Low Anterior Bowel Resection at the Time of Robotic-Assisted Total Laparoscopic Hysterectomy Due to Deep Infiltrating Endometriosis

INTRODUCTION: Bowel endometriosis occurs in 10% of all patients with endometriosis; and 80% of these lesions arise from the sigmoid colon or rectum. Surgical intervention for bowel endometriosis includes serosal shaving, discoid resection, or segmental resection. Segmental resection is often utilized when the endometriotic lesion is greater than 3 cm or involving more than 50% of bowel wall circumference or multifocal lesions. OBJECTIVE: To highlight a case of deep infiltrating endometriosis involving the rectum and to demonstrate its successful resection using a minimally invasive approach. METHODS: This is a video case presentation of a 44-year-old G3P3003 patient who presents with severe dysmenorrhea, dyspareunia, dyschezia, and abnormal uterine bleeding. The patient desired surgical management of her symptoms. RESULTS: Preoperative imaging with a pelvic MRI revealed multiple endometriotic cysts bilaterally as well as the distinctive mushroom cap sign indicating deep endometriosis extending to the rectosigmoid colon measuring 3.9 cm. At surgery, the sigmoid colon and upper rectum were densely adherent to the posterior uterus; there were multiple bilateral endometriotic cysts as well. She successfully underwent a robotic-assisted total laparoscopic hysterectomy with low anterior bowel resection due to the deep infiltrating endometriosis. The patient recovered from her procedure and was doing clinically well at her postoperative visit. CONCLUSIONS: With good surgical planning and employment of a minimally invasive approach, resection of deep infiltrating endometriosis can be undertaken with excellent clinical outcomes, as was noted in this case.