Disc Excision using Transanal Circular Stapler for Deep Endometriosis of the Rectum in 10 Steps

OBJECTIVE: Deep endometriosis infiltrating the rectum may be managed by full-thickness disc excision, with the goal of preserving rectal function and avoiding low anterior rectal resection syndrome (Supplemental Appendix 1). Transanal staplers may be successfully used to remove rectal wall discs and concomitantly to perform rectal suture. The goal of this video article is to identify 10 steps that may render the procedure standardized and reproducible. DESIGN: Step-by-step video demonstration of the procedure. SETTING: A French tertiary referral center. INTERVENTIONS: The video presents disc excision of deep endometriosis infiltrating the rectum using a transanal circular stapler, following 10 steps: (1) nodule dissection and rectum releasing; (2) rectal shaving; (3) removal of fat tissue on the lateral rectal wall; (4) placement of a suture on the shaved area; (5) introduction of the closed transanal circular stapler; (6) stapler opening at the nodule's level; (7) knot performing; (8) stapler closing and firing; (9) stitches reinforcing the stapled line; and (10) performing a bubbles test. From 2009 to 2020, the author has performed this procedure in 205 patients: the mean disc diameter was 40 ± 8 mm; microscopic foci were found on the disc edges in 25.7%; and the rectal recurrence rate was 1.5%, whereas the leakage rate was 4.4%. The local institutional review board stated that approval was not required because the video describes a technique and does not report a clinical case. CONCLUSION: Disc excision using a transanal circular stapler following 10 steps is a standardized and reproducible procedure. The learning curve may be short because colorectal surgeons routinely employ the stapler to perform laparoscopic colorectal anastomosis.