Rectal surgery for endometriosis--should we be aggressive?

STUDY OBJECTIVE: To assess the outcome of aggressive but conservative laparoscopic surgery in the treatment of severe endometriosis involving the rectum. DESIGN: Retrospective study (Canadian Task Force classification III). SETTING: Endosurgery unit of a tertiary referral center. PATIENTS: One hundred sixty-nine women. INTERVENTION: Laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS: The procedure was completed successfully laparoscopically in 145 (86%) and by laparotomy in 24 women (14%). The rate of preoperative symptoms was higher in 25 women who underwent bowel resection compared with those who had other bowel surgery. In addition to bowel surgery, excision of uterosacral ligaments, adhesiolysis, excision of endometrioma, and oophorectomy were the four most commonly performed procedures. At 35-month follow-up 61 patients (36%) required further surgery for pain. The average time between primary and repeat surgery was 16 months. This second operation was performed by laparoscopy in over three-fourths of the women. Overall recurrent endometriosis was found in 26 patients (15%). Overall morbidity associated with all surgery was 12.4%. CONCLUSION: Surgery for endometriosis of the cul-de-sac and bowel involves some of the most difficult dissections encountered, but it can be accomplished successfully with the low postoperative morbidity typical of laparoscopy.