Laparoscopic repair of small bowel and colon. A report of 26 cases

Objective metrics for hand-sewn bowel anastomoses can differentiate novice from expert surgeons

BACKGROUND

Assessing performance automatically in a virtual reality trainer or from recorded videos is advantageous but needs validated objective metrics. The purpose of this study is to obtain expert consensus and validate task-specific metrics developed for assessing performance in double-layered end-to-end anastomosis.

MATERIALS AND METHODS

Subjects were recruited into expert (PGY 4-5, colorectal surgery residents, and attendings) and novice (PGY 1-3) groups. Weighted average scores of experts for each metric item, completion time, and the total scores computed using global and task-specific metrics were computed for assessment.

RESULTS

A total of 43 expert surgeons rated our task-specific metric items with weighted averages ranging from 3.33 to 4.5 on a 5-point Likert scale. A total of 20 subjects (10 novices and 10 experts) participated in validation study. The novice group completed the task significantly more slowly than the experienced group (37.67 ± 7.09 vs 25.47 ± 7.82 min, p = 0.001). In addition, both the global rating scale (23.47 ± 4.28 vs 28.3 ± 3.85, p = 0.016) and the task-specific metrics showed a significant difference in performance between the two groups (38.77 ± 2.83 vs 42.58 ± 4.56 p = 0.027) following partial least-squares (PLS) regression. Furthermore, PLS regression showed that only two metric items (Stay suture tension and Tool handling) could reliably differentiate the performance between the groups (20.41 ± 2.42 vs 24.28 ± 4.09 vs, p = 0.037).

CONCLUSIONS

Our study shows that our task-specific metrics have significant discriminant validity and can be used to evaluate the technical skills for this procedure.

Voiding Dysfunction after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

OBJECTIVE

Surgical management of deep endometriosis is associated with a high incidence of lower urinary tract dysfunction. The aim of the current systematic review and meta-analysis was to assess the rates of voiding dysfunction according to colorectal shaving, discoid excision, and segmental resection for deep endometriosis.

DATA SOURCES

We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. Medical Subject Headings terms for colorectal endometriosis and voiding dysfunction were combined and restricted to the French and English languages. The final search was performed on August 28, 2019. The outcome measured was the occurrence of postoperative voiding dysfunction.

METHODS OF STUDY SELECTION

Study Quality Assessment Tools were used to assess the quality of included studies. Studies rated as good and fair were included. Two reviewers independently assessed the quality of each included study, discrepancies were discussed; if consensus was not reached, a third reviewer was consulted.

TABULATION, INTEGRATION AND RESULTS

Out of 201 relevant published reports, 51 studies were ultimately reviewed systematically and 13 were included in the meta-analysis. Rectal shaving was statistically less associated with postoperative voiding dysfunction than segmental colorectal resection (Odds ratio [OR] 0.34; 95% confidence intervals [CI], 0.18-0.63; I² = 0%; p <.001) or discoid excision (OR 0.22; 95% CI, 0.09-0.51; I² = 0%; p  <.001). No significant difference was noted when comparing discoid excision and segmental colorectal resection (OR 0.74; 95% CI, 0.32-1.69; I² = 29%; p = .47). Similarly, rectal shaving was associated with a lower risk of self-catheterization >1 month than segmental colorectal resection (OR 0.3; 95% CI, 0.14-0.66; I² = 0%; p = .003). This outcome was no longer significant when comparing discoid excision and segmental colorectal resection (OR 0.72; 95% CI, 0.4-1.31; I² = 63%; p = .28).

CONCLUSION

Colorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection.

Improvement in quality of life and pain scores after laparoscopic management of deep endometriosis: a retrospective cohort study

PURPOSE

This is a retrospective cohort study that evaluates the postoperative pain findings of a consecutive series of laparoscopic surgeries for deep endometriosis (DE).

METHODS

This multi-center retrospective cohort study was carried out in university hospitals (Istanbul, Turkey). Sixty-five patients diagnosed through bimanual gynecologic examination, gynecologic ultrasound or magnetic resonance imaging-confirmed endometrioma and DE together; who underwent a laparoscopic surgery between 2013 and 2019 by a team of gynecologists, colorectal surgeons, and a urologist were retrospectively evaluated. The data were collected in a specific database and analyzed for postoperative pain outcomes through a comparison with preoperative symptoms scored using a visual analogue score (VAS), and the British Society of Gynecologic Endoscopy (BSGE) pelvic pain questionnaire.

RESULTS

Sixty-five patients who met the criteria were included. The mean age of all patients was 35.0 ± 6.3 (range 22-50) years. The mean operative time was 121.3 ± 50.2 (range, 60-270) minutes. Preoperative and postoperative comparison of VAS scores for dysmenorrhea (8.57 vs. 2.91), dyspareunia (6.62 vs. 1.66), dyschezia (7.46 vs. 2.43), dysuria (5.67 vs. 1.34), chronic pelvic pain (4.11 vs. 1.22), and BSGE score (40.98 vs. 11.00) showed significantly reduced pain scores, respectively (p < 0.01).

CONCLUSION

Laparoscopic management of DE is a valid treatment option in terms of reduced postoperative pain and increased quality of life according to pain score outcomes. To have more robust conclusions, a prospective cohort study with a larger sample size which evaluates patients who had segmental bowel resection and those who did not have segmental bowel resection is necessary.

Bowel and Bladder Injury Repair and Follow-up After Gynecologic Surgery

Bowel and bladder injuries are relatively rare, but there can be serious complications of both open and minimally invasive gynecologic procedures. As with most surgical complications, timely recognition is key in minimizing serious patient morbidity and mortality. Diagnosis of such injuries requires careful attention to surgical entry and dissection techniques and employment of adjuvant diagnostic modalities. Repair of bowel and bladder may be performed robotically, laparoscopically, or using laparotomy. Repair of these injuries requires knowledge of anatomic layers and suture materials and testing to ensure that intact and safe repair has been achieved. The participation of consultants is encouraged depending on the primary surgeon's skill and expertise. Postoperative care after bowel or bladder injury requires surveillance for complications including repair site leak, abscess, and fistula formation.

Discoid resection for colorectal endometriosis: results from a prospective cohort from two French tertiary referral centres

AIM

Using a prospective database of discoid resection performed in two tertiary referral centres, the aim of this study is to assess the feasibility, short-term complication rates and clinical outcomes, including voiding dysfunction, of the procedure.

METHOD

A retrospective analysis of a prospective cohort database was conducted from February 2010 to October 2017 in two tertiary referral centres. One hundred and forty-eight consecutive patients scheduled for colorectal endometriosis by discoid resection were enrolled. The median follow-up was 21 months. All the women underwent complete preoperative assessment (MRI, transvaginal ultrasonography and rectal echo-endoscopy) before the removal of colorectal endometriosis. Postoperative complications were classified according to the Clavien-Dindo classification system as minor (grades I and II) or major (grades IIIA, IIIB and IV). Cases of voiding dysfunction were also noted.

RESULTS

The procedure was abandoned in seven patients. In 91 (64.5%) of the remaining 141 patients, the diameter of discoid resection removed was ≥ 30 mm. Surgery was performed by laparoscopy in 137/141 cases (92.7%). Grade I-III complications were observed in 37 patients (26.2%) with 11 grade IIIb (7.8%). Postoperative voiding dysfunction occurred in 16 patients (11.3%), 11 of whom required self-catheterization for < 1 month. In a multivariate analysis including age, body mass index, lesion size and history of previous surgery for endometriosis, a history of previous surgery was independently correlated to complication outcome (P = 0.043).

CONCLUSIONS

This analysis suggests that discoid resection is associated with good short-term results for women with colorectal endometriosis in a tertiary referral centre as it is associated with a low rate of postoperative complications.

Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial

STUDY QUESTION

Is there a difference in functional outcome between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 2 years postoperatively?

SUMMARY ANSWER

No evidence was found that functional outcomes differed when conservative surgery was compared to radical rectal surgery for deeply invasive endometriosis involving the bowel.

WHAT IS KNOWN ALREADY

Adopting a conservative approach to the surgical management of deep endometriosis infiltrating the rectum, by employing shaving or disc excision, appears to yield improved digestive functional outcomes. However, previous comparative studies were not randomized, introducing a possible bias regarding the presumed superiority of conservative techniques due to the inclusion of patients with more severe deep endometriosis who underwent colorectal resection.

STUDY DESIGN SIZE, DURATION

From March 2011 to August 2013, we performed a 2-arm randomized trial, enroling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring more than 20 mm in length, involving at least the muscular layer in depth and up to 50% of rectal circumference. No women were lost to follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients were enroled in three French university hospitals and had either conservative surgery, by shaving or disc excision, or radical rectal surgery, by segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of the results of randomization. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), defecation pain, anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were the values of the Visual Analog Scale (VAS), Knowles-Eccersley-Scott-Symptom Questionnaire (KESS), the Gastrointestinal Quality of Life Index (GIQLI), the Wexner scale, the Urinary Symptom Profile (USP) and the Short Form 36 Health Survey (SF36).

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 60 patients were enroled. Among the 27 patients in the conservative surgery arm, two were converted to segmental resection (7.4%). In each group, 13 presented with at least one functional problem at 24 months after surgery (48.1 versus 39.4%, OR = 0.70, 95% CI 0.22-2.21). The intention-to-treat comparison of the overall scores on KESS, GIQLI, Wexner, USP and SF36 did not reveal significant differences between the two arms. Segmental resection was associated with a significant risk of bowel stenosis.

LIMITATIONS REASONS FOR CAUTION

The inclusion of only large infiltrations of the rectum does not allow the extrapolation of conclusions to small nodules of <20 mm in length. The presumption of a 40% difference favourable to conservative surgery in terms of postoperative functional outcomes resulted in a lack of power to demonstrate a difference for the primary endpoint.

WIDER IMPLICATIONS OF THE FINDINGS

Conservative surgery is feasible in patients managed for large deep rectal endometriosis. The trial does not show a statistically significant superiority of conservative surgery for mid-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum. There is a higher risk of rectal stenosis after segmental resection, requiring additional endoscopic or surgical procedures.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a grant from the clinical research programme for hospitals (PHRC) in France. The authors declare no competing interests related to this study.

TRIAL REGISTRATION NUMBER

This study is registered with ClinicalTrials.gov, number NCT 01291576.

TRIAL REGISTRATION DATE

31 January 2011.

DATE OF FIRST PATIENT’S ENROLMENT

7 March 2011.

Bowel endometriosis: diagnosis and management

The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long-term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5-8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short- and long-term complications.

Diagnostic and treatment guidelines for gastrointestinal and genitourinary endometriosis

Endometriosis is commonly misdiagnosed, even among many experienced gynecologists. Gastrointestinal and genitourinary endometriosis is particularly difficult to diagnose, and is commonly mistaken for other pathologies, such as irritable bowel syndrome, interstitial cystitis, and even psychological disturbances. This leads to delays in diagnosis, mismanagement, and unnecessary testing. In this review, we will discuss the diagnosis and management of genitourinary and gastrointestinal endometriosis. Medical management may be tried first, but often fails in cases of urinary tract endometriosis. This is particularly important in cases of ureteral endometriosis because silent obstruction can lead to eventual kidney failure. Thus, we recommend complete surgical treatment in these cases. Bladder endometriosis may be managed more conservatively, and only if symptomatic, because these rarely lead to significant morbidity. In cases of bowel endometriosis, we recommend medical management first in all cases, and the least invasive surgical management only if medical treatment fails. This is due to the extensive nervous and vasculature supply to the lower rectum. Injury to these nerves and vessels can cause significant complications and postoperative morbidity.

Bowel injury in robotic gynecologic surgery: risk factors and management options. A systematic review

OBJECTIVE

We sought to analyze the published literature on bowel injuries in patients undergoing gynecologic robotic surgery with the aim to determine its incidence, predisposing factors, and treatment options.

DATA SOURCES

Studies included in this analysis were identified by searching PubMed Central, OVID Medline, EMBASE, Cochrane, and ClinicalTrials.gov databases. References for all studies were also reviewed. Time frame for data analysis spanned from November 2001 through December 2014.

STUDY ELIGIBILITY CRITERIA

All English-language studies reporting the incidence of bowel injury or complications during robotic gynecologic surgery were included. Studies with data duplication, not in English, case reports, or studies that did not explicitly define bowel injury incidence were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

The Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies were used to complete the systematic review with the exception of scoring study quality and a single primary reviewer.

RESULTS

In all, 370 full-text articles were reviewed and 144 met the inclusion criteria. There were 84 bowel injuries recorded in 13,444 patients for an incidence of 1 in 160 (0.62%; 95% confidence interval, 0.50-0.76%). There were no significant differences in incidence of bowel injury by procedure type. The anatomic location of injury, etiology, and management were rarely reported. Of the bowel injuries, 87% were recognized intraoperatively and the majority (58%) managed via a minimally invasive approach. Of 13,444 patients, 3 (0.02%) (95% confidence interval, 0.01-0.07%) died in the immediate postoperative period and no deaths were a result of a bowel injury.

CONCLUSION

The overall incidence of bowel injury in robotic-assisted gynecologic surgery is 1 in 160. When the location of bowel injuries were specified, they most commonly occurred in the colon and rectum and most were managed via a minimally invasive approach.

Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis

BACKGROUND

Two surgical approaches usually are used in the surgical management of deep infiltrating endometriosis of the rectum: the radical approach that mainly is based on colorectal resection and the conservative or symptom-guided approach that prioritizes conservation of the rectum. There are no data available that compare long-term functional digestive outcomes of 1 approach to the other.

OBJECTIVE

The purpose of this study was to compare long-term digestive outcomes in women who were treated by either rectal shaving or colorectal resection for deep endometriosis infiltrating the rectum.

STUDY DESIGN

A retrospective comparative study was performed. All women who were treated with surgery for deep endometriosis infiltrating the rectum by either shaving or colorectal resection at the University Hospital of Rouen from January 2005 to January 2010 were enrolled. Follow-up evaluation was carried out for a minimum of 5 years. Postoperative evaluation of digestive symptoms was performed by 4 standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index, the Knowles-Eccersley-Scott-Symptom score for constipation, the Wexner score for anal continence, and the Bristol Stool Score. Symptoms that were related to endometriosis, fertility, and disease recurrence were obtained from a specific questionnaire.

RESULTS

A total of 77 women were included. Three women were lost to follow up (3.9%), and 3 were treated by disc excision (3.9%). The mean follow-up time was 80±19 months. Forty-six women underwent conservative rectal shaving, and 25 women underwent colorectal resection. Patient characteristics and the severity of the disease were comparable in both groups. Patients who were treated by rectal shaving had significantly better Gastrointestinal Quality of Life Index values, lower Knowles-Eccersley-Scott-Symptom scores for postoperative constipation, and better anal continence. No statistically significant differences were revealed for postoperative pelvic pain. Rectal recurrence occurred in 8.7% of patients who were treated by conservative surgery: 4.3% underwent secondary colorectal resection and 4.3% were treated secondarily by rectal shaving. Consequently, avoiding a recurrence for merely 1 patient would have required 11 patients to undergo colorectal resection instead of shaving.

CONCLUSION

Our data suggest that, in patients who are treated for rectal endometriosis, colorectal resection does not improve long-term postoperative functional outcomes when compared with rectal shaving.

Full-Thickness Disc Excision in Deep Endometriotic Nodules of the Rectum: A Prospective Cohort

BACKGROUND

To date, a majority of patients presenting with large endometriosis of the rectum are managed worldwide by colorectal resection. However, postoperative rectal function may be impacted by radical rectal surgery.

OBJECTIVE

The purpose of this study was to assess the postoperative outcomes of patients with rectal endometriosis who are managed by full-thickness disc excision and to compare outcomes of the 2 procedures using a transanal approach.

DESIGN

This was a prospective study.

SETTINGS

The study was conducted at a university hospital.

PATIENTS

Fifty patients with colorectal endometriosis that was managed by disc excision between June 2009 and November 2014 were included in the study.

INTERVENTIONS

The procedure included laparoscopic deep shaving, followed by full-thickness disc excision to remove the shaved rectal area. Disc excision was performed using a semicircular transanal stapler (the Rouen technique) in 20 patients, an end-to-end anastomosis circular transanal stapler in 28 patients, and transvaginal excision in 2 patients.

MAIN OUTCOMES MEASURES

Preoperative and postoperative assessments of pelvic symptoms and digestive function using standardized gastrointestinal questionnaires were the main measures.

RESULTS

The largest diameter of specimens achieved was significantly higher using the Rouen technique (58 ± 9 mm) than the end-to-end anastomosis stapler (34 ± 6 mm). Two rectovaginal fistulas were recorded (4%), and 8 patients presented with transitory bladder voiding (16%). Median postoperative values for the Gastrointestinal Quality of Life Index and the Knowles-Eccersley-Scott-Symptom Questionnaire improved progressively 1 and 3 years after surgery. For patients intending to get pregnant, the cumulative pregnancy rate was 80%, and 63% of pregnancies were spontaneous.

LIMITATIONS

The study sample size is small and the design is not comparative; however, direct comparison of patients managed by disc excision and colorectal resection would be inappropriate, because of differences regarding nodule localization and size.

CONCLUSIONS

Disc excision is a valuable alternative to colorectal resection in selected patients presenting with rectal endometriosis, achieving better preservation of rectal function. The Rouen technique allows for successful removal of large nodules of the low and midrectum, with favorable postoperative outcomes. (See video abstract, http://links.lww.com/DCR/A208.).

Fast-track surgery in intestinal deep infiltrating endometriosis

STUDY OBJECTIVE

To evaluate the length of hospital stay (LOS) and the readmission rate in patients undergoing laparoscopic surgery to treat intestinal deep infiltrating endometriosis (DIE) with application of the concepts of fast-track surgery.

DESIGN

Retrospective study of women undergoing laparoscopic treatment of intestinal DIE (Canadian Task Force classification II-3).

SETTING

Tertiary referral private hospital.

INTERVENTIONS

We evaluated 161 women who underwent laparoscopic surgery between January 2010 and April 2013 for complete treatment of intestinal DIE, via either conservative surgery (rectal shaving, mucosal skinning, or anterior disk resection) or radical surgery (segmental bowel resection). After surgery, all specimens were sent for pathologic examination to confirm the presence of endometriosis.

MEASUREMENTS AND MAIN RESULTS

Patients were divided into 2 groups according to type of surgery (conservative [n = 102] or radical [n = 59]), and LOS and readmission rate were measured in both groups. Median LOS was shorter in the conservative group compared with the segmental bowel resection group (19 vs 28 hours; p < .001). Ninety-two patients (90.2%) in the conservative surgery group were discharged to home on the first postoperative day, compared with only 38 patients (64.4%) in the segmental bowel resection group. Overall, the readmission rate was low (3.1%): 6.8% in the segmental bowel resection group and 1% in the conservative group (p = .04; odds ratio, 7.34; 95% confidence interval, 0.8-67.3); however, the need for repeat operation was similar in both groups (3.4% vs 1%; p = .28; odds ratio, 3.54; 95% confidence interval, 0.31-39.95).

CONCLUSION

Implementation of fast-track concepts in the laparoscopic treatment of intestinal DIE resulted in a short LOS and low readmission rate in both the segmental bowel resection and conservative surgery groups.

Double circular stapler technique for bowel resection in rectosigmoid endometriosis

To reduce bladder function impairment and avert the serious complications of anastomotic leakage after segmental rectosigmoidectomy and to minimize the persistence of endometriotic lesions associated with discoid resection, we used the double circular stapling (DCS) technique. This technique enables excision of bowel endometriosis nodules larger than those that can be removed with the single-load technique of the circular stapler. Of 120 patients who underwent surgery to treat bowel endometriosis, intestinal shaving was performed in 24, discoid resection with single circular stapling in 40, and rectosigmoidectomy in 55. Eleven patients (9.2%) underwent the DCS technique. In the DCS group, the size of the rectosigmoid lesion ranged from 2.2 cm to 4.2 cm. Median operative time for the DCS technique was 100 minutes, compared with 150 minutes for rectosigmoidectomy (p = .04). Only 1 of 11 patients (9%) had urinary retention, compared with postoperative urinary retention in 14 of 55 patients (25%) who had undergone rectosigmoidectomy (difference not significant). Only 1 patient, with a 4.2-cm nodule, had a positive margin in the specimen obtained at the second stapling. DCS is a promising technique and may avert rectosigmoidectomy in selected patients.

Laparoscopic management of bowel endometriosis: predictors of severe disease and recurrence

This study suggests that laparoscopic management of bowel endometriosis can be safe and effective. Two statistically significant predictors of higher stage disease were identified that showed the need for careful surgical planning.

Background and Objectives:

The identification of high-stage and recurrent cases of bowel endometriosis is critical, because these cases require careful surgical planning. We aim to describe the clinical characteristics of women with bowel endometriosis, our principles in laparoscopic management of this pathology, and to identify predictors of severe disease and recurrence.

Methods:

This was a retrospective study of 193 patients with pathologically confirmed bowel endometriosis.

Results:

Predictors of higher-stage endometriosis include a history of previous laparoscopic surgery (P=.04) and a presenting complaint of abnormal uterine bleeding (P=.01). The higher the stage of endometriosis, the more likely there would be coexistent urinary tract endometriosis (P=.02), a need for enterolysis (P=.002), ovarian cystectomy (P<.001), and bowel resection (P=.01) performed during laparoscopy. Patients with higher body mass index (BMI) had significantly higher recurrence rates of endometriosis compared to those with lower BMI (P=.002). Within our cohort, 87% of our patients achieved amelioration of symptoms by the end of the first postoperative month.

Conclusions:

Our study confirms that laparoscopic management of bowel endometriosis is safe and effective. We found 2 statistically significant predictors of higher-stage disease that should prompt careful surgical planning. Obesity is associated with a higher rate of recurrence of endometriosis.

Robotic-assisted laparoscopic treatment of bowel, bladder, and ureteral endometriosis

Robotic-assisted laparoscopic repair of a vesicouterine fistula allows for a three-dimensional view of the operative filed and intricate movements necessary for complex suturing and dissection.

Background:

Endometriosis commonly affects the pelvic organs but can also affect organs outside the pelvis and is then termed extragenital endometriosis.

Cases:

Successful robotically assisted laparoscopic management of extragenital endometriosis, specifically, endometriosis of the bowel, bladder, and ureter in 5 patients.

Conclusion:

A substantial body of evidence supports the laparoscopic approach as the preferred method for many procedures; yet, a majority of procedures today still are performed by laparotomy. This preference for open procedures is likely due to the lack of trained endoscopic surgeons, the difficulty in obtaining proper instruments, and the long learning curve of operative laparoscopy. The recent advent of computer-enhanced technology may provide the bridge necessary for more surgeons to incorporate laparoscopic surgery in the treatment of complex cases.

Pathophysiological approach to bowel dysfunction after segmental colorectal resection for deep endometriosis infiltrating the rectum: a preliminary study

BACKGROUND

Colorectal segmental resection is performed worldwide in a majority of women presenting with symptomatic deep endometriosis infiltrating the rectum. The aim of the present study was to investigate the pathophysiological mechanisms involved in post-operative digestive dysfunction.

METHODS

We selected patients managed by colorectal resection for rectal endometriosis, who had developed post-operative severe constipation and whose follow up was superior to 24 months. To assess the mechanisms involved in the pathogenesis of this complaint, we performed a step-by-step work up including: low digestive tract endoscopy, colonic transit time measurement and when appropriate anorectal manometry, electromyography and defecographic evaluation.

RESULTS

Five out of 25 (20%) patients, whose age ranged from 27 to 41 years, were investigated for severe post-operative terminal constipation. Four different mechanisms responsible for terminal constipation were identified: tight stenosis of the colorectal anastomosis, post-operative neurological sequelae, colonic intussusception through the colorectal anastomosis and transit constipation that developed post surgery.

CONCLUSIONS

Post-operative constipation is a frequent complaint in women managed by colorectal resection for rectal endometriosis. A multidisciplinary approach is mandatory as pathophysiologic mechanisms may vary and prove difficult to understand. The risk of post-operative bowel dysfunction following colorectal endometriosis must be taken into account whenever this technique is proposed in young women presenting with a benign disease such as deep endometriosis.

Fertility after colorectal resection for endometriosis: results of a prospective study comparing laparoscopy with open surgery

OBJECTIVE

To determine whether the surgical route of colorectal resection for endometriosis is a determinant factor for fertility.

DESIGN

Prospective study.

SETTING

Tertiary-care university hospital.

PATIENT(S)

Fifty-two patients with endometriosis were randomly assigned to laparoscopic or open surgery.

INTERVENTION(S)

Laparoscopically assisted vs. open colorectal resection.

MAIN OUTCOME MEASURE(S)

Evaluation of fertility outcomes spontaneously and after assisted reproductive therapy.

RESULT(S)

The mean follow-up was 29 months. Among the 28 patients wishing to conceive, 11 (39.3%) became pregnant. Overall cumulative pregnancy rate at 52 months for these patients was 45.1%. For patients with or without infertility, the cumulative pregnancy rate was 37.6% and 55.6%, respectively, and the cumulative spontaneous pregnancy rate 13.3% and 36.5%, respectively. All the spontaneous pregnancies were observed in the laparoscopy group.

CONCLUSION(S)

This study demonstrates that spontaneous pregnancy is more frequent after laparoscopy compared with open surgery for colorectal endometriosis.

Dealing with complications in laparoscopy

With increasing adoption of laparoscopic surgery in gynaecology, there has been a corresponding rise in the types and rates of complications reported. This article sets out to classify complications associated with laparoscopy according to the phases of the surgery; assess the incidence, the mechanisms, the presentations; and recommend methods for preventing and dealing with complications in laparoscopic surgery. Its aim is to promote a culture of risk management based on the development of strategies to improve patient safety and outcome.

Evaluation of the outcomes of electrosurgical induced bowel injury treated with tissue glue/sealant versus sutured repair in a rabbit model

INTRODUCTION

Bowel injury is an uncommon, although potentially devastating, intraoperative laparoscopic complication. Questions have been raised about the possible use of a tissue adhesive to repair injured bowel. We compared glued repair and sutured repair of both large bowel (LB) and small bowel (SB) electrosurgical injuries in a rabbit model.

METHODS

Pneumoperitoneum was obtained, and four laparoscopic ports were placed in each of 48 New Zealand rabbits. The hook electrode was used in a specified manner to create an equal number of uniform full-thickness injuries to either the SB or the LB. Laparoscopic repair was performed with a 3-0 silk Lembert suture (LS), fibrin glue (FG), or BioGlue (BG), or repair was not performed (i.e., no repair, NR); the animals were monitored for 3 weeks. Adverse clinical outcomes and findings at laparotomy were recorded. Pathologic assessment included an objective scaled evaluation of the intensity of the inflammatory response and degree of healing.

RESULTS

In the SB injury group, deteriorating clinical condition necessitated early euthanasia in one animal repaired with FG, one animal repaired with BG, and two animals with NR. LS repair animals had no adverse clinical outcomes. The LB injury group had no adverse clinical outcomes regardless of the method of repair, including the control group. Of the animals that survived for 3 weeks, the animals repaired with BG had more intraabdominal adhesions (100%) than LS (33%), FG (55%), and NR (50%) (p = 0.001). The pathologic assessment revealed that BG induced a more intense inflammatory response (p < 0.05).

CONCLUSION

In the rabbit, suture repair of an electrosurgical SB injury appears to have improved outcomes when compared with a glued repair. In contrast, LB injury responded well to any form of treatment. The data suggest that suture is superior to biological glues when dealing with a laparoscopic electrosurgical bowel injury.

Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study

OBJECTIVE

To evaluate the efficacy of discoid resection for the treatment of deep infiltrating endometriosis and whether it could be considered to be a valid alternative to the rectosigmoid segmental resection.

DESIGN

Case-control study.

SETTING

Departments of Obstetrics and Gynecology, Ospedale Sacro Cuore of Negrar, Verona, and Catholic University of the Sacred Heart, Rome, Italy.

PATIENT(S)

Women with deep infiltrating and intestinal endometriosis divided into study group (48 patients) and control group (88 patients).

INTERVENTION(S)

All patients underwent laparoscopic endometriosis excision plus discoid rectosigmoid resection (study group) or segmental resection (control group).

MAIN OUTCOME MEASURE(S)

Short- and long-term outcomes.

RESULT(S)

In the study group, median operating time was 200 minutes, with a median estimated blood loss of 203 mL. Median ileus was 3 days with a median postoperative hospitalization of 7 days. Early complications were observed in six patients (12.5%), and in two of them (4.16%) a surgical management was necessary. Median follow-up period was 33 months, and five recurrences (10.4%) were registered. In the control group, no significant differences were noticed except for longer operative time, more temporary ileostomy, postoperative fever, and long-term bladder dysfunctions.

CONCLUSION(S)

Laparoscopic mechanical discoid resection is feasible, markedly improved endometriosis related symptoms, and could be considered as a worthy alternative to classic segmental resection in selected patients.

Laparoscopic disk resection for bowel endometriosis using a circular stapler and a new endoscopic method to control postoperative bleeding from the stapler line

BACKGROUND

Complete laparoscopic excision of endometriosis offers good longterm symptomatic relief, especially for those with severe or debilitating symptoms. Intestinal endometriosis affect between 3% and 36% of women with endometriosis and 50% of women with disease severe enough that intestinal surgery, with or without intestinal segmental resection, may be required.

STUDY DESIGN

Between January 2003 and September 2006, we performed 35 laparoscopic complete excisions of endometriosis with full thickness disk resections of bowel endometriosis using the CEEA stapler (US Surgical) inserted transanally.

RESULTS

The endometriotic nodule of the bowel was completely removed in all patients. No major or minor surgical complications occurred during the primary surgical procedure. One patient underwent a diverting temporary ileostomy because of air loss after insufflation of the rectosigmoid colon, which was closed successfully 1 month after surgery. In three of seven cases of rectal bleeding from the stapler line, for the first time, we successfully used conservative endoscopic management.

CONCLUSIONS

In properly selected patients, full thickness disk excision using a circular stapler is a feasible procedure that avoids the potential morbidities of a low anastomosis. We suggest conservative management by endoscopic hemostasis before referring patients for a new operation in cases of rectal bleeding from the anastomotic site.

The role of intraoperative proctosigmoidoscopy in laparoscopic pelvic surgery

STUDY OBJECTIVE

To report the outcome of rigid sigmoidoscopy during operative laparoscopy in patients at high risk for rectosigmoid and large bowel injury.

DESIGN

Prospective patient database with retrospective chart review (Canadian Task Force classification II-3).

SETTING

Referral practice and tertiary medical center.

PATIENTS

Two hundred sixty-two women with rectosigmoid endometriosis and adhesions.

INTERVENTIONS

Rigid sigmoidoscopy during laparoscopy. At the end of surgery, proctosigmoidoscopy was performed to evaluate intraluminal abnormality or rectosigmoid injury. The pelvis was then filled with isotonic fluid to observe laparoscopically for air leakage.

MEASUREMENTS AND MAIN RESULTS

Sigmoidoscopy was performed due to a lesion involving the rectum or sigmoid in 60.7%, large bowel in 11.1%, and posterior cul-de-sac in 28.2% of patients. During laparoscopy, endometriosis was found in 30.5%, adhesions in 20.2%, and both in 43.5%. Four women (1.5%) had bowel injury identified during sigmoidoscopy; all bowel injuries were treated by intracorporeal laparoscopic suturing. One incomplete repair was detected by sigmoidoscopy. In one woman (0.4%) a rectal polyp was detected.

CONCLUSION

Bowel injury is one of the most serious complications of laparoscopy. Early detection and prompt intraoperative management are essential to prevent a potentially catastrophic outcome. Sigmoidoscopy is a relatively easy procedure and aids during laparoscopy in the diagnosis of bowel perforation and in assessment of bowel wall invasion and potential stricture caused by endometriosis. It is a safe procedure even when performed immediately after extensive laparoscopic surgical treatment of rectosigmoid endometriosis and adhesions.

Ovarian remnant syndrome after laparoscopic oophorectomy

OBJECTIVE

To report the surgical history, clinical characteristics, and operative technique used in patients with ovarian remnant syndrome after laparoscopic oophorectomy.

DESIGN

Observational study.

SETTING

Teaching hospital and private practice office.

PATIENT(S)

Nineteen patients with documented history of unilateral or bilateral laparoscopic oophorectomies with histologic confirmation of ovarian remnants.

INTERVENTION(S)

Operative laparoscopy for resection of ovarian remnants.

MAIN OUTCOME MEASURE(S)

Risk factors and surgical technique contributing to ovarian remnant syndrome.

RESULT(S)

The patients underwent a mean of 4.7 previous surgical procedures (range, two to nine): 12 had bilateral oophorectomy, and seven had unilateral oophorectomy. The infundibulopelvic ligament had been secured with bipolar desiccation in 11 patients, pretied surgical loops in six, and a linear stapler in two. Cystic ovarian remnants were identified by pelvic sonography in 12 women and by computed tomography (CT) scan in one. Six women underwent reoperation, two for ovarian remnants in different sites.

CONCLUSION(S)

With laparoscopic oophorectomy there is risk of ovarian remnant due to improper tissue extraction or misapplication or improper use of pretied surgical loops, linear stapler, or bipolar electrodesiccation on the infundibulopelvic ligament, especially in women with a history of multiple pelvic surgeries, adhesions, or endometriosis.

Laparoscopic bowel injury: incidence and clinical presentation

PURPOSE

Bowel injury is a potential complication of any abdominal or retroperitoneal surgical procedure. We determine the incidence and assess the sequelae of laparoscopic bowel injury, and identify signs and symptoms of an unrecognized injury.

MATERIALS AND METHODS

Between July 1991 and June 1998 laparoscopic urological procedures were performed in 915 patients, of whom 8 had intraoperative bowel perforation or abrasion injuries. In addition, 2 cases of unrecognized bowel perforation referred from elsewhere were reviewed. A survey of the surgical and gynecological literature revealed 266 laparoscopic bowel perforation injuries in 205,969 laparoscopic cases.

RESULTS

In our series laparoscopic bowel perforation occurred in 0.2% of cases (2) and bowel abrasion occurred in 0.6% (6). The 6 bowel abrasion injuries were recognized intraoperatively and 5 were repaired immediately. In 4 cases, including 2 referred from elsewhere, perforation injuries were not recognized intraoperatively and they had an unusual presentation postoperatively. These patients had severe, single trocar site pain, abdominal distention, diarrhea and leukopenia followed by acute cardiopulmonary collapse secondary to sepsis within 96 hours of surgery. The combined incidence of bowel complications in the literature was 1.3/1,000 cases. Most injuries (69%) were not recognized at surgery. Of the injuries 58% were of small bowel, 32% were of colon and 50% were caused by electrocautery. Of the patients 80% required laparotomy to repair the bowel injuries.

CONCLUSIONS

Bowel injury following laparoscopic surgery is a rare complication that may have an unusual presentation and devastating sequelae. Any bowel injury, including serosal abrasions, should be treated at the time of recognition. Persistent focal pain in a trocar site with abdominal distention, diarrhea and leukopenia may be the first presenting signs and symptoms of an unrecognized laparoscopic bowel injury.

Laparoscopically assisted ileocecal resection for Crohn's disease associated with intestinal stenosis and ileovesical fistula

We describe a 22-year-old man with Crohn's ileocolitis accompanied by intestinal stenosis and ileovesical fistula in whom laparoscopically-assisted surgery was successfully performed after thorough nutritional therapy. Laparoscopic procedures are characterized by minimal access and minimal invasion, features which can contribute to the early recovery of patients who undergo surgery. It is suggested that laparoscopic (or laparoscopically-assisted) surgery after strict nutritional therapy can be effective in the treatment of patients with Crohn's disease who have intestinal complications.

Therapeutic laparoscopy in trauma

PURPOSE

To assess the therapeutic potential of emergent laparoscopy in the trauma setting, a retrospective review was performed in a busy urban trauma center.

PATIENTS AND METHODS

Between December 1991 and October 1993, 133 hemodynamically stable patients with suspected abdominal injury were evaluated laparoscopically. All laparoscopic procedures were performed in the operating room under general anesthesia. Mechanism of injury was stab wound (58), gunshot wound (57), and blunt trauma (18). No significant injuries were found in 72 patients (54%), and these patients received no further treatment. On the basis of laparoscopic findings, 52 patients underwent formal exploratory laparotomy. Surgical exploration confirmed the presence of significant injuries in 44 of the 52 patients (85%). Therapeutic laparoscopy was performed in 6 patients (5%) for diaphragm repair (4), gastrotomy repair (1), and splenorrhaphy (1). Additionally, 10 patients underwent laparoscopy-guided blood salvage for autotransfusion during laparoscopic evaluation of blunt trauma. Three small-bowel enterotomies were repaired during minilaparotomy.

RESULTS

No significant injuries were missed as a result of our use of laparoscopy in trauma assessment. Complications--trocar enterotomy, trocar laceration of the inferior epigastric artery, and transient hypotension--occurred in 3 patients secondary to the use of laparoscopy.

CONCLUSIONS

Trauma laparoscopy is a safe method for the evaluation of selected patients with abdominal trauma and can reduce the number of negative and nontherapeutic trauma laparotomies performed. Limited therapeutic intervention is possible in a small number of patients.

Operative laparoscopy and the gynecologic oncologist. Commentary and review

BACKGROUND

A rapid evolution in technology and surgical applications of endoscopy have occurred over the past 5 years. Surgical procedures once thought impossible except through large abdominal incisions are being performed with the use of laparoscopic surgical techniques. Laparoendoscopic techniques have limitations as well as advantages over conventional surgical approaches.

METHODS

The medical literature as it relates to laparoscopy and gynecologic oncology was reviewed.

RESULTS

Procedures performed through the laparoscope include total hysterectomies, bilateral oophorectomies, pelvic and periaortic lymphadenectomies, omentectomies, colostomies, bowel resections, oophoropexies, and pelvic lid constructions as well as radical hysterectomies and ovarian cancer debulking procedures. These techniques are gaining popularity among gynecologic oncologists, and studies of individual case reports have been followed by studies involving a series of patients. Numerous limiting factors exist, however, foremost among these being the wide variability of endoscopic skills among surgeons and lack of objective long term data supporting the efficacy and safety of these techniques.

CONCLUSION

Application of endoscopic techniques in gynecologic oncology procedures is occurring rapidly and is driven partly by market economy forces. Many gynecologic oncologists, however, do not have the necessary endoscopic skills and experience with which to perform such procedures. For these physicians to remain sufficiently qualified, fellowship training programs must encompass formal training curricula in endoscopic surgery, and such programs should often include the faculty as well. Formal and organized credentialing of laparoscopic cancer surgical expertise will ensure a minimum safe level of skills.

Laparoscopically assisted bowel surgery. Analysis of 114 cases

In order to help determine the risks and benefits, we retrospectively analyzed the results of our first 114 laparoscopically assisted bowel procedures. Procedures performed consisted of partial colectomy (85), total or subtotal abdominal colectomy (8), total proctocolectomy with J-pouch ileal reservoir (11), and diverting procedures (10). Forty-nine procedures were for malignancy. The rate of conversion to laparotomy was 13.2%. Oral feedings were resumed in 2.4 days (range 1-5), and bowel function returned in 3.8 days (range 2-8). The average length of stay was 4.2 days for partial colectomy and 6 days for total, subtotal, and proctocolectomy. The mean return to normal activity for all groups was 16.7 days (10.8 days for partial colectomy). There were no deaths. Major morbidity (6%) consisted of abscess (3), anastomotic leak (2), and hemorrhage (1). Mean operative costs analyzed for the initial 37 patients were higher for laparoscopic colectomies when compared to traditional colectomies; however, the mean total hospital costs were less for the laparoscopic procedures. These data suggest that the laparoscopic approach to colorectal resection is an acceptable alternative to laparotomy for a variety of disease processes, allowing patients an early return to normal activity.

Minimally invasive surgery

With the widespread introduction of laparoscopic cholecystectomy in late 1989, the practice and expectations of general surgery were changed forever. The techniques of laparoscopy were not new--they had been adopted by gynecologists and orthopedic surgeons at least a decade before--but it was laparoscopic cholecystectomy that captured the attention of the surgical profession and the public and spawned the tremendous growth in what has come to be called minimally invasive surgery. Although this surgery has tremendous appeal, offering quicker recovery, less pain, and possibly greater safety, it presents new challenges in the areas of training, credentialing, and quality assessment and raises serious questions about the real benefits of new technology at a time when the political and economic sensitivity of these issues is greater than ever. In this chapter I limit myself to a discussion of laparoscopy in general surgery, with a focus on what we have learned from laparoscopic cholecystectomy and on what this knowledge suggests for the future of other laparoscopic general surgical procedures.

Complications of therapeutic laparoscopy

Laparoscopic surgery holds great promise as a technique for reducing hospital stay and convalescence. Although advantages in hospital cost cannot be shown for all such procedures, improvements in technique and operator experience will undoubtedly improve the situation. Analysis of the pertinent physiologic aspects and complication rates indicates that laparoscopy is not minimally invasive, but rather exposes the patient to many of the risks normally incurred by open procedures. Enthusiasm for the use of these techniques must be tempered by good judgment and scientific evidence supporting equivalent or better long-term results at equal or lower rates of morbidity and mortality.

Laparoscopic surgery for colorectal neoplasms

Laparoscopy is being used to assist in an increasing number and variety of bowel procedures. However, when being used for neoplastic disease concerns of margins and adequacy of mesenteric dissection must be addressed. We've performed 110 laparoscopic-assisted bowel procedures, with 45 of these performed for neoplastic disease. Ninety-two bowel resections were performed including 24 subtotal, total, or proctocolectomies. In this chapter we review the results of our series, as well as other reported series, and discuss some of the controversies involved with laparoscopy for neoplastic disease.