Robotic-Assisted Laparoscopic Surgery for Deep Infiltrating Rectal Endometriosis

Madhu Ragupathi, MD, Jonathan L Zurawin, Javier Nieto, MD, Robert K Zurawin, MD, Eric M Haas, MD, FACS, FASCRS

Colorectal Surgical Associates, Ltd, LLP / Minimally Invasive Colon

INTRODUCTION: Deep infiltrating endometriosis (DIE) is a chronic gynecologic disorder that can have devastating ramifications on overall patient quality of life. Although open and minimally invasive surgery have been utilized for the management of DIE of the rectum, these procedures are often technically challenging due to the restrictive nature of the pelvis and the potential anatomic distortions associated with the disease. Robotic-assisted laparoscopic surgery (RALS) affords an approach that may assist in overcoming many of the technical limitations encountered during surgery. We assessed our experience and outcomes utilizing robotic-assisted laparoscopic technique for deep infiltrating endometriosis of the rectum.

METHODS AND PROCEDURES: Consecutive patients presenting with rectal DIE were treated with RALS technique at the Texas Medical Center in Houston, TX between December 2008 and April 2011. All procedures were performed using the da Vinci® S Surgical System. Isolated rectal lesions less than 2 cm in diameter were excised in a full thickness fashion and the rectal wall defect was subsequently closed using interrupted sutures. Low anterior resection (LAR) was performed for those lesions not readily removed by excision. A diverting loop ileostomy was fashioned for fecal diversion in those cases with an ultra-low pelvic anastomosis. Demographic data and perioperative outcomes were analyzed.

RESULTS: Robotic technique was utilized for the management of complex rectal DIE in 12 female patients with a mean age of 38.3±6.9 (range: 29-49) years, mean BMI of 29.3±6.5 (range: 19.0-39.0) kg/m2, and median ASA of 2 (range: 1-3). All but one patient (91.7%) had a previous history of abdomino-pelvic surgery. Nine patients (75%) had undergone a previous procedure for endometriosis and six (50%) had undergone a previous hysterectomy. Five rectal resections and seven disc excisions were performed (Table). The mean total operative time and estimated blood loss for all procedures were 215.4±78.1 (range: 90-360) min and 99.5±86.3 (range: 20-300) ml, respectively. Three patients with an ultra-low pelvic anastomosis required a loop ileostomy for diversion of the fecal stream. One intraoperative complication, a thermal injury, was encountered and required primary colorrhaphy for repair. None of the procedures required conversion to an open approach. The mean length of hospital stay was 2.4±1.8 (range: 1-7) days. There were no anastomotic leaks or mortalities. Three complications (25%) occurred during 30-day follow-up. One patient developed a urinary tract infection requiring treatment with antibiotics. The other two patients (16.7%) required readmission. The first patient presented with vaginal bleeding and a partial dehiscence of the vaginal cuff. The patient required a secondary surgical procedure to revise the cuff. The second patient was readmitted for a presacral abscess, which was successfully treated with intravenous antibiotics and transvaginal drainage.

CONCLUSIONS: Robotic-assisted laparoscopic surgery is a safe and feasible approach for the surgical management of deep infiltrating endometriosis of the rectum. This procedure facilitates discoid excision and low pelvic anastomosis without significant morbidity or conversion in this complex subset of patients.

Session: Poster Presentation

Program Number: P652

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