Publications de l'équipe IFEMEndo

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Horace Roman
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Colorectal surgeons often participate in the multidisciplinary management of young females with endometriosis. Complications of endometriosis as well as its management often result in infertility since they can involve all pelvic organs including the procreative organs: uterus, ovaries and fallopian tubes. Complete excision of all endometriotic lesions should not be performed at the expense of irreversible destruction of the procreative organs; definitive infertility should not be the price to pay in order to obtain an improvement of the painful symptoms caused by endometriosis. Surgery for ovarian endometriomas should be specifically adapted to the patient's desire for future conception and to her preoperative ovarian reserve. Two main techniques are used to treat ovarian endometriomas: ovarian cystectomy excises the wall of the cyst while ablation consists of destruction of the internal surface of the cyst. The use of mono polar or biolar coagulation for cyst ablation is strongly contra-indicated. Ablation using laser or plasma energy has resulted in comparable rates of post-operative pregnancy to those obtained by ovarian cystectomy. Patients who wish to delay their attempt to conceive for some period of time, should be placed on long-term oral contraception with prevention of menstruation to reduce the risk of recurrent endometriosis. When surgery for colorectal endometriosis is necessary, the laparoscopic approach increases the chances of spontaneous conception compared to laparotomy. Surgery for deep-seated endometriosis has been accompanied by a high rate of spontaneous conception and successful pregnancy and does not seem to decrease the chances for conception by in vitro fertilization.
Objective Deep endometriosis infiltrating the rectum may be managed by full thickness disc excision, with the goal of preserving rectal function and avoiding low anterior rectal resection syndrome. Transanal staplers may be successfully used to remove rectal wall disc and concomitantly to perform rectal suture. The goal of the video article is to identify 10 steps which may render the procedure standardized and reproducible. Design Step-by-step video demonstration of the procedure. Setting A French tertiary referral center. Intervention The video presents disc excision of deep endometriosis infiltrating the rectum using transanal circular stapler, following 10 steps: 1) Nodule dissection and rectum releasing; 2) Rectal shaving; 3) Removal of fat tissue on lateral rectal wall; 4) Placement of a suture on shaved area; 5) Introduction of the transanal circular stapler closed; 6) Stapler opening at nodule's level; 7) Knot performing; 8) Stapler closed and fired; 9) Stiches to reinforce the stapled line; 10) Bubbles’ test. From 2009 to 2020, the author has performed this procedure in 205 patients; mean disc diameter was 40+/-8 mm, microscopic foci were found on disc edges in 25.7%, rectal recurrences rate was 1.5%, while leakage rate was 4.4%. The local institutional review board stated that approval was not required because the video describes a technique and does not report a clinical case. Conclusion Disc excision using transanal circular stapler following 10 steps is a standardized and reproducible procedure. The learning curve may be short, as colorectal surgeons routinely employ the stapler to perform laparoscopic colorectal anastomosis.