Totally Laparoscopic Resection with Transanal Natural Orifice Specimen Extraction for Deep Endometriosis Infiltrating the Rectum

OBJECTIVE: To show the surgical steps used to perform a totally laparoscopic segmental rectal resection, with intracorporeal anastomosis and transanal natural orifice specimen extraction (NOSE), in a context of deep endometriosis. DESIGN: Step-by-step video demonstration of the technique. SETTING: Even though the combined use of intracorporeal anastomosis and NOSE has increasingly been investigated during the last decade, there is still lack of defined consensus, both in terms of patient eligibility and operative technique. In particular, experience with intracorporeal anastomosis and NOSE for treatment of deep rectal endometriosis is very limited. Preliminary reports have documented that a totally laparoscopic rectal resection is equally effective and safe compared with the conventional approach using an abdominal minilaparotomy for extracorporeal anastomosis and specimen retrieval. In comparison to the latter, intracorporeal anastomosis with NOSE seems to offer advantages in terms of less postoperative pain, fewer wound-related complications, better cosmetic results, quicker return of bowel function and shorter hospital stay. PATIENT: A 31-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain unresponsive to hormonal therapies. Preoperative ultrasonography showed partial obliteration of the Douglas' pouch due to a rectal endometriotic nodule of 42 × 12 × 18 mm in contiguity with a deeply infiltrating retrocervical lesion of 13 × 3 × 17 mm. The rectal nodule resulted in the infiltration of the tunica muscularis with a distance of 12 cm from the anal verge and a circumferential extent of 45%. INTERVENTIONS: A 3-dimensional laparoscopic system was used. Rectal mobilization was performed according to our standardized technique [1]. After determining the proximal and distal resection margins, the rectum was transected using a tissue sealing-device. The resected specimen was placed in a retrieval bag and pulled out through the anus. Proximal and distal resection lines were closed using a 60 mm linear endo-stapler, and a totally intracorporeal, side-to-end anastomosis was performed using a 29 mm circular stapler. MAIN RESULTS: The overall operative time was 85 minutes. The estimated blood loss was 10 mL. Neither intra- nor postoperative complications occurred. The patient was discharged 5 days after surgery. The bowel endometriotic nodule measured 41 × 12 × 18 mm on the fresh unfixed specimen. CONCLUSIONS: Advanced surgical skills are needed to perform an effective and safe, totally laparoscopic rectal resection. The operative technique displayed in this video may contribute to the standardization of such surgical procedure. Accurate patient selection, including adequate preoperative evaluation, is of utmost importance for the best chance of surgical success.