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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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IMAGING AND OTHER DIAGNOSTICS
Physical findings associated with bowel endometriosis are variable and may well depend upon the specific location and size
of implants.
Rectovaginal exam may reveal nodularity and localized implants.
Colonoscopy is mainly utilized to rule out alternative source of pathology such as colorectal cancer, inflammatory bowel
diseases, extrinsic compression, or a fixed area of narrowed lumen suggestive of endometriosis.
Both transvaginal sonography (TVUS) and transrectal sonography (TRUS) can detect bowel endometriosis as irregular
hypoecoic nodules, with or without hypoecoic or hyperechoic foci throughout intestinal wall.
In the TVUS the most important limitations are the impossibility of evaluating the depth of rectal wall involvement and of
detecting the distance of the rectal lesion from the anal margin.
In contrast, TRUS does not visualize the upper part of the colon and is strictly correlated to the sonographer’s experience.
TRUS can evaluate the involvement of the muscularis mucosa and the distance of the rectal lesion from the anus.
Double contrast barium enema (DCBE) often demonstrates nonspecific findings suggestive of bowel endometriosis. These
findings include extrinsic mass effect with fine mucosal crenulations (serrated, wavy outline of colonic mucosa).
Magnetic Resonance Imaging (MRI) can detect endometriotic lesions with areas of hemorrhage, but is limited in detecting
fibrotic lesions. It also lacks sensitivity in detecting the depth of infiltration of endometriotic lesions.
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PREOPERATIVE PLANNING
These procedures are clean-contaminated and require intravenous prophylactic antibiotics 30 to 60 minutes before incision.
We do recommend a clear liquid diet the day before surgery and three enemas the night before surgery to decompress the
rectum and allow the better visualization of the posterior cul-de-sac.
The need for mechanical bowel preparation is controversial as studies have shown that this may increase the likelihood of
spillage of bowel content and meta-analysis has shown no advantage to bowel preparation.
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SURGICAL MANAGEMENT
Surgical treatment has been considered the mainstay of therapy for rectovaginal or bowel endometriosis.
Surgical management of bowel and rectovaginal endometriosis is determined by the location, size, and depth of infiltration of
endometriosis.
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Positioning
The patient is placed in the dorsal lithotomy position with arms abducted.
Trendelenburg positioning and right tilt may facilitate mobilization of small bowel loops, exposing the pelvis and to further
expose the base and posterior attachments of the meso-sigmoid colon to the retroperitoneum.
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Procedures and Techniques
This procedure requires an umbilical incision to accommodate the video camera and laser laparoscope, in addition to three
accessory trocars (two lateral 5-mm trocars and one 5-mm suprapubic trocar.
Bowel endometriosis at sites other than rectosigmoid are treated by shaving or superficial excision of lesion, full thickness
disc resection, or bowel resection.
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Laparoscopic shaving of superficial bowel endometriosi s lesions (Video 6.3.1 )
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The superficial lesion involving the serosa or the adventitia is grasped with grasping forceps at the junction of fibrotic
endometriosis and yellow or pink soft tissue. The lesion is lifted and excised with CO
2
laser or sharp dissection. We prefer
CO
2
laser for its precise application, excellent hemostatic properties, and minimal thermal damage to adjacent tissue.
Generalized oozing or bleeding is controlled with dilute vasopressin or the bipolar electrocoagulator.
Bleeding caused by dissection or vaporization of a vessel should be controlled by clips or the bipolar electrocoagulator.
The use of cautery in this area must be done with extreme caution as thermal damage to bowel may result in delayed
necrosis and fistula formation.
Proctoscopy should be performed at the end of the procedure to ensure no evidence of air leak.
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Laparoscopic full thickness disc resection (Video 6.3.2 )
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When submucosal fibrosis is present and the lesion constricts the lumen but the lesion is not circumferential, full thickness
disc resection is performed.
The rectosigmoid colon needs to be completely mobilized after identifying the ureters.
The pararectal area is entered bilaterally, ureterolysis is performed to identify ureters, and the colon is separated from
adjacent organs.
Full thickness disc resection is done starting above the area of visible lesion until normal tissue is identified.
The lesion is held at its proximal end with grasping forceps and an incision is made through the bowel serosa and
muscularis. The lumen is then entered.
The lesion is then excised entirely.
Two traction sutures are placed to both sides of the bowel defect, transforming it into a transverse opening. The bowel
lumen is then closed in two layers. The mucosa is closed with continuous 3–0 Vicryl
®
suture (Ethicon, Inc., Somerville, NJ)
and submuscularis with interrupted 2–0 Vicryl
®
(Ethicon, Inc., Somerville, NJ) or silk sutures in 0.4- to 0.6-cm increments.
Proctoscopy should be performed at the end of the procedure to ensure no evidence of air leak.
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Laparoscopic bowel resection (Vi deo 6.3.3 )
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Bowel resection is usually recommended when the following conditions exist: A single lesion ≥3 cm in diameter, single lesion
infiltrating ≥50% of the bowel wall, and if more than three lesions infiltrating the muscular layer are present.
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The medial aspect of the peritoneum covering the mesosigmoid is then cut open from the sacral promontory up to the origin
of the colic artery.
The entire rectum is mobilized; the lateral rectal pedicles are coagulated.
Both perirectal space is developed and ureters are identified.
The branches of the inferior mesenteric vessels of bowel segment to be resected are coagulated and cut.
Hollow of sacrum is visualized in the presacral space and rectovaginal space is developed.
The rectum is stapled and transected proximal to the lesion using the Endo GIA™ 45 mm (Covidien, Medtronic Minimally
Invasive Therapies, Minneapolis, MN).
Mini-laparotomy is then performed, so proximal bowel can be exteriorized.
Anvil from a 29 mm EEA™ stapler (Covidien, Medtronic Minimally Invasive Therapies, Minneapolis, MN) is secured to the
proximal end of the bowel.
Distally the 29 mm EEA™ stapler is introduced through the rectum and the pin is advanced.
The anvil is engaged to the pin. The stapler is closed and fired.
Proctoscopy should be performed at the end of the procedure to ensure no evidence of air leak.
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PEARLS AND PITFALLS
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OUTCOMES
Significant pain improvement has been shown with surgical treatment but potential benefit should be weighed against the
individual-specific surgical risk.
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