Anatomical and Surgical Considerations for Ileocolic Endometriosis

OBJECTIVE: We aim to review the incidence, location, and management of bowel endometriosis and demonstrate relevant surgical principles while emphasizing anatomic considerations for minimally invasive resection of ileocolic lesions. DESIGN: This video briefly reviews the background of bowel endometriosis and indications for surgical excision. We present a case of a patient diagnosed with symptomatic terminal ileum endometriosis and review the preoperative imaging. We demonstrate the steps of a medial-to-lateral surgical approach for ileocolic resection and highlight the relevant surgical anatomy. Institutional review board approval was not required. SETTING: This procedure was performed at a large academic institution with a multidisciplinary team of minimally invasive gynecologic and colorectal surgeons. PATIENTS OR PARTICIPANTS: The case presented is a 44-year-old female with a known history of stage IV endometriosis. She presented with acute abdominal pain and was found to have a small bowel obstruction from a 3-centimeter lesion thought to be an endometrioma. She failed conservative management and was thoroughly counseled about the need for surgical intervention. Pelvic magnetic resonance imaging was performed for preoperative planning. INTERVENTION: Laparoscopic ileocolic resection is performed using a medial-to-lateral approach for excision of a symptomatic 3-centimeter ileocecal endometrioma. The following techniques are highlighted: (1) Evaluation of the entire small bowel starting at the ligament of Treitz (2) Entry into the retroperitoneum below the ileum with cranial and caudal dissection (3) Mobilization of the ascending colon to the level of the falciform ligament (4) Extension of the umbilical incision to perform an extracorporeal ileocecal resection and anastomosis CONCLUSION: The bowel is the most common extragenital site for endometriosis to occur, with the highest rate of lesions located in the rectosigmoid colon [1]. Lesions can be either superficial or deeply infiltrative and can lead to a range of symptoms. A serious sequela of bowel endometriosis includes bowel obstruction requiring surgical intervention.