Objective: To describe a combined robotic and trans-anal technique used to treat ultra-low rectal endometriosis in a 36-years-old patient with multiple pelvic compartments which was responsible for infertility, dyspareunia, left sciatic pain and severe dyschezia. Design: Surgical video article. Setting: The achievement of a perfect bowel anastomosis in patients with low rectal endometriosis could be challenging due to technical and anatomical limitations [1]. By allowing a right angle rectotomy with a single-stapled anastomosis, the TTSS technique overcomes these technical difficulties ensuring a good quality anastomosis with an easier correction of postoperative anastomotic leakage when it occurs [2,3]. Interventions: The surgery starts by splitting the nodule in three components according to different anatomical structures involved (parametrium, vagina and rectum). Parametrial and vaginal fragments are excised as previously described [4]. The rectal involvement is approached following several steps: isolation and cut of inferior mesenteric vessels (IMA, IMV) and left colic artery in order to obtain a proper colon mobilization; transanal rectotomy immediately below the lower limit of the nodule; extraction of the specimen through the anus; proximal bowel segment transection 1 cm above the upper limit of the nodule; introduction of circular stapler anvil into the sigmoid colon; placement of two pursestring to secure the anvil and at distal rectal cuff, respectively; connection of the anvil to the shoulder of circular stapler; stapler closing and firing with coloanal anastomosis formation; stapled line reinforcement by stitching and integrity anastomosis test. No preventive diverting stoma was performed according with our policy [5]. Conclusions: Although no data are yet available in patients with endometriosis, the use of TTSS technique may be an interesting approach in patients with very low rectal endometriosis involvement.
Combined robotic transanal transection single-stapled technique (TTSS) in ultra-low rectal endometriosis involvement associated with parametrial and vagina infiltration
Angioni, Stefano;
In corso di stampa
Abstract
Objective: To describe a combined robotic and trans-anal technique used to treat ultra-low rectal endometriosis in a 36-years-old patient with multiple pelvic compartments which was responsible for infertility, dyspareunia, left sciatic pain and severe dyschezia. Design: Surgical video article. Setting: The achievement of a perfect bowel anastomosis in patients with low rectal endometriosis could be challenging due to technical and anatomical limitations [1]. By allowing a right angle rectotomy with a single-stapled anastomosis, the TTSS technique overcomes these technical difficulties ensuring a good quality anastomosis with an easier correction of postoperative anastomotic leakage when it occurs [2,3]. Interventions: The surgery starts by splitting the nodule in three components according to different anatomical structures involved (parametrium, vagina and rectum). Parametrial and vaginal fragments are excised as previously described [4]. The rectal involvement is approached following several steps: isolation and cut of inferior mesenteric vessels (IMA, IMV) and left colic artery in order to obtain a proper colon mobilization; transanal rectotomy immediately below the lower limit of the nodule; extraction of the specimen through the anus; proximal bowel segment transection 1 cm above the upper limit of the nodule; introduction of circular stapler anvil into the sigmoid colon; placement of two pursestring to secure the anvil and at distal rectal cuff, respectively; connection of the anvil to the shoulder of circular stapler; stapler closing and firing with coloanal anastomosis formation; stapled line reinforcement by stitching and integrity anastomosis test. No preventive diverting stoma was performed according with our policy [5]. Conclusions: Although no data are yet available in patients with endometriosis, the use of TTSS technique may be an interesting approach in patients with very low rectal endometriosis involvement.
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