Excision Decisions: Surgical Management of Bowel Endometriosis

INTRODUCTION: Deeply infiltrative endometriosis involves the bowel in 5–12% of women with the disease, which adds an additional layer of complexity to surgical resection. Specifically, when endometriosis involves the GI tract, the rectum and rectosigmoid are the most common locations. OBJECTIVE: The objective of this video is to discuss three surgical options for bowel endometriosis based on two prominent decision trees by Professor Mario Malzoni and Dr. Mauricio Abrao, while reviewing video clips of each technique. METHODS: Review of two prominent decision trees from experts in the field, depending on the dimensions and characteristics of the bowel lesions. Four surgical demonstrations of rectal DIE include shaving, discoid resection with hand-sewn repair, discoid resection using a transanal circular stapler, and a segmental resection. All surgeries were completed at a tertiary referral center and performed by a fellowship-trained minimally invasive gynecologic surgeon and a general surgeon. RESULTS: Using the decision trees, each nodule was excised while providing background information, explanation of the ultrasound (and occasionally MRI findings), and potential changes to the surgical plan, depending on intraoperative findings. The resections were completed without postoperative complications. CONCLUSIONS: Minimally invasive bowel resection is a viable treatment for rectal DIE. A combination of preoperative imaging, multidisciplinary teams, and evidence-based surgical recommendations allows for safe and effective surgery for our patients.Figure 1