HYBRID NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY FOR THE TREATMENT OF RECTAL ENDOMETRIOSIS
EAES Online Library. Hamada M. Jan 10, 2012; 20037
Prof. Madoka Hamada
Prof. Madoka Hamada
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Abstract
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Endometriosis involving the large bowel sometimes requires surgical resection in order to relieve the clinical symptoms. Laparoscopic surgery has been considered to be a useful option for the treatment. However, extraction of the surgical specimen requires a large incision. We present our novel technique of low anterior resection using hybrid natural orifice transluminal endoscopic surgery for rectal endometriosis.
The patient was a 37-year-old female who had a history of endometriosis with the complaint of constipation and severe lower abdominal pain in relation to her menstrual cycle. All laboratory data except the serum value of carcinoantigen 125 (49.1 U/ml) were within normal limits. Barium enema showed narrowing of the rectosigmoid colon, and colonoscopy revealed a submucosal tumor of the rectum. T2 weighted MRI images showed thickening of the wall of the rectosigmoid colon and tumor formation at the rectovaginal septum, which were compatible with endometriosis.
Under general anesthesia, the patient was placed in a dorsal lithotomy position. Three 12-mm trocars were introduced into the abdomen (under the umbilicus, rt. upper and lower quadrants) and two 5-mm trocars were also introduced (lt. upper and lower quadrants). We used a vagi-pipe to maintain pneumoperitoneum after the vaginal incision. A careful intra-abdominal inspection revealed two separate rectal endometriosis lesions. The first lesion was at the rectosigmoid colon and second was at the rectovaginal pouch.
After dissection of the mesorectal plane initially at the posterior side, the rectal wall was exposed. Transection of the rectum at the healthy wall was performed with an Echelon-flex 60TM (Ethicon End-Surgery, Cincinnati, OH) between the two lesions in order to make it easier to approach the distal lesion. As the next step, we dissected the distal rectum. Firstly, at the lt. lateral side, secondary anterior side taking care to include the rectovaginal septum with the tumor. After exposing the healthy rectal wall, transection of the rectal wall was performed at the distal side of the second lesion. Using a Vagi-pipe (Hakko CO., LTD, Tokyo, Japan), the anvil of the CDH 29 mm (Ethicon End-Surgery, Cincinnati, OH) was introduced into the abdominal cavity through the vagina. An incision was made at the healthy colon proximal to the first lesion, the length of which was sufficient to introduce the anvil head. Migration of the anvil head was prevented by an Endo-bowel clamp proximal to the incision. After complete introduction of the anvil, transection of the sigmoid colon between the anvil and incised wall was performed with a Echelon Flex 60. After clamping the sigmoid colon, including the anvil, just above the anvil head using the forceps, the tip of the anvil shaft could be detected through the edge of the stapling line. The small incision that was sufficient for extraction of the anvil shaft through the stapler edge was sutured and tied to the anvil shaft.
The resected specimens were retrieved into the EZ purse and removed through the vagina. As the stump of the colon could not reach the rectum, mobilization of the splenic flexor was required. Using CDH 29 mm, the colorectal anastomosis was performed under pneumoperitneum. Finally, the incised vaginal wall was closed with interrupted suturing. Total amount of the blood loss was under 10 ml and duration of the operation was 4 h 54 min. Postoperative course was uneventful. Oral intake was permitted on the 2nd postoperative day. The patient was discharged on the 7th postoperative day. Pathological diagnosis was rectal endometriosis.
The technique of transvaginal extraction of the specimen after laparoscopic surgery has been reported in some papers and which is recently reported as Hybrid NOTES.
However, with these technique, as the anvil head should be introduced into the proximal stump of the colon outside of the body, it is highly depending on the location of the lesion. Our technique enable us to introduce the anvil head in the abdominal cavity and can be adapted in various situation of the rectal lesion. This technique will be available for the minimally invasive surgery of the rectal endometriosis.
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