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Mucosal skinning for bowel endometriosis: standard technique
Bowel endometriosis is described in 3% to 37% of patients with endometriosis. In 90% of these cases, the rectum, the sigmoid colon or both are involved. It is the most severe form of the disease and its surgical management is complex. Surgery is very challenging and the degree of radical excision should always be counterbalanced with the risk of complications and functional disorders. Four types of surgery can be chosen: superficial excision or shaving, mucosal skinning, discoid excision, and segmental bowel resection. We believe that bowel resection can be avoided in some cases if mucosal skinning is first attempted. This video shows 2 endometriotic lesions of the rectosigmoid junction that were treated by mucosal skinning, hence avoiding an unnecessary segmental resection. The final result was satisfactory and postoperative outcome was uneventful. In 2008, the patient underwent a laparoscopic intervention, which revealed the presence of a deep infiltrating endometriosis and bilateral endometriotic cysts. Bilateral ovarian cystectomy was performed. Postoperative MRI for pelvic pains revealed a persistent lesion of the recto-vaginal septum. The patient then presented with persistent dysmenorrhea (8/10), chronic pelvic pain (8/10), dyschezia (6/10) without dyspareunia or bladder-related symptoms. Clinical examination showed a mobile anteverted uterus without clear evidence of a nodule lesion at the rectovaginal septum neither was it at the level of uterosacral ligaments, but most probably the presence of adhesions between the uterus and the rectosigmoid junction. Despite treatment with GnRH agonist, the patient was referred to the emergency department several times for bouts of intense pain.
A Wattiez, E Faller, J Albornoz, P Messori, T Boisramé
Surgical intervention
7 years ago
1517 views
75 likes
0 comments
11:40
Mucosal skinning for bowel endometriosis: standard technique
Bowel endometriosis is described in 3% to 37% of patients with endometriosis. In 90% of these cases, the rectum, the sigmoid colon or both are involved. It is the most severe form of the disease and its surgical management is complex. Surgery is very challenging and the degree of radical excision should always be counterbalanced with the risk of complications and functional disorders. Four types of surgery can be chosen: superficial excision or shaving, mucosal skinning, discoid excision, and segmental bowel resection. We believe that bowel resection can be avoided in some cases if mucosal skinning is first attempted. This video shows 2 endometriotic lesions of the rectosigmoid junction that were treated by mucosal skinning, hence avoiding an unnecessary segmental resection. The final result was satisfactory and postoperative outcome was uneventful. In 2008, the patient underwent a laparoscopic intervention, which revealed the presence of a deep infiltrating endometriosis and bilateral endometriotic cysts. Bilateral ovarian cystectomy was performed. Postoperative MRI for pelvic pains revealed a persistent lesion of the recto-vaginal septum. The patient then presented with persistent dysmenorrhea (8/10), chronic pelvic pain (8/10), dyschezia (6/10) without dyspareunia or bladder-related symptoms. Clinical examination showed a mobile anteverted uterus without clear evidence of a nodule lesion at the rectovaginal septum neither was it at the level of uterosacral ligaments, but most probably the presence of adhesions between the uterus and the rectosigmoid junction. Despite treatment with GnRH agonist, the patient was referred to the emergency department several times for bouts of intense pain.
Ureteral endometriosis: general outcomes, our experience
This lecture presents ureteral endometriosis, which is a rare pathology (0.1% of cases). In 50% of cases, the condition is asymptomatic and can lead to loss of renal functions. In the literature, ureteral endometriosis increases with the presence of rectovaginal endometriosis, which does not appear in the study presented (221 cases of endometriosis, 19.5% of which are ureteral tract endometriosis). It seems to be significantly associated with uterosacral ligament (USL) endometriosis (p=0.01) but not with bladder endometriosis. Medical treatment is not indicated and conservative laparoscopic surgical management shows a long-term relief of symptoms and a low rate of anatomical recurrence (0-11%).
B Gabriel
Lecture
7 years ago
528 views
6 likes
0 comments
14:29
Ureteral endometriosis: general outcomes, our experience
This lecture presents ureteral endometriosis, which is a rare pathology (0.1% of cases). In 50% of cases, the condition is asymptomatic and can lead to loss of renal functions. In the literature, ureteral endometriosis increases with the presence of rectovaginal endometriosis, which does not appear in the study presented (221 cases of endometriosis, 19.5% of which are ureteral tract endometriosis). It seems to be significantly associated with uterosacral ligament (USL) endometriosis (p=0.01) but not with bladder endometriosis. Medical treatment is not indicated and conservative laparoscopic surgical management shows a long-term relief of symptoms and a low rate of anatomical recurrence (0-11%).
Laparoscopic management of endometriosis
This lecture reviews the surgical treatment of endometriosis from an evidence-based perspective focusing on outcomes such as pain and infertility in order to provide practical guidelines and recommendations.
The main endometriotic symptoms are pelvic pain (dysmenorrhea and dyspareunia) and infertility. Randomized controlled trials provide evidence that it is better to perform laparoscopy in patients with pain as compared to a wait and see approach. Regarding fertility, laparoscopic ablation or resection of lesions in minimal and mild endometriosis is significantly better than diagnostic laparoscopy alone. Laparoscopic uterosacral nerve ablation (LUNA) is not effective for relief of pain symptoms, but presacral neurectomy might be useful. In contrast, conservative surgery for rectovaginal septum endometriosis is beneficial for pain improvement, quality of life and sexual life, but do not improve fertility. Regarding radical surgery and bowel resection in endometriosis, there is a clear benefit in terms of pain improvement, but not on fertility. Regarding endometrial cyst treatment, excision is better than drainage in terms of risk of relapse, and the use of anti-adhesion barriers (Interceed®) have demonstrated a decreased risk of adhesion formation after endometriosis surgery.
Keys for surgical treatment of endometriosis should be identification of the disease, restoration of normal anatomy, excision of endometriosis, and finally reconstruction.
RP Pasic
Lecture
7 years ago
2040 views
28 likes
0 comments
44:23
Laparoscopic management of endometriosis
This lecture reviews the surgical treatment of endometriosis from an evidence-based perspective focusing on outcomes such as pain and infertility in order to provide practical guidelines and recommendations.
The main endometriotic symptoms are pelvic pain (dysmenorrhea and dyspareunia) and infertility. Randomized controlled trials provide evidence that it is better to perform laparoscopy in patients with pain as compared to a wait and see approach. Regarding fertility, laparoscopic ablation or resection of lesions in minimal and mild endometriosis is significantly better than diagnostic laparoscopy alone. Laparoscopic uterosacral nerve ablation (LUNA) is not effective for relief of pain symptoms, but presacral neurectomy might be useful. In contrast, conservative surgery for rectovaginal septum endometriosis is beneficial for pain improvement, quality of life and sexual life, but do not improve fertility. Regarding radical surgery and bowel resection in endometriosis, there is a clear benefit in terms of pain improvement, but not on fertility. Regarding endometrial cyst treatment, excision is better than drainage in terms of risk of relapse, and the use of anti-adhesion barriers (Interceed®) have demonstrated a decreased risk of adhesion formation after endometriosis surgery.
Keys for surgical treatment of endometriosis should be identification of the disease, restoration of normal anatomy, excision of endometriosis, and finally reconstruction.
Urinary complications during deep endometriosis surgery
During deep endometriosis surgery, bladder and ureter lesions are the most frequent complications.
Bladder lesions. The cystoscopy must be first carried out to assess the location of the endometriosis. If the nodule is close to the ureter, a stent is needed. To prevent lesion to the intramural part of the ureter, it is advisable to enter the bladder at its upper part. To minimize complications, an adequate surgical technique is necessary, a catheter must be placed for 1 to 3 weeks, a large catheter must be placed to drain clots, and control cystoscopy must be achieved before catheter removal. Intraoperative bladder lesions are never a major problem since the bladder wall heals well. Late complications are as follows: vesicovaginal fistula, rare but more frequent after hysterectomy, and the clinical sign is continuous leakage from the vagina, and the treatment is laparoscopy immediately or 50 days after surgery (with, in the last case, treatment with antibiotics until laparoscopic treatment begins). In addition, urinary retention is another late complication, more frequent, especially after resection of large nodules with lateral extension; it is due to parasympathetic nerve injury. Nerve-sparing prevention in endometriosis is not possible; the important thing is not to resect bilaterally. If injury is monolateral, it heals spontaneously in 3 months, rarely longer than 6-12 months.
Ureteral lesions. They occur mainly in cases of hydronephrosis or nodules bigger than 3 centimeters. In case of hydronephrosis, it is necessary to stent the patient before surgery; in all cases, especially when dealing with a nodule, the ureter should be isolated. After surgery a control cystoscopy must be carried out if the ureter works properly. It is important to monitor drain volume and CRP daily. CRP increases on the second day, and decreases on the third day. If CRP increases again, it means there is a complication (infection, ureteral lesion, leakage from rectum). Treatment is immediate laparoscopy with stitch and stent. Another complication is urinoma; symptoms are pain, diarrhea and high temperature. In these cases laparoscopy should be repeated. In case of ureterovaginal fistula, the leakage is intermittent. It usually becomes evident after 1 to 3 weeks. The diagnosis is made by intravenous pyelogram (IVP); treatment is carried out through laparoscopy. In case of unrecognized ureteral transection, there is a late ureteral leak (even after 25 days); ureteral re-anastomosis is the first-line treatment.
A Ussia
Lecture
7 years ago
929 views
18 likes
0 comments
17:28
Urinary complications during deep endometriosis surgery
During deep endometriosis surgery, bladder and ureter lesions are the most frequent complications.
Bladder lesions. The cystoscopy must be first carried out to assess the location of the endometriosis. If the nodule is close to the ureter, a stent is needed. To prevent lesion to the intramural part of the ureter, it is advisable to enter the bladder at its upper part. To minimize complications, an adequate surgical technique is necessary, a catheter must be placed for 1 to 3 weeks, a large catheter must be placed to drain clots, and control cystoscopy must be achieved before catheter removal. Intraoperative bladder lesions are never a major problem since the bladder wall heals well. Late complications are as follows: vesicovaginal fistula, rare but more frequent after hysterectomy, and the clinical sign is continuous leakage from the vagina, and the treatment is laparoscopy immediately or 50 days after surgery (with, in the last case, treatment with antibiotics until laparoscopic treatment begins). In addition, urinary retention is another late complication, more frequent, especially after resection of large nodules with lateral extension; it is due to parasympathetic nerve injury. Nerve-sparing prevention in endometriosis is not possible; the important thing is not to resect bilaterally. If injury is monolateral, it heals spontaneously in 3 months, rarely longer than 6-12 months.
Ureteral lesions. They occur mainly in cases of hydronephrosis or nodules bigger than 3 centimeters. In case of hydronephrosis, it is necessary to stent the patient before surgery; in all cases, especially when dealing with a nodule, the ureter should be isolated. After surgery a control cystoscopy must be carried out if the ureter works properly. It is important to monitor drain volume and CRP daily. CRP increases on the second day, and decreases on the third day. If CRP increases again, it means there is a complication (infection, ureteral lesion, leakage from rectum). Treatment is immediate laparoscopy with stitch and stent. Another complication is urinoma; symptoms are pain, diarrhea and high temperature. In these cases laparoscopy should be repeated. In case of ureterovaginal fistula, the leakage is intermittent. It usually becomes evident after 1 to 3 weeks. The diagnosis is made by intravenous pyelogram (IVP); treatment is carried out through laparoscopy. In case of unrecognized ureteral transection, there is a late ureteral leak (even after 25 days); ureteral re-anastomosis is the first-line treatment.
Laparoscopic rectovaginal resection for endometriosis: transvaginal specimen extraction and anastomosis
The authors demonstrate a rectovaginal resection technique for invasive endometriosis. The original nature of this approach hinges on the mesorectum dissection technique in contact with the rectal wall in order to preserve rectal vascularization and innervation. Additionally, rectal exteriorization through the vagina to prepare for the colorectal anastomosis using a mechanical circular stapling without any abdominal incision is truly original as it contributes to limiting parietal trauma and improving cosmesis. The film truly focuses on the digestive approach just after anterior pelvic dissection has been completed by the team of gynecologic surgeons.
J Leroy, CY Akladios, V Thoma, A Wattiez, J Marescaux
Surgical intervention
7 years ago
1392 views
23 likes
0 comments
21:33
Laparoscopic rectovaginal resection for endometriosis: transvaginal specimen extraction and anastomosis
The authors demonstrate a rectovaginal resection technique for invasive endometriosis. The original nature of this approach hinges on the mesorectum dissection technique in contact with the rectal wall in order to preserve rectal vascularization and innervation. Additionally, rectal exteriorization through the vagina to prepare for the colorectal anastomosis using a mechanical circular stapling without any abdominal incision is truly original as it contributes to limiting parietal trauma and improving cosmesis. The film truly focuses on the digestive approach just after anterior pelvic dissection has been completed by the team of gynecologic surgeons.
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
5450 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.
Laparoscopic partial cystectomy for big bladder endometriosis nodule
Bladder endometriosis is the most common presentation of urinary tract endometriosis and is frequently associated with specific symptoms such as dysuria, hematuria and recurrent urinary tract infections. Although it may be associated with ureteral endometriosis in severe cases, in most cases, it presents as an isolated disease.
The laparoscopic approach for bladder endometriosis nodule excision requires careful dissection of the paravesical spaces and identification of both ureters entering each ureteral tunnel. The shaving technique until healthy tissue is reached should be attempted, but if mucosal invasion is found, complete wall excision should be performed. In some occasions, when the nodule invades the bladder trigone, a double-J catheter may be inserted and left in place for 6 to 8 weeks.
In this video, we present the case of a 23-year-old woman complaining with significant dysuria associated with hematuria, dysmenorrhea, dyspareunia, and chronic pelvic pain. Magnetic resonance imaging described a 5cm nodule located in the bladder dome, and cystoscopy confirmed the diagnosis. The patient was referred to our Endometriosis Centre after diagnostic laparoscopy.
A Wattiez, J Albornoz, M Puga, E Faller
Surgical intervention
7 years ago
1823 views
24 likes
0 comments
32:41
Laparoscopic partial cystectomy for big bladder endometriosis nodule
Bladder endometriosis is the most common presentation of urinary tract endometriosis and is frequently associated with specific symptoms such as dysuria, hematuria and recurrent urinary tract infections. Although it may be associated with ureteral endometriosis in severe cases, in most cases, it presents as an isolated disease.
The laparoscopic approach for bladder endometriosis nodule excision requires careful dissection of the paravesical spaces and identification of both ureters entering each ureteral tunnel. The shaving technique until healthy tissue is reached should be attempted, but if mucosal invasion is found, complete wall excision should be performed. In some occasions, when the nodule invades the bladder trigone, a double-J catheter may be inserted and left in place for 6 to 8 weeks.
In this video, we present the case of a 23-year-old woman complaining with significant dysuria associated with hematuria, dysmenorrhea, dyspareunia, and chronic pelvic pain. Magnetic resonance imaging described a 5cm nodule located in the bladder dome, and cystoscopy confirmed the diagnosis. The patient was referred to our Endometriosis Centre after diagnostic laparoscopy.
Radical excision or bowel resection for deep endometriosis
In this key lecture, the author focuses on bowel endometriosis. This disease is often multifocal and there are 8% of resection margins which are not free despite segmental resection. Although bowel resection is widely performed, indications are poorly documented regarding nodule size or localization. Segmental resection at the level of the rectum is associated with bowel, bladder, and sexual complications as found in other conditions (such as cancer). The author insists on the need to first perform a discoid resection except if the size of the lesion takes up more than 50% of the wall area and exceeds 2-3cm. For this procedure, it is recommended that the operation be carried out by pelvic surgeons with perfect expertise in endometriosis.
P Koninckx
Lecture
7 years ago
1355 views
8 likes
0 comments
21:48
Radical excision or bowel resection for deep endometriosis
In this key lecture, the author focuses on bowel endometriosis. This disease is often multifocal and there are 8% of resection margins which are not free despite segmental resection. Although bowel resection is widely performed, indications are poorly documented regarding nodule size or localization. Segmental resection at the level of the rectum is associated with bowel, bladder, and sexual complications as found in other conditions (such as cancer). The author insists on the need to first perform a discoid resection except if the size of the lesion takes up more than 50% of the wall area and exceeds 2-3cm. For this procedure, it is recommended that the operation be carried out by pelvic surgeons with perfect expertise in endometriosis.
Laparoscopic excision of bladder endometriosis
This is the case of a 34-year-old woman, G1P0010, with a long standing history of chronic pelvic and bladder pain occurring on a monthly basis. The patient has had laparoscopic diagnosis of endometriosis in the past with no resection performed at that time. Given cyclic bladder pain, the patient also underwent cystoscopy, which revealed an implant of bladder endometriosis measuring approximately 2cm in diameter. She has failed medical therapy including oral contraceptives and Lupron from several months. Given her continued bladder pain and severe dysmenorrhea and dyspareunia for the last 5 years, the decision was made to proceed with a surgical intervention.
Operating room specificities:
The patient was positioned in the dorsal lithotomy position with arms tucked bilaterally.
A 12mm port was placed within the umbilicus for the laparoscope. A 5mm port was placed in the left lower quadrant about 2cm superior to the left anterior superior iliac spine. Another 5mm port was placed in the right upper quadrant about 8cm lateral and 2cm inferior to the umbilical port. A final 12mm port was placed in the right lower quadrant, about 2cm superior to the right anterior superior iliac spine. A 7cm clear view uterine manipulator was used.
The primary surgeon was positioned on the left side of the patient. The main surgical assistant, the resident, was positioned on the right side of the patient. The secondary surgical assistant, the fellow, was positioned between the patient’s legs.
M Milad, L Griffin, I Moy, S Bulun
Surgical intervention
7 years ago
2031 views
23 likes
0 comments
03:59
Laparoscopic excision of bladder endometriosis
This is the case of a 34-year-old woman, G1P0010, with a long standing history of chronic pelvic and bladder pain occurring on a monthly basis. The patient has had laparoscopic diagnosis of endometriosis in the past with no resection performed at that time. Given cyclic bladder pain, the patient also underwent cystoscopy, which revealed an implant of bladder endometriosis measuring approximately 2cm in diameter. She has failed medical therapy including oral contraceptives and Lupron from several months. Given her continued bladder pain and severe dysmenorrhea and dyspareunia for the last 5 years, the decision was made to proceed with a surgical intervention.
Operating room specificities:
The patient was positioned in the dorsal lithotomy position with arms tucked bilaterally.
A 12mm port was placed within the umbilicus for the laparoscope. A 5mm port was placed in the left lower quadrant about 2cm superior to the left anterior superior iliac spine. Another 5mm port was placed in the right upper quadrant about 8cm lateral and 2cm inferior to the umbilical port. A final 12mm port was placed in the right lower quadrant, about 2cm superior to the right anterior superior iliac spine. A 7cm clear view uterine manipulator was used.
The primary surgeon was positioned on the left side of the patient. The main surgical assistant, the resident, was positioned on the right side of the patient. The secondary surgical assistant, the fellow, was positioned between the patient’s legs.
Complications of endometriosis surgery
This lecture focuses on complications in laparoscopic surgery for endometriosis. First, the expert addresses how to define complications. Surgeons sometimes need to remove part of the adjacent structures such as bowel, vagina and ureter, which should be included in the surgery – to achieve a complete excision of the disease. Complications can always occur and the most important thing to be borne in mind is to know how to deal with them by laparoscopy.
Complications may include adhesions, bowel, ureter and vascular injuries. The rate of complications in rectal shaving ranges from 0.2 to 1.4%. In case of discoid bowel resection, the morbidity rate published in the literature is 13%. Regarding rectal segmental resection, the rate of complications in laparoscopy (4.25%) is similar to that of laparotomy (4.5%). The rate of rectovaginal fistula in case of rectal shaving is 8.3%, and in rectal segmental resection 3.1%, which is not associated with the distance between the anastomosis and the rectum. Voiding problems are frequent and the incidence of urinary retention ranges from 1 to 29% and depends on the interval of observation. Finally, in case of ureteral endometriosis, a double J catheter should be always placed in order to decrease the risk of ureteral fistula.
J Nassif
Lecture
7 years ago
1588 views
37 likes
0 comments
18:10
Complications of endometriosis surgery
This lecture focuses on complications in laparoscopic surgery for endometriosis. First, the expert addresses how to define complications. Surgeons sometimes need to remove part of the adjacent structures such as bowel, vagina and ureter, which should be included in the surgery – to achieve a complete excision of the disease. Complications can always occur and the most important thing to be borne in mind is to know how to deal with them by laparoscopy.
Complications may include adhesions, bowel, ureter and vascular injuries. The rate of complications in rectal shaving ranges from 0.2 to 1.4%. In case of discoid bowel resection, the morbidity rate published in the literature is 13%. Regarding rectal segmental resection, the rate of complications in laparoscopy (4.25%) is similar to that of laparotomy (4.5%). The rate of rectovaginal fistula in case of rectal shaving is 8.3%, and in rectal segmental resection 3.1%, which is not associated with the distance between the anastomosis and the rectum. Voiding problems are frequent and the incidence of urinary retention ranges from 1 to 29% and depends on the interval of observation. Finally, in case of ureteral endometriosis, a double J catheter should be always placed in order to decrease the risk of ureteral fistula.
Segmental bowel resection and transanal specimen extraction for Deep Infiltrating Endometriosis (DIE)
Endometriosis can affect the bowel in 5-15% of cases and the most common sites are the rectum, the sigmoid colon, the appendix, and the small bowel. Patients may present dysmenorrhea, dyspareunia and chronic pelvic pain, as well as digestive symptoms such as dyschezia, constipation and diarrhea during menstruation. Preoperative work-up includes transanal ultrasound and magnetic resonance imaging, which according to the nodule’s location, can accurately describe the lesions. The laparoscopic approach includes adhesiolysis (shaving), partial thickness wall excision (mucosal skinning), discoid resection, and segmental bowel resection. In this video, we present the case of a 30-year-old patient complaining from severe dysmenorrhea, dyspareunia and dyschezia associated with deep infiltrating endometriosis (DIE) of the sigmoid colon that was treated by means of nodule excision, segmental bowel resection, and transanal specimen extraction.
A Wattiez, J Leroy, J Albornoz, E Faller, M Puga
Surgical intervention
7 years ago
2469 views
15 likes
0 comments
10:12
Segmental bowel resection and transanal specimen extraction for Deep Infiltrating Endometriosis (DIE)
Endometriosis can affect the bowel in 5-15% of cases and the most common sites are the rectum, the sigmoid colon, the appendix, and the small bowel. Patients may present dysmenorrhea, dyspareunia and chronic pelvic pain, as well as digestive symptoms such as dyschezia, constipation and diarrhea during menstruation. Preoperative work-up includes transanal ultrasound and magnetic resonance imaging, which according to the nodule’s location, can accurately describe the lesions. The laparoscopic approach includes adhesiolysis (shaving), partial thickness wall excision (mucosal skinning), discoid resection, and segmental bowel resection. In this video, we present the case of a 30-year-old patient complaining from severe dysmenorrhea, dyspareunia and dyschezia associated with deep infiltrating endometriosis (DIE) of the sigmoid colon that was treated by means of nodule excision, segmental bowel resection, and transanal specimen extraction.
Deep endometriosis excision with ureteral anastomosis followed by segmental rectosigmoid resection, transvaginal specimen extraction, and a transanal colorectal anastomosis
We present the case of a 29-year-old nulligest woman. Four years ago, she had a previous surgery with a rectovaginal nodule removed both by laparoscopy and vaginal approach. She has complained of dyspareunia (8/10), dysmenorrhea (8/10), dyschezia (8/10) and infertility over the last 2 years, but she also suffers from bladder dysfunction requiring urinary self-catheterization during her menstrual periods. The laparoscopic exploration revealed a big fibrotic nodule located in the right pelvic sidewall involving the right ureter and the rectum. Right ureter resection and anastomosis were performed. Segmental rectosigmoid resection was followed by transvaginal specimen extraction and a transanal colorectal anastomosis. The intracorporeal laparoscopic technique allows for a limited bowel devascularization and for an appropriate anastomosis with no need for extra abdominal incisions. No complications were noted and the patient had a good clinical evolution.
A Wattiez, J Leroy, E Faller, J Albornoz, P Messori
Surgical intervention
7 years ago
2583 views
22 likes
0 comments
30:14
Deep endometriosis excision with ureteral anastomosis followed by segmental rectosigmoid resection, transvaginal specimen extraction, and a transanal colorectal anastomosis
We present the case of a 29-year-old nulligest woman. Four years ago, she had a previous surgery with a rectovaginal nodule removed both by laparoscopy and vaginal approach. She has complained of dyspareunia (8/10), dysmenorrhea (8/10), dyschezia (8/10) and infertility over the last 2 years, but she also suffers from bladder dysfunction requiring urinary self-catheterization during her menstrual periods. The laparoscopic exploration revealed a big fibrotic nodule located in the right pelvic sidewall involving the right ureter and the rectum. Right ureter resection and anastomosis were performed. Segmental rectosigmoid resection was followed by transvaginal specimen extraction and a transanal colorectal anastomosis. The intracorporeal laparoscopic technique allows for a limited bowel devascularization and for an appropriate anastomosis with no need for extra abdominal incisions. No complications were noted and the patient had a good clinical evolution.
Laparoscopic partial cystectomy for deep endometriosis
Patients with bladder endometriosis may present with variable painful symptoms, hematuria, repeated urinary infection and/or infertility. The main treatment is a complete resection of the lesion. We report the case of a 30-year-old patient with no previous pregnancies presenting with pelvic endometriosis recurrence located at the level of the bladder dome. Her medical history shows a cystoscopic coagulation of an endometriotic nodule of the bladder. Preoperative MRI showed a 3cm single nodule protruding of the bladder. The procedure started by the dissection of the vesicouterine space followed by partial cystectomy using a monopolar hook. A running suture in two layers was carried out to close the cystotomy, and its integrity and bilateral ureteral patency was confirmed. Six weeks later at postoperative follow-up the patient was pain-free and without any urinary symptoms.
This video was awarded first place at the AAGL 5th International Congress on Minimally Invasive Gynecology held in conjunction with the Turkish Society of Gynecological Endoscopy (TSGE) 4th Annual Scientific Meeting.
A Wattiez, S Haddad, A Marot-Richter, A Vázquez Rodriguez, P Trompoukis, S Maia
Surgical intervention
8 years ago
2169 views
14 likes
0 comments
07:37
Laparoscopic partial cystectomy for deep endometriosis
Patients with bladder endometriosis may present with variable painful symptoms, hematuria, repeated urinary infection and/or infertility. The main treatment is a complete resection of the lesion. We report the case of a 30-year-old patient with no previous pregnancies presenting with pelvic endometriosis recurrence located at the level of the bladder dome. Her medical history shows a cystoscopic coagulation of an endometriotic nodule of the bladder. Preoperative MRI showed a 3cm single nodule protruding of the bladder. The procedure started by the dissection of the vesicouterine space followed by partial cystectomy using a monopolar hook. A running suture in two layers was carried out to close the cystotomy, and its integrity and bilateral ureteral patency was confirmed. Six weeks later at postoperative follow-up the patient was pain-free and without any urinary symptoms.
This video was awarded first place at the AAGL 5th International Congress on Minimally Invasive Gynecology held in conjunction with the Turkish Society of Gynecological Endoscopy (TSGE) 4th Annual Scientific Meeting.
Fully laparoscopic segmental rectosigmoid resection with Natural Orifice Specimen Extraction (NOSE) for bowel endometriosis
We report the case of a 45-year-old woman, G2P2, who presents with rectal bleeding, constipation and subocclusive syndrome caused by rectosigmoid endometriosis. The laparoscopic exploration revealed a sigmoid stuck by a few adhesions to the lateral abdominal wall underneath the left ovary and obliteration of the left uterosacral ligament and rectovaginal septum. A segmental bowel resection was performed with all necessary steps for mechanical bowel anastomosis carried out laparoscopically. The transvaginal specimen extraction obviated the need to create an abdominal incision. There were no complications and the patient presented a clinical remission following surgery. This surgical technique has the advantage of a shorter division of the mesentery, which enables a better vascularization of the bowel.
A Wattiez, J Leroy, S Maia, A Vázquez Rodriguez, P Trompoukis, J Alcocer
Surgical intervention
8 years ago
2375 views
10 likes
0 comments
08:03
Fully laparoscopic segmental rectosigmoid resection with Natural Orifice Specimen Extraction (NOSE) for bowel endometriosis
We report the case of a 45-year-old woman, G2P2, who presents with rectal bleeding, constipation and subocclusive syndrome caused by rectosigmoid endometriosis. The laparoscopic exploration revealed a sigmoid stuck by a few adhesions to the lateral abdominal wall underneath the left ovary and obliteration of the left uterosacral ligament and rectovaginal septum. A segmental bowel resection was performed with all necessary steps for mechanical bowel anastomosis carried out laparoscopically. The transvaginal specimen extraction obviated the need to create an abdominal incision. There were no complications and the patient presented a clinical remission following surgery. This surgical technique has the advantage of a shorter division of the mesentery, which enables a better vascularization of the bowel.
Laparoscopic total hysterectomy and unilateral adnexectomy with resection of urinary bladder nodule for endometriosis
This video demonstrates the technique of a total laparoscopic hysterectomy with unilateral adnexectomy and the excision of a vesical endometriotic nodule.
This patient is a 46-year-old lady with a previous surgical history of one laparotomy for a hemoperitoneum (endometriotic ovarian cyst rupture) and 6 laparoscopies because of endometriosis, the last one 3 years ago with a segmental sigmoid resection. After this last surgery, the patient starts to complain of dysmenorrhea, chronic pelvic pain and dysuria. She has never had any urinary infection.
Because of urinary stress incontinence, she had botulinic toxin injection and underwent a cystoscopy, which revealed a bladder nodule.
A Wattiez, S Barata, AM Furtado Lima, P Trompoukis, B Gabriel, J Nassif
Surgical intervention
9 years ago
610 views
31 likes
0 comments
10:14
Laparoscopic total hysterectomy and unilateral adnexectomy with resection of urinary bladder nodule for endometriosis
This video demonstrates the technique of a total laparoscopic hysterectomy with unilateral adnexectomy and the excision of a vesical endometriotic nodule.
This patient is a 46-year-old lady with a previous surgical history of one laparotomy for a hemoperitoneum (endometriotic ovarian cyst rupture) and 6 laparoscopies because of endometriosis, the last one 3 years ago with a segmental sigmoid resection. After this last surgery, the patient starts to complain of dysmenorrhea, chronic pelvic pain and dysuria. She has never had any urinary infection.
Because of urinary stress incontinence, she had botulinic toxin injection and underwent a cystoscopy, which revealed a bladder nodule.
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
1864 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.
Laparoscopic ureteral anastomosis in a patient with hydronephrosis due to a severe endometriosis
Ureteral endometriosis is unfrequent and it is defined by the presence of endometrial glands in the ureteric or pre-ureteric tissue. The prevalence reported is less than 1% and usually confined to the lower one-third of the left ureter. This pathology generates a ureteral stenosis, with an extrinsic compression of the ureteral wall by the inflammatory response and fibrosis, or an intrinsic stenosis with the invasion of the uro-epithelium and submucosal layer of the ureteral wall. We present a short video describing the technique of the laparoscopic segmental ureteral resection followed by the re-anastomosis.
I Miranda-Mendoza, J Nassif, E Kovoor, A Wattiez
Surgical intervention
9 years ago
3488 views
9 likes
0 comments
07:57
Laparoscopic ureteral anastomosis in a patient with hydronephrosis due to a severe endometriosis
Ureteral endometriosis is unfrequent and it is defined by the presence of endometrial glands in the ureteric or pre-ureteric tissue. The prevalence reported is less than 1% and usually confined to the lower one-third of the left ureter. This pathology generates a ureteral stenosis, with an extrinsic compression of the ureteral wall by the inflammatory response and fibrosis, or an intrinsic stenosis with the invasion of the uro-epithelium and submucosal layer of the ureteral wall. We present a short video describing the technique of the laparoscopic segmental ureteral resection followed by the re-anastomosis.
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
2605 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.