et al. (2004) Deep endometriosis: definition, pathogenesis, and clinical management. J Am Assoc \nGynecol Laparosc 11: 153-61.\n8. Somigliana E, Garcia-Velasco JA (2015) Treatment of infertility associated with deep endometriosis: definition of therapeutic balances. Fertil Steril 104: 764-70.\n9. Vercellini P , Carmignani L, Rubino T, Barbara G, Abbiati A, et al. (2009) Surgery for deep endometriosis: a pathogenesis-oriented approach. Gynecol Obstet \nInvest 68: 88-103.\n10. Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset B, et al. (2003) Anatomical distribution of deeply infiltrating endometriosis: surgical implications and \nproposition for a classification. Hum Reprod 18: 157-61.\n11. Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B, et al. (2002) Relation between pain symptoms and the anatomic location of deep infiltrating \nendometriosis. Fertil Steril 78: 719-26.\n12. Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, et al. (2006) Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribu-\ntion. Hum Reprod 21: 1839-45.\n13. Kondo W , Ribeiro R, Trippia C, Zomer MT (2012) [Deep infiltrating endometriosis: anatomical distribution and surgical treatment]. Rev Bras Ginecol Obstet \n34: 278-84.\n14. Dai Y , Leng JH, Lang JH, Li XY , Zhang JJ (2012) Anatomical distribution of pelvic deep infiltrating endometriosis and its relationship with pain symptoms. \nChin Med J (Engl) 125: 209-13.\n15. Pereira RM, Zanatta A, Preti CD, de Paula FJ, da Motta EL, et al. (2009) Should the gynecologist perform laparoscopic bowel resection to treat endometriosis? \nResults over 7 years in 168 patients. J Minim Invasive Gynecol 16: 472-9.\n16. Abrão MS, Petraglia F , Falcone T, Keckstein J, Osuga Y , et al. (2015) Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before man-\nagement. Hum Reprod Update 21: 329-39.\n17. Donnez J, Squifflet J (2010) Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep \nrectovaginal endometriotic nodules. Hum Reprod 25: 1949-58.\n18. Ruffo G, Scopelliti F , Scioscia M, Ceccaroni M, Mainardi P , et al. (2010) Laparoscopic colorectal resection for deep infiltrating endometriosis: analysis of 436 \ncases. Surg Endosc 24: 63-7.\n19. Kondo W , Bourdel N, Tamburro S, Cavoli D, Jardon K, et al. (2011) Complications after surgery for deeply infiltrating pelvic endometriosis. BJOG 118: 292-8.\n20. Rausei S, Sambucci D, Spampatti S, Cassinotti E, Dionigi G, et al. (2015) Laparoscopic treatment of deep infiltrating endometriosis: results of the combined \nlaparoscopic gynecologic and colorectal surgery. Surg Endosc 29: 2904-9.\n21. Darai E, Thomassin I, Barranger E, Detchev R, Cortez A, et al. (2005) Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis. \nAm J Obstet Gynecol 192: 394-400.\n22. Ianieri MM, Mautone D, Ceccaroni M (2018) Recurrence in deep infiltrating endometriosis: a systematic review of the literature. J Minim Invasive Gynecol \n2018: S1553-4650.\n23. Duffy JMN, Arambage K, Correa FJS, Olive D, Farquhar C, et al. (2014) Laparoscopic surgery for endometriosis. Cochrane Database Syst Rev 2014: CD011031.\n24. Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J (2012) Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril 98: 564-71.\n25. De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, et al. (2011) Bowel resection for deep endometriosis: a systematic review. BJOG 118: 285-91.\n\nAnnex Publishers | www.annexpublishers.com                    \n \nVolume 3 | Issue 2\nJournal of Surgery and Operative Care\n \n6\nSubmit your next manuscript to Annex Publishers and \nbenefit from:\n                                    Submit your manuscript at\n              http://www.annexpublishers.com/paper-submission.php\n→  Easy online submission process\n→  Rapid peer review process\n→  Open access: articles available free online\n→  Online article availability soon after acceptance for Publication\n→  Better discount on subsequent article submission\n→  More accessibility of the articles to the readers/researchers within the field","source_license":"CC0","license_restricted":false}