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1 yechniques,!nd Instrumentation l FERTILITY AND STERILITY Copyright 1996 American Society for Reproductive Medicine Vol. 6, No.1, January 1996 Printed on acid-free paper in U. S. A Laparoscopically assisted transvaginal segmental resection of the rectosigmoid colon for endometriosis David B. Redwine, M.D. *t Marinus Koning, M.D.:j: Dean R. Sharpe, M.D. St. Charles Medical Center, Bend, and Central Oregon District Hospital, Redmond, Oregon Objective: To compare three methods of segmental lower colon resection for treatment of symptomatic intestinal endometriosis. Design: Retrospective case study. Setting: Private practice patients in a rural community hospital. Patients: Patients with nodular, invasive rectosigmoid endometriosis requiring segmental resection and anastomosis for treatment. Laparotomy patients were matched with laparoscopy patients for severity of intestinal endometriosis. Interventions: Segmental resection of the rectosigmoid colon by laparotomy, by a laparoscopic intracorporeal technique or by a laparoscopically assisted transvaginal technique. Main Outcome Measures: Length of surgery, length of hospital stay, operating room charges and total hospital charges corrected to 199 dollars. Results: Compared with laparotomy segmental colon resection for endometriosis, laparoscopic transvaginal segmental resection resulted in a shorter length of stay, equivalent operating room charges, and significantly lower total hospital charges. The laparoscopic transvaginal technique is much faster, safer, and less fatiguing to the surgeon than a total intracorporeal technique. Conclusions: Laparoscopically assisted transvaginal segmental rectosigmoid resection for endometriosis is a promising technique that is simpler than a laparoscopic intracorporeal segmental resection technique and is less costly than a laparotomy segmental resection technique. Fertil Steril 1996;6:193-7 Key Words: Endometriosis, intestinal endometriosis, surgical treatment, bowel resection, laparoscopy, laparotomy Nodular invasive endometriosis ofthe lower rectosigmoid colon can result in symptoms including rectal pain, rectal pain with bowel movements, rectal pain with sitting on a hard surface, constipation, and lower abdominal pain preceding bowel movements. Received January 16, 199; revised and accepted August 21, 199. * Endometriosis Institute of Oregon and St. Charles Medical Center, Bend, Oregon. t Reprint requests: David B. Redwine, M.D., 2190 NE Professional Court, Bend, Oregon (FAX: ). :j: Department of Surgery, Central Oregon District Hospital. Vice President of Medical Affairs and Department of Surgery, St. Charles Medical Center. Cyclic rectal bleeding is uncommon, however (1). Laparoscopic intracorporeal segmental resection and anastomosis ofthe lower colon for endometriosis first was described in 1991 (2). The use ofthe circular stapler was fraught with problems, however, leading to conversion to laparotomy in 0% ofthe early cases (3). These concerns, coupled with surgeon fatigue due to lengthy operating times, caused this procedure to be abandoned by the authors who developed it. Recently, a simple and efficient laparoscopically assisted transvaginal procedure that avoids a laparotomy incision and allows a hand-sutured bowel anastomosis to be completed without chance of intraperitoneal spill of intestinal contents has been developed. Vol. 6, No.1, January 1996 Redwine et al. Techniques and instrumentation 193

2 MATERIALS AND METHODS Five women with significant intestinal endometriosis underwent laparoscopically assisted transvaginal segmental resection of the lower colon. Two had nodular disease of the rectosigmoid colon, and three had both obliteration of the cul-de-sac with a large rectal nodule as well as nodular sigmoid disease. All complained of pelvic and intestinal symptoms compatible with endometriosis. Three had undergone previous laser therapy, one had undergone medical therapy with progestins and birth control pills, one had undergone previous therapy with birth control pills, and one had no previous therapy. Two patients also underwent laparoscopic hysterectomy. These were the first five patients to undergo this transvaginal procedure. No patient was excluded. The surgical technique is outlined in Figure 1. Triple-puncture laparoscopy was performed, with a 10- mm operating laparoscope inserted through an umbilical port and two.-mm sheaths inserted in the lower quadrants lateral to the inferior epigastric vessels. A suction irrigator was passed through the right lower port, and a -mm grasper was passed through the left. Monopolar electroexcision of endometriosis () is performed using 3-mm scissors A B c o Figure 1 Surgical steps in laparoscopically assisted transvaginal segmental resection of the rectosigmoid colon for endometriosis. (A), Sagittal section of the pelvis showing a larger rectal nodule (large arrowhead) of endometriosis with obliteration of the cul-de-sac, as well as a smaller midsigmoid nodule (small arrowhead). (B), An intrauterine manipulator is displacing the uterus anteriorly, putting the mesentery of the lower rectosigmoid colon on stretch. (e), The obliterated cul-de-sac has been mobilized by en bloc resection of the invasive endometriosis of the pelvic floor (). An intrafascial dissection down the posterior cervix has led to the rectovaginal septum, which has been dissected bluntly to expose normal rectal wall distal to the rectal nodule. (D), Using 0 W of monopolar coagulation current through a 3-mm monopolar scissors, the mesentery is separated from the bowel beneath the segment to be removed. The scissors work directly against the bowel wall where the vessels are smaller. The dashed lines represent the sites of peritoneal incisions that can facilitate intestinal mobilization without disruption of the blood supply to the unaffected bowel. (E), After the affected segment of bowel has been separated from its mesentery, the intrauterine manipulator is removed, and a posterior colpotomy incision is made. The bowel is delivered through the vagina to the introitus. The affected segment is resected (dashed line), and a hand-sutured anastomosis is performed. Mter returning the bowel to the abdomen, the vagina is closed from below. 19 Redwine et al. Techniques and instrumentation Fertility and Sterility

3 passed down the operating channel of the laparoscope. Videolaparoscopy was not used. After excision of all pelvic endometriosis, obliteration of the cul-desac in three patients was treated by en bloc resection (1), resulting in complete isolation of nodular pelvic floor disease onto the anterior bowel wall. Bilateral peritoneal incisions were created alongside the affected bowel segment, exposing the retroperitoneal fibrofatty attachments. These attachments are progressively severed using 0 W of coagulation current passed down the 3-mm scissors. Separation of these lateral attachments is best performed immediately adjacent to the bowel wall because the vessels are smaller and easy to coagulate before transection. As the lateral attachments are severed, the mesentery attached to the posterior bowel wall comes into view, although it does not differ significantly in visual appearance from the lateral attachments. The small vessels entering the bowel wall can be touched and coagulated instantly with coagulation current, and then severed immediately with a short sweeping action of the scissors using either blunt dissection or coagulation current. This technique can be applied repeatedly and rapidly along the bowel wall as the bowel is rotated around its longitudinal axis. Surgery can be performed alternately from the right or left side of the bowel, and the resulting operative symmetry results in an easy dissection. The mesentery is dissected no more than 2 cm past the nodular mass deforming the bowel wall in order to maintain adequate blood supply to the edges to be anastomosed. If a sigmoid nodule of endometriosis is present, the cephalad portion of the dissection occasionally will encounter larger branches of the inferior mesenteric artery, which can be controlled with electrocoagulation or with surgical clips. To ensure sufficient mobility to allow vaginal delivery of the affected bowel segment, the bilateral peritoneal incisions should extend several centimeters cephalad to the nodule, and the rectovaginal septum must be developed bluntly for several centimeters to separate the rectum from the posterior vaginal wall. After sufficient isolation and mobilization of the affected bowel segment, a vaginal incision is created. In two patients undergoing laparoscopic hysterectomy, removal of the uterus resulted in the vaginal entry, while, in three patients undergoing conservative surgery, a posterior culdotomy was created for vaginal entry. The affected loop of bowel is delivered vaginally to the introitus, and the affected segment is excised. The anastomosis is completed with a standard hand-sewn double-layer technique using interrupted 3-0 silk on the seromuscular layer and continuous 3-0 chromic on the mucosal layer. After returning the repaired bowel to the pelvis, the vagina is closed from below. The technique for laparoscopic intracorporeal segmental colonic resection has been described (2, 3). The three patients successfully operated with a total intracorporeal technique constitute one comparison group. After abandonment of the intracorporeal segmental resection technique for the reasons stated above, the authors resumed laparotomy bowel resections until the transvaginal technique was developed. During this hiatus from laparoscopic segmental bowel resections, among those patients requiring laparotomy for segmental resection of the rectosigmoid colon for endometriosis, 10 consecutive patients with extent of intestinal disease matched to the laparoscopy groups constituted a second comparison group. None of 13 patients in the comparison groups underwent hysterectomy, and all underwent complete excision of endometriosis also. Invasive intestinal endometriosis was confirmed histologically by the presence of glands and stroma within the muscularis of the bowel wall in all cases, with no luminal penetration. All patients in the study group and the comparison groups had symptoms suggestive of intestinal endometriosis before surgery. After segmental bowel resection performed laparoscopically or at laparotomy, nasogastric suctioning is not used. No oral intake is allowed until flatus is passed, at which time clear liquids are begun. If the patient is stable and if oral intake is tolerated, she is discharged and instructed in a graduated diet., mean, median, and minimum of surgery length (from initial skin incision to last wound closure), length of hospital stay (Julian day of discharge minus Julian day of surgery), operating room charges (including anesthetic supplies and recovery room charges), and total hospital charges (including operating room charges) were tabulated for all groups. Operating room and total hospital charges were obtained from the hospital business office. No charge correction was made for the two patients also undergoing laparoscopic hysterectomy. RESULTS There has been no intestinal complication in any patient. One patient undergoing transvaginal bowel resection had persistent granulation tissue of the vaginal incision that required office treatment. The study comparisons are listed in Table 1. The average operating time for laparoscopically assisted transvaginal bowel resection was faster than a laparoscopic intracorporeal technique, but slightly slower than laparotomy. The median length of stay was longer for the laparotomy approach. Operating room charges were greatest for laparoscopic intracorpor- Vol. 6, No.1, January 1996 Redwine et al. Techniques and instrumentation 19

4 Table 1 Comparisons Between Laparoscopy and Laparotomy Techniques for Segmental Colonic Resection Technique Group 1 laparoscopic intracorporeal (n = 3) Group 2 laparoscopic transvaginal (n = ) Group 3 laparotomy (n = 10) Surgery length (min) Length of stay (d) Operating room charge (US dollars) Total hospital charge (US dollars) ± 00.3 ± 0.7 2,700,973,29 ± 1,132,211,232 8,72 7,89 ± 1,880 9, ± ± ,701 3,66 3,89 ± 26 3,80,81 8,37 8,069 ± 1,163 9, ± ± ,78 3,969 3,72 ± 719,967 6,626 9,16 9,919 ± 2,1 1,68 eal bowel resection. The laparoscopic approaches were associated with lower total hospital charges, which were related to a shorter hospital stay. Transvaginal procedures were associated with the lowest variability among the study parameters. DISCUSSION Most patients with intestinal endometriosis do not require segmental bowel resection. In this referral practice, among 1, women with surgically treated endometriosis, 1 have had intestinal disease, resulting in 113 segmental colonic resections. The laparoscopically assisted transvaginal technique presented here is an option for treatment of nodular rectosigmoid disease, which is not amenable to partial thickness bowel resection, mucosal skinning, or full thickness disc resection. The technique is reproducible, efficient, reduces the chance of intraperitoneal contamination, and avoids the problems (3) and fatigue associated with a long surgery using a total intracorporeal technique. This makes the transvaginal approach preferable. Mean total hospital charges were less for the laparoscopy-treated groups. Because operating room charges were similar for the transvaginal and laparotomy groups but increased for the intracorporeal group, this reduction in total charges probably was due to a shorter length of stay. Hospital charges do not necessarily directly reflect hospital costs. There currently is no accurate way to measure our institu- tional costs, which can include supplies, salaries, depreciation, staff pensions, and taxes among other things. In the laparotomy group, all patients had laparoscopy immediately preceding celiotomy. This was done to confirm the presence of significant intestinal endometriosis and the need for laparotomy for treatment. These patients underwent surgery in a hiatus between abandonment of the intracorporeal technique and the initiation of the transvaginal technique. Because invasive intestinal endometriosis frequently is missed by intestinal studies, surgery is necessary for diagnosis. Therefore, laparoscopy in these women was unavoidable but did not result in greater operating room charges. Statistical analysis of significance can be misleading when the universally and easily understood parameters of time and money are studied in small numbers of patients. Most surgeons would consider any 30-minute or greater difference in mean operating time or $00 or greater difference in mean charges to be significant. Because two patients undergoing the transvaginal segmental resection technique also had laparoscopic hysterectomy, whereas none of those undergoing laparotomy had a hysterectomy, the economic advantage of the transvaginal approach over the laparotomy approach is underestimated. The number of patients in this study treated by laparoscopically assisted transvaginal bowel resection is small, but the procedure is promising, partic- 196 Redwine et ai. Techniques and instrumentation Fertility and Sterility

5 ularly because the trends toward favorable time and economic advantages have been realized at the beginning of the learning curve for this procedure. With adequate peritoneal-releasing incisions alongside the bowel, the transvaginal technique has treated successfully nodular disease of the sigmoid near the pelvic brim. The lower the intestinal lesion, the more amenable it is to a transvaginal approach. A long-billed posterior vaginal retractor can push the rectum higher in the pelvis, resulting in surgical difficulty during the transvaginal anastomosis. Patients requiring segmental resection for additional invasive disease of the ileum or cecum would be served better by laparotomy or by laparoscopically assisted laparotomy because these areas would be difficult to reach with a transvaginal approach. More study is needed to determine the advantages oflaparoscopically assisted transvaginal segmental bowel resection. REFERENCES 1. Redwine DB. Laparoscopic en bloc resection for treatment of the obliterated cui de sac in endometriosis. J Reprod Med 1992; 37: Redwine DB, Sharpe DR. Laparoscopic segmental resection of the sigmoid colon. J Laparoendosc Surg 1991; 1: Sharpe DR, Redwine DB. Laparoscopic segmental resection of the sigmoid and rectosigmoid colon for endometriosis. Surgical Laparoscopy Endoscopy 1992;2: Redwine DB. Laparoscopic excision of endometriosis with 3 mm scissors: comparison of operating times between sharp excision and electro-excision. J Am Assoc Gynecol Laparosc 1993; 1:2-30. Vol. 6, No.1, January 1996 Redwine et al. Techniques and instrumentation 197