Primary vaginal anterior rectum resection with laparoscopic anastomosis in a woman suffering from rectal stenosis because of deep-infiltrating endometriosis (DIE)

In deep-infiltrating endometriosis (DIE) advanced surgical techniques, such as laparoscopic-assisted anterior rectum resection and others are recognized as safe and effective therapeutic approaches. For technical reasons in most cases, a laparotomy or minilaparotomy has to be done, which can be avoided in some cases by transvaginal-laparoscopic low anterior rectum resection. In search for additional low invasive approaches, the primary vaginal anterior rectum resection with laparoscopic anastomosis was developed. This technique, we report here in detail, can be characterized as a 2-step-procedure. Step 1 (vaginal): rectovaginal examination, preparation of the rectovaginal septum; opening of the Douglas pouch and the bilateral pararectal spaces; mobilization of the endometriotic nodule and the rectum; caudal (aboral) rectum resection using a endo-GIA; cranial (oral) resection of the lesion; preparation of the oral anvil; final closure of the vagina; Step 2 (laparoscopic): removal of additional endometriotic lesions, adhesiolysis, final mobilization of the rectum (if nessessary); laparoscopic-assisted transanal stapler anastomosis and “under-water-rectoscopy“, prophylaxis of adhesions, drainage. We used this procedure in a 46-year old woman (0 gravida) who was admitted to our hospital for severe lower abdominal pain, obstipation, dyspareunia, and dyschezia due to a palpable rectum stenosis. As a gynaecological N.O.T.E.S. approach, the primary vaginal anterior rectum resection (VARR) with laparoscopic anastomosis might be an additional useful surgical technique which could be offered by surgical gynecologists to some women suffering from DIE.