Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement

BACKGROUND: Adequate treatment of severe deep pelvic endometriosis requires complete excision of all implants, but formal bowel resection is not generally recommended. The purpose of this study was to describe our experience with planned complete laparoscopic management of deep pelvic endometriosis with bowel involvement. STUDY DESIGN: All patients presenting to the Department of Obstetrics and Gynecology and the Department of Colorectal Surgery at our institution with stage IV endometriosis and bowel involvement from February 1998 to December 2001 were identified from a prospective database and were retrospectively analyzed. Data analysis included age, previous history of endometriosis, previous pregnancies, operative procedure, body mass index, operating room time, intra- and postoperative complications, length of stay, 30-day readmission, and pain relief. Laparoscopic excision of all visible disease was planned. RESULTS: The series consisted of 51 patients with median age of 34 years (range, 32 to 39 years), with history of earlier abdominal operation in 66.7%. Preoperative symptoms were present as dysmenorrhea (85.3%), dyspareunia (55.9%), rectal pain (41.2%), constipation (44.1%), rectal bleeding (14.7%), bloating (29.4%), and tenesmus (8.8%). Management of the bowel disease included superficial excision of serosal endometriosis implants (n = 26), bowel resection (n = 18), and disc excision (n = 5). Five patients required management of disease other than rectosigmoid involvement. Median operating room time was 187 minutes (range, 145 to 277 minutes), and the median length of stay was 2 days (range, I to 4 days). Thirty-three percent of excisions were outpatient procedures. Postoperative complications occurred in 10.3%: four cases (7.8%) were converted to formal laparotomy. and three patients (7.7%) were readmitted within 30 days. Only 7 of 47 patients with a uterus (14.9%) required abdominal hysterectomy or bilateral salpingo-oophorectomy. Postoperatively, 87% of patients reported a clinically significant improvement of their symptoms. CONCLUSIONS: Though technically demanding, complete radical laparoscopic excision of endometriotic implants can be accomplished with preservation of the reproductive organs and appropriate use of bowel resection in the majority of patients. The surgeon or gynecologist who plans to perform laparoscopic excision of deep pelvic endometriosis should have the ability or access to expertise for laparoscopic partial or segmental bowel resection or plan to convert to laparotomy when faced with this disease location.