Conservative Management using the Triple Approach and the Rouen Technique in Large Deep Rectovaginal Endometriosis

Background Colorectal resection is performed in numerous patients presenting with large endometriosis of mid and lower rectum; however, it may lead to low anterior rectal resection syndrome. To avoid such outcomes, we propose an original technique combining vaginal excision of infiltrated vaginal cul de sac, laparoscopic deep rectal shaving and transanal disc excision using a semi-circular stapler: the Rouen technique. Methods The video presents the procedure performed in a 31-year-old nullipara referred with a large endometriotic nodule infiltrating the vaginal posterior cul de sac and the anterior wall of the mid rectum on more than 30 mm length responsible for symptomatic stenosis. The first step of the procedure is represented by the excision of vaginal infiltration using a vaginal approach. The second step includes a laparoscopic deep rectal shaving performed using exclusively the plasma energy. Then, transanal excision is performed from rectal approach, by placing traction parachute sutures on the shaved area. Their traction induces the prolapse of shaved rectal wall that is resected using a semi-circular stapler. Results Operative time was 140 min. Immediate postoperative outcomes were uneventful. One year after the surgery, the patient reported one stool/day, without dyskesia, normal anal continence and no deep dsypareunia. To date, the Rouen technique was successfully carried out in 42 women with large deep endometriosis of the mid and lower rectum. Conclusions The Rouen technique is feasible and reproducible in large mid and lower rectal endometriosis and might avoid the risk of unfavourable outcomes related to low colorectal resection.