Laparoscopic management of colorectal endometriosis
B. L. Jerby,
1
H. Kessler,
1
T. Falcone,
2
J. W. Milsom
1
1
Department of Colorectal Surgery and The Minimally Invasive Surgery Center, The Cleveland Clinic Foundation, 9500 Euclid Avenue,
Cleveland, OH 44195, USA
2
Department of Gynecology and The Minimally Invasive Surgery Center, The Cleveland Clinic Foundation, 9500 Euclid Avenue,
Cleveland, OH 44195, USA
Received: 1 April 1998/Accepted: 22 March 1999
Abstract
Background: In the past, intestinal endometriosis diagnosed
at laparoscopy has generally required conversion to conven-
tional surgery. The purpose of this study was to describe the
laparoscopic management of colorectal endometriosis at a
tertiary referral center.
Methods: From November 1994 to March 1998, 509 con-
secutive patients with endometriosis requiring laparoscopic
intervention were prospectively evaluated. Those with co-
lorectal involvement were analyzed for stage of disease,
procedure, operative time, conversion rate, length of hospi-
talization, and complications.
Results: In 30 of the 509 patients (5.9%), colorectal involve-
ment was identified. Twenty-eight of these 30 had stage IV
disease. Intestinal involvement was suspected preopera-
tively in 13 of 30. Twelve required superficial excision of
colon or rectal endometriomas. Protectomy/procto-
sigmoidectomy was done in seven cases, and rectal disc
excision was performed in five patients. Four cases required
conversion due to the overall severity of the pelvic disease.
For those who did (n ס 12) and did not (n ס 18) require
full-thickness excisions/resections, the median operative
time was 180 min (range, 90–390) and 110 min (range,
45–355), respectively; the median length of hospitalization
was 4 days (range, 3–7) and 1 day (range, 0–4), respec-
tively. A major complication occurred in one patient (colo-
vaginal fistula). At a median follow-up of 10 months (range
1–32), 28 patients were improved, and 24 of these had near
or total resolution of preoperative symptoms.
Conclusions: Extensive pelvic endometriosis generally re-
quires rectal disc excision or bowel resection. In our expe-
rience, laparoscopic treatment of colorectal endometriosis,
even in advanced stages, is safe, feasible, and effective in
nearly all patients.
Key words: Laparoscopic surgery — Endometriosis — In-
testinal endometriosis — Bowel resection
Endometriosis, defined as functioning ectopic endometrial
tissue, affects 2.5–3.3% [1, 8] of women in the reproductive
age group. Of these women, ∼5–10% have intestinal in-
volvement [2, 17]. Resection of these infiltrating intestinal
lesions has traditionally necessitated laparotomy. However,
with the recent evolution of instrumentation and techniques,
laparoscopic excision of intestinal endometriosis, including
proctosigmoidectomy, now seems feasible. The purpose of
this study was to prospectively evaluate the feasibility and
efficacy of the laparoscopic treatment of intestinal endome-
triosis.
Patient and methods
From November 1994 to March 1998, 509 consecutive patients with pelvic
endometriosis required operative intervention at The Cleveland Clinic,
Cleveland, Ohio, USA. At the time of the initial gynecologic evaluation,
the patients were asked questions related to intestinal symptoms that may
indicate intestinal endometriosis (i.e., constipation, diarrhea, rectal pain,
obstructive symptoms, cyclic rectal bleeding, and dyspareunia with pain
radiating to the rectum). A rectovaginal examination was also performed to
assess for nodularity of the rectovaginal septum. When the patient had
symptoms or physical findings suggestive of intestinal endometriosis, she
was referred preoperatively to a colorectal surgeon specializing in laparo-
scopic methods (J.W.M.). When intestinal involvement was not suspected
preoperatively but was identified at the time of gynecologic surgery, an
intraoperative colorectal surgery consultation was obtained. This study is
comprised of patients who required excision of endometriotic lesions that
invovled the intestinal tract. Patients who had only endometriosis of the
perirectal peritoneum (cul de sac or lateral spaces) were not included in this
group.
Patients with intestinal endometriosis were classified according to age,
history, organs involved, operative procedures, total operative time, com-
plications, and length of hospitalization. The disease was staged according
to the American Fertility Society classification of endometriosis [2]. Fol-
low-up via telephone questionnaire was performed to determine postop-
erative bowel function, the amelioration of preoperative symptoms, and the
patient’s overall satisfaction with the laparoscopic procedure.
The lesion distribution and the depth of invasion dictated the laparo-
scopic method of excision of the intestinal endometriosis. For lesions that
did not definitely invade the muscularis, a superficial excision was per-
formed, and, where necessary, the area was oversewn with interrupted
absorbable sutures. When submucosal fibrosis was present or when the
Correspondence to: J. W. Milsom
Surg Endosc (1999) 13: 1125–1128
© Springer-Verlag New York Inc. 1999