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Laparoscopic rectal shaving for rectocervical endometriotic nodule
This is the case of a 32-year-old G0P0 woman presenting with severe dysmenorrhea, severe dyspareunia, and constipation. Pelvic examination showed a normal vagina, a fixed uterus, and mobile adnexae. Transvaginal ultrasonography (TvUSG) showed that the uterus and both ovaries were normal. A left parasalpingeal endometrioma (15mm), an obliterated Douglas pouch, as well as rectocervical and infiltrated rectal nodules (18mm and 0.6mm respectively) were also evidenced. Since bilateral ovaries were fixed to the pelvic sidewall, the operative strategy included bilateral ureterolysis and dissection of the hypogastric nerve and the pararectal fossa. Finally, the rectocervical nodule was mobilized by performing cervical and rectal shaving. The rectum was controlled by means of a methylene blue test. The final pathology was endometriosis.
H Altuntaş
Surgical intervention
1 year ago
5742 views
490 likes
0 comments
06:58
Laparoscopic rectal shaving for rectocervical endometriotic nodule
This is the case of a 32-year-old G0P0 woman presenting with severe dysmenorrhea, severe dyspareunia, and constipation. Pelvic examination showed a normal vagina, a fixed uterus, and mobile adnexae. Transvaginal ultrasonography (TvUSG) showed that the uterus and both ovaries were normal. A left parasalpingeal endometrioma (15mm), an obliterated Douglas pouch, as well as rectocervical and infiltrated rectal nodules (18mm and 0.6mm respectively) were also evidenced. Since bilateral ovaries were fixed to the pelvic sidewall, the operative strategy included bilateral ureterolysis and dissection of the hypogastric nerve and the pararectal fossa. Finally, the rectocervical nodule was mobilized by performing cervical and rectal shaving. The rectum was controlled by means of a methylene blue test. The final pathology was endometriosis.
Colorectal resection in deep endometriosis: multidisciplinary laparoscopic approach (colorectal and gynecologic surgical teams)
In this video, we present the clinical case of a 42-year-old woman with deep pelvic endometriosis with rectal infiltration. After hormone therapy, the patient was operated on due to chronic pain. A laparoscopic approach was performed by a multidisciplinary team including colorectal and gynecologic surgeons having a wide experience in this field.
A CT-scan, MRI, and colonoscopy were performed before the surgery showing a deep infiltrating endometriosis with anterior rectal bowel involvement in the images and normal colorectal mucosa in the endoscopy.
Under general anesthesia, the laparoscopic approach was performed with 4 trocars. Deep infiltrating endometriosis (DIE) required a hysterectomy and rectal resection to clean all the pelvic space. An end-to-end colorectal anastomosis was performed and the extraction of the specimen (uterus and rectum) was carried out transvaginally. The patient was discharged on postoperative day 4 without complications.
JF Noguera, MD, PhD, J Gilabert-Estelles, J Aguirrezabalaga, B López, J Dolz
Surgical intervention
2 years ago
3213 views
304 likes
1 comment
09:55
Colorectal resection in deep endometriosis: multidisciplinary laparoscopic approach (colorectal and gynecologic surgical teams)
In this video, we present the clinical case of a 42-year-old woman with deep pelvic endometriosis with rectal infiltration. After hormone therapy, the patient was operated on due to chronic pain. A laparoscopic approach was performed by a multidisciplinary team including colorectal and gynecologic surgeons having a wide experience in this field.
A CT-scan, MRI, and colonoscopy were performed before the surgery showing a deep infiltrating endometriosis with anterior rectal bowel involvement in the images and normal colorectal mucosa in the endoscopy.
Under general anesthesia, the laparoscopic approach was performed with 4 trocars. Deep infiltrating endometriosis (DIE) required a hysterectomy and rectal resection to clean all the pelvic space. An end-to-end colorectal anastomosis was performed and the extraction of the specimen (uterus and rectum) was carried out transvaginally. The patient was discharged on postoperative day 4 without complications.
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
A Wattiez, R Nasir, I Argay
Surgical intervention
2 years ago
5445 views
314 likes
1 comment
42:42
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
Severe complex endometriosis with ascites: laparoscopic management
Frozen pelvis due to endometriosis is one of the most complex and risky situations which surgeons sometimes face. Its laparoscopic management requires a systematic approach, a good anatomical knowledge and a high level of surgical competency. This is a frozen pelvis case secondary to a complicated severe endometriosis in a young nulliparous lady. She had hemorrhagic abdominal ascites secondary to endometriosis, with a sub-occlusive syndrome. Her disease was further complicated with upper abdominal and pelvic fibrosis with a large umbilical endometriotic nodule as well as splenic, omental and sigmoid endometriosis. This video demonstrates the strategy of the laparoscopic management of this condition.
A Wattiez, R Nasir, A Host
Surgical intervention
3 years ago
4070 views
162 likes
0 comments
31:22
Severe complex endometriosis with ascites: laparoscopic management
Frozen pelvis due to endometriosis is one of the most complex and risky situations which surgeons sometimes face. Its laparoscopic management requires a systematic approach, a good anatomical knowledge and a high level of surgical competency. This is a frozen pelvis case secondary to a complicated severe endometriosis in a young nulliparous lady. She had hemorrhagic abdominal ascites secondary to endometriosis, with a sub-occlusive syndrome. Her disease was further complicated with upper abdominal and pelvic fibrosis with a large umbilical endometriotic nodule as well as splenic, omental and sigmoid endometriosis. This video demonstrates the strategy of the laparoscopic management of this condition.
Laparoscopic treatment of bilateral endometriotic cysts
The different surgical approaches to ovarian endometriosis are the following: ovarian cystectomy, endometrioma fenestration and removal, or a technique combining cystectomy and removal.
In order to perform a cystectomy without damaging the ovary, different steps must be followed, including adhesiolysis between the ovary and the broad ligament, cyst opening at the site of eversion and adhesion. Traction and counter-traction allow to separate the cyst’s wall from the ovarian cortex. As the endometrioma is surrounded by a fibrotic capsule, there is a risk of removing normal ovarian tissue and ovocytes. Blood vessels must be identified and selective coagulation must be performed to prevent destruction of the normal ovarian tissue.
Endometrioma fenestration and removal can be performed with different sources of energy such as bipolar coagulation, carbon dioxide laser and plasma energy. Depending on the size of the endometrioma, the removal technique can be performed in one or three steps. But to avoid 2 laparoscopic procedures, a combined technique of excision and removal of the endometrioma could be offered in cases of large cysts.
Medical treatment is administered preoperatively only in cases of pelvic pain and postoperatively in cases of pelvic pain and if there is no desire for pregnancy.
According to a recent systematic review and meta-analysis, the ovarian reserve, evaluated by the AMH level, is affected by surgery, and even more in cases of bilateral cysts.

To conclude, ovarian endometrioma surgery requires a learning curve to prevent ovarian damage, which can be caused by normal ovarian tissue removal or by a strong coagulation. Repetitive surgery has to be clearly evaluated as it is also responsible for ovarian reserve decrease.
M Nisolle
Lecture
4 years ago
2601 views
96 likes
0 comments
19:00
Laparoscopic treatment of bilateral endometriotic cysts
The different surgical approaches to ovarian endometriosis are the following: ovarian cystectomy, endometrioma fenestration and removal, or a technique combining cystectomy and removal.
In order to perform a cystectomy without damaging the ovary, different steps must be followed, including adhesiolysis between the ovary and the broad ligament, cyst opening at the site of eversion and adhesion. Traction and counter-traction allow to separate the cyst’s wall from the ovarian cortex. As the endometrioma is surrounded by a fibrotic capsule, there is a risk of removing normal ovarian tissue and ovocytes. Blood vessels must be identified and selective coagulation must be performed to prevent destruction of the normal ovarian tissue.
Endometrioma fenestration and removal can be performed with different sources of energy such as bipolar coagulation, carbon dioxide laser and plasma energy. Depending on the size of the endometrioma, the removal technique can be performed in one or three steps. But to avoid 2 laparoscopic procedures, a combined technique of excision and removal of the endometrioma could be offered in cases of large cysts.
Medical treatment is administered preoperatively only in cases of pelvic pain and postoperatively in cases of pelvic pain and if there is no desire for pregnancy.
According to a recent systematic review and meta-analysis, the ovarian reserve, evaluated by the AMH level, is affected by surgery, and even more in cases of bilateral cysts.

To conclude, ovarian endometrioma surgery requires a learning curve to prevent ovarian damage, which can be caused by normal ovarian tissue removal or by a strong coagulation. Repetitive surgery has to be clearly evaluated as it is also responsible for ovarian reserve decrease.
DIE and laparoscopic treatment
Hormone therapy was designed to suppress estrogen synthesis and to reduce the size of ectopic endometrial implants. However, the recurrence of pain after cessation is estimated at 50% and indicates that surgery is required for symptomatic patients.
Conservative surgery is effective in terms of pain reduction if complete excision is obtained, and consequently a preoperative assessment is mandatory to put forward a multidisciplinary approach in specialized centers.
In cases of excision of the nodular lesion by means of mucosal skinning, the resection of uterosacral ligaments and of the posterior vaginal fornix is usually recommended. A comparison between standard and reverse laparoscopic techniques demonstrated a statistically significant lower rate of major postoperative complications by using the reverse technique.
Bowel endometriosis requires bowel resection if the size is estimated to exceed 3cm, to affect 50% of the bowel's diameter or to induce a stenosis. Different techniques could be proposed such as a segmental bowel resection, a discoid resection or a stapled resection.
Concerning the rate of complications, it has been published that mucosal skinning is associated with fewer complications than segmental resection.
Recently, robotic assisted laparoscopy was used for the treatment of advanced stage endometriosis; however, it is associated with an increased operative time and a longer hospital stay.

To conclude, a skilled surgical team is necessary to perform the complete removal of lesions without increasing the risk of complications and to obtain good results in terms of pelvic pain and fertility.
M Nisolle
Lecture
4 years ago
1862 views
78 likes
0 comments
23:49
DIE and laparoscopic treatment
Hormone therapy was designed to suppress estrogen synthesis and to reduce the size of ectopic endometrial implants. However, the recurrence of pain after cessation is estimated at 50% and indicates that surgery is required for symptomatic patients.
Conservative surgery is effective in terms of pain reduction if complete excision is obtained, and consequently a preoperative assessment is mandatory to put forward a multidisciplinary approach in specialized centers.
In cases of excision of the nodular lesion by means of mucosal skinning, the resection of uterosacral ligaments and of the posterior vaginal fornix is usually recommended. A comparison between standard and reverse laparoscopic techniques demonstrated a statistically significant lower rate of major postoperative complications by using the reverse technique.
Bowel endometriosis requires bowel resection if the size is estimated to exceed 3cm, to affect 50% of the bowel's diameter or to induce a stenosis. Different techniques could be proposed such as a segmental bowel resection, a discoid resection or a stapled resection.
Concerning the rate of complications, it has been published that mucosal skinning is associated with fewer complications than segmental resection.
Recently, robotic assisted laparoscopy was used for the treatment of advanced stage endometriosis; however, it is associated with an increased operative time and a longer hospital stay.

To conclude, a skilled surgical team is necessary to perform the complete removal of lesions without increasing the risk of complications and to obtain good results in terms of pelvic pain and fertility.
Management of a severe bleeding during laparoscopy for recurrent rectovaginal endometriosis
This case demonstrates the potential danger of a repetitive surgery after an incomplete resection of rectovaginal endometriosis. A severe bleeding occurred during the dissection of the recurrent nodule. It was managed through multiple coagulations, which could only be performed safely and effectively because important landmarks had been identified and retracted prior to resecting the nodule. A key point in the surgery was also circumventing the nodule in order to pass in sano as the bleeding came from vessels entrapped in fibrosis and scarring tissue which could not be effectively coagulated.
A Wattiez, R Murtada, G Centini, R Fernandes, K Afors, C Meza Paul, J Castellano
Surgical intervention
5 years ago
3250 views
60 likes
0 comments
08:06
Management of a severe bleeding during laparoscopy for recurrent rectovaginal endometriosis
This case demonstrates the potential danger of a repetitive surgery after an incomplete resection of rectovaginal endometriosis. A severe bleeding occurred during the dissection of the recurrent nodule. It was managed through multiple coagulations, which could only be performed safely and effectively because important landmarks had been identified and retracted prior to resecting the nodule. A key point in the surgery was also circumventing the nodule in order to pass in sano as the bleeding came from vessels entrapped in fibrosis and scarring tissue which could not be effectively coagulated.
Laparoscopic ileocaecal and sigmoid resection with transanal natural orifice specimen extraction (NOSE) for endometriosis
In 12 to 30% of endometriosis cases, the disease is located in the bowel. Caecum and small bowel endometriosis are found in only 3.6% and 7% respectively of those cases while the sigmoid colon and the rectum are most commonly affected in 85% of cases. The laparoscopic management of this disease has evolved drastically over the last decade, and even delicate cases such as small bowel endometriosis can be completely managed by laparoscopy. It is key to be locally invasive towards the disease but conservative with regards to organ function preservation. The specimen will be extracted through natural orifices and without any ileostomy. Our patients are commonly young and healthy women who will certainly benefit from a tailored surgery with immediate symptom relief in addition to minimum abdominal scarring can have a significant positive impact on patient’s psychological well-being and subsequent recovery.
In the present case, we present a 36-year old woman who was diagnosed with endometriosis and presented with 3 episodes of bowel pseudo-obstruction and dyschezia, and put under medical treatment. She was found to have multiple endometriotic nodules, with concurrent ileocaecal and rectosigmoid disease, for which a double bowel resection with transanal natural orifice specimen extraction (NOSE) was performed without complications.
A Wattiez, J Leroy, C Meza Paul, K Afors, J Castellano, G Centini, R Fernandes, R Murtada
Surgical intervention
5 years ago
1941 views
46 likes
0 comments
38:15
Laparoscopic ileocaecal and sigmoid resection with transanal natural orifice specimen extraction (NOSE) for endometriosis
In 12 to 30% of endometriosis cases, the disease is located in the bowel. Caecum and small bowel endometriosis are found in only 3.6% and 7% respectively of those cases while the sigmoid colon and the rectum are most commonly affected in 85% of cases. The laparoscopic management of this disease has evolved drastically over the last decade, and even delicate cases such as small bowel endometriosis can be completely managed by laparoscopy. It is key to be locally invasive towards the disease but conservative with regards to organ function preservation. The specimen will be extracted through natural orifices and without any ileostomy. Our patients are commonly young and healthy women who will certainly benefit from a tailored surgery with immediate symptom relief in addition to minimum abdominal scarring can have a significant positive impact on patient’s psychological well-being and subsequent recovery.
In the present case, we present a 36-year old woman who was diagnosed with endometriosis and presented with 3 episodes of bowel pseudo-obstruction and dyschezia, and put under medical treatment. She was found to have multiple endometriotic nodules, with concurrent ileocaecal and rectosigmoid disease, for which a double bowel resection with transanal natural orifice specimen extraction (NOSE) was performed without complications.
Laparoscopic treatment of a deep endometriotic nodule in the ischiatic tuberosity
In this challenging surgery performed by Professor Arnaud Wattiez, we present the case of a 39-year-old woman suffering from deep infiltrating endometriosis and infertility with no previous surgeries. The patient presented with chronic pelvic pain, dyschezia, and dyspareunia. Preoperative workup included MRI and rectosigmoidoscopy. MRI revealed a nodule at the level of the right uterosacral ligament. Rectosigmoidoscopy revealed a bulging of the anterior rectal wall located at 6cm from the anal verge where biopsy revealed fibrosis. The patient’s physical examination demonstrated the presence of a retrouterine nodule at the site of the right uterosacral ligament measuring 3cm.
A Wattiez, R Fernandes, M Puga, J Alves, C Redondo Guisasola
Surgical intervention
6 years ago
2047 views
35 likes
0 comments
03:00
Laparoscopic treatment of a deep endometriotic nodule in the ischiatic tuberosity
In this challenging surgery performed by Professor Arnaud Wattiez, we present the case of a 39-year-old woman suffering from deep infiltrating endometriosis and infertility with no previous surgeries. The patient presented with chronic pelvic pain, dyschezia, and dyspareunia. Preoperative workup included MRI and rectosigmoidoscopy. MRI revealed a nodule at the level of the right uterosacral ligament. Rectosigmoidoscopy revealed a bulging of the anterior rectal wall located at 6cm from the anal verge where biopsy revealed fibrosis. The patient’s physical examination demonstrated the presence of a retrouterine nodule at the site of the right uterosacral ligament measuring 3cm.
Laparoscopic segmental resection in a patient with deep infiltrating endometriosis
We present the case of a 33-year-old-woman suffering from deep infiltrating endometriosis. In her previous history, three laparoscopies had been performed due to endometriosis. In the first two laparoscopies, bilateral ovarian cystectomies had been carried out while the third laparoscopy had been indicated to puncture the ovaries after hormonal stimulation for in vitro fertilization (IVF), due to the impossibility of reaching follicles transvaginally.
The patient presented with dysmenorrhea, dyspareunia and dyschezia, as well as rectorrhagia and diarrhea. The patient’s physical examination demonstrated the presence of a retrouterine mass suggestive of adhesions. Preoperative work-up included MRI and colonoscopy. MRI showed an endometriotic nodule affecting the rectosigmoid junction and infiltrating its wall. A colonoscopy was performed and allowed to visualize the endometriotic nodule.
A Wattiez, C Redondo Guisasola, M Puga, J Alves, R Fernandes
Surgical intervention
6 years ago
2678 views
31 likes
0 comments
18:50
Laparoscopic segmental resection in a patient with deep infiltrating endometriosis
We present the case of a 33-year-old-woman suffering from deep infiltrating endometriosis. In her previous history, three laparoscopies had been performed due to endometriosis. In the first two laparoscopies, bilateral ovarian cystectomies had been carried out while the third laparoscopy had been indicated to puncture the ovaries after hormonal stimulation for in vitro fertilization (IVF), due to the impossibility of reaching follicles transvaginally.
The patient presented with dysmenorrhea, dyspareunia and dyschezia, as well as rectorrhagia and diarrhea. The patient’s physical examination demonstrated the presence of a retrouterine mass suggestive of adhesions. Preoperative work-up included MRI and colonoscopy. MRI showed an endometriotic nodule affecting the rectosigmoid junction and infiltrating its wall. A colonoscopy was performed and allowed to visualize the endometriotic nodule.