The implications of the anatomy of the nerves and vessels in the treatment of rectosigmoid endometriosis

Abstract

Endometriosis is a common benign gynecological disease characterized by the presence of endometrial glands and stroma outside the uterus. It can be defined as endometrioma, superficial peritoneal endometriosis or deep infiltrating endometriosis (DIE) depending on the location and the depth of infiltration of the organs. In 5%–12% of cases, DIE affects the digestive tract, frequently involving the distal part of the sigmoid colon and rectum. Surgery is generally recommended in cases of obstructive symptoms and in cases with pain that is non‐responsive to medical treatment. Selection of the most optimal surgical technique for the treatment of bowel endometriosis must consider different variables, including the number of lesions, eventual multifocal lesions, as well as length, width and grade of infiltration into the bowel wall. Except for some major and widely accepted indications regarding bowel resection, established international guidelines are not clear on when to employ a more conservative approach like rectal shaving or discoid resection, and when, instead, to opt for bowel resection. Damage to the pelvic autonomic nervous system may be avoided by detection of the middle rectal artery, where its relationship with female pelvic nerve fibers allows its use as an anatomical landmark. To reduce the risk of potential vascular and nervous complications related to bowel resection, a less invasive approach such as shaving or discoid resection can be considered as potential treatment options. Additionally, the middle rectal artery can be used as a reference point in cases of upper bowel resection, where a trans mesorectal technique should be preferred to prevent devascularization and denervation of the bowel segments not affected by the disease.

Deep Infiltrating Endometriosis in Adolescence: Early Diagnosis and Possible Prevention of Disease Progression

“…As already stated here, many authors consider endometriosis a chronic disease [131], while others believe it to be an eradicable disease [132]. Performing surgery at an early stage might eradicate the initial disease while preventing the difficulties related to the treatment of advanced disease [133], and it has been observed that the complexity of surgical procedures progressively increases from adolescence until the age of 30 years, thus suggesting that the severity of the disease could follow the same trend [74]. On the other hand, surgical treatment early in life is often one of the causes of repetitive surgery, adhesion syndrome and the persistence of painful symptoms due to the surgery itself and should only be performed in cases where is strictly necessary, such as in symptomatic young patients not responding to medical therapy.…”