Ten-Step Approach to Ileocolonic Anastomosis with Natural Orifice Specimen Extraction (NOSE) for Deep Endometriosis

OBJECTIVE: To present a standardized and reproducible ten-step approach to ileocolonic anastomosis with natural orifice specimen extraction (NOSE) in the context of laparoscopic or robotic surgery for deep endometriosis. DESIGN: Surgical video article demonstrating a step-by-step technique. SETTING: Tertiary referral center for advanced minimally invasive surgery for deep endometriosis. INTERVENTIONS: Bowel endometriosis involves rectum and sigmoid in 90% of cases [1,2]. NOSE during these procedures have proven to be safe, better cosmesis, lower risk of incisión complications and faster recovery. [3,4]. Excision of deep endometriosis of the distal ileum or cecum can be performed in 10 successive steps [1]. (1) Cecum Mobilization: The lateral peritoneum is incised along the line of Toldt. (2) Dissection of Ileal Mesentery: The mesentery of the terminal ileum is divided up to the planned transection point. (3) Transection of the Ileum: The ileum is transected with a linear stapler at a disease-free segment (4) Removal of Pericecal and Pericolonic Fat: Fat surrounding the cecum and ascending colon is cleared to improve exposure of the bowel wall and facilitate further dissection. (5) Section of the Cecum: The cecum is transected distal to the lesion using a stapler. (6) Approximation of Ileum and Ascending Colon: The ileum and ascending colon are brought together in an isoperistaltic orientation, aligned without tension. (7) Incision of Ileum and Ascending Colon: Enterotomies are performed on the antimesenteric borders of both segments, adequately sized for stapler insertion. (8) Stapling of the Ileum and Colon: A side-to-side intracorporeal anastomosis is constructed using a linear stapler. (9) Suture of the Bowel Wall: The common enterotomy is closed with absorbable sutures, either continuous or interrupted. (10) Natural Orifice Specimen Extraction (NOSE): The specimen may be extracted transvaginally if a posterior colpotomy or hysterectomy has been performed, or transrectally following segmental rectal resection. CONCLUSION: The ten-step technique presented in this video article provides a standardized method for performing ileocolonic anastomosis with natural orifice specimen extraction in selected cases of deep endometriosis. Dividing the procedure into systematic steps facilitates teaching and improves reproducibility. VIDEO ABSTRACT.