Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection?

Abstract

Deep endometriosis (DE) remains the most difficult endometriotic entity to treat. Medical treatment for DE can reduce symptoms but does not cure the disease, and surgical removal of the lesion is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions. Although several surgical techniques such as laparoscopic bowel resection, disc excision, and rectal shaving have been described, there is no consensus regarding the choice of technique or the timing of surgery. Our review of publications reporting results and complications of surgery for rectovaginal DE reveals a relatively higher complication rate after bowel resection compared with shaving and disc excision, especially for rectovaginal fistulas, anastomotic leakage, delayed hemorrhage, and long-term bladder catheterization. Data show that shaving is feasible even in advanced disease. The risk of immediate complications after shaving and disc excision is probably lower than after colorectal resection, allowing for better functional outcomes. The presumed higher risk of recurrence related to shaving has not been demonstrated. For these reasons, surgeons should consider rectal shaving as a first-line surgical treatment of rectovaginal DE, regardless of nodule size or association with other digestive localizations. When the result of rectal shaving is unsatisfactory (rare cases), disc excision may be performed either exclusively by laparoscopy or by using transanal staplers. Segmental resection may ultimately be reserved for advanced lesions responsible for major stenosis or for several cases of multiple nodules infiltrating the rectosigmoid junction or sigmoid colon.

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

“…> 1 month) of 3.5%, whereas the literature review of Roman et al . described no cases . One explanation could be related to the lesion size of rectal nodules removed in the current report (> 3 cm in 64.3% of cases) as well as the high rate of additional lesions resected compared with other studies – vaginal (34.7%) and parameters (22%) – which are known as voiding dysfunction risk factors .…”

“…According to Roman et al . 's review of disc excision procedures, the overall major complication and the rectovaginal fistula rates vary between 0% and 15.3% and 0% and 7.2%, respectively. We report a postoperative global incidence of pelvic abscess of 1.4%: one case required a second surgery (0.7%) and the other (0.7%) was managed exclusively by antibiotics.…”

“…Roman et al . 's review of the literature shows that this information was not reported in almost half of the published works. Moreover, voiding dysfunction is a concept which has several definitions: urinary retention, bladder atony, voiding dysfunction, requiring intermittent bladder catheterization after postoperative day 7 or a postvoiding bladder volume > 100 ml .…”

C‐reactive protein assessment to predict early septic complications after laparoscopic bowel resection for endometriosis: a diagnostic study

“…Surgical management of deep infiltrating endometriosis (DIE) may require excision of the posterior vagina when infiltrated, as well as the excision of bowel involvement by conservative or radical procedures . Intraoperative opening of the vagina or the bowel, either voluntary or unintended, may be followed by postoperative infectious complications, such as pelvic abscess, bowel suture leakage or rectovaginal fistula . These complications routinely occur in patients managed for other digestive tract diseases, such as colorectal cancer or inflammatory bowel diseases, and may lead to reoperations, longer hospital stay, increased cost treatment, and psychological and physical pain .…”

Accuracy and clinical value of an adhesion scoring system: A preoperative diagnostic method using transvaginal ultrasonography for endometriotic adhesion

“…Finally, cystectomy of any endometriomas was meticulously performed to preserve ovarian function . Lesions on the surface of the rectum were removed by shaving if necessary . In some cases, interventions for vaginal endometriosis, uterine adenomyosis, or fibroids were performed in consultation with the patient prior to the surgery.…”