直肠子宫内膜异位结节盘状切除术的腹腔镜技术,Journal of Minimally Invasive Gynecology

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直肠子宫内膜异位结节盘状切除术的腹腔镜技术
Journal of Minimally Invasive Gynecology ( IF 3.5 ) Pub Date : 2021-01-01 , DOI: 10.1016/j.jmig.2020.05.016
Mario Malzoni ₁ , Marina Coppola ₁ , Marianna Rasile ₁ , Domenico Luzzolino ₁ , Lucia Casarella ₁ , Alessandra Di Giovanni ₁ , Francesca Falcone ₁

Affiliation

目的展示在深部浸润性子宫内膜异位症的背景下进行直肠椎间盘切除术的手术步骤，其特征是肠道病变和宫颈后区域之间的连续性。设计该技术的分步视频演示。设置虽然越来越多地研究了治疗直肠乙状结肠子宫内膜异位症的手术选择，但对于患者是否适合剃须、盘状或节段性切除术尚未达成共识。在我们的实践中，直肠乙状结肠切除术的候选者被认为是结节大 ≤ 3 cm 且深度 >7 mm 的女性 [1]。这样的患者选择，再加上采用标准化的手术技术，使我们能够最大限度地提高成功切除盘状体的机会，最大限度地减少这种手术可能导致的并发症。干预措施该患者是一名 30 岁女性，有便秘、排便困难、痛经、性交痛和慢性盆腔痛病史，对激素疗法无反应。术前超声显示由于直肠子宫内膜异位结节（21 × 7 × 12 毫米）与宫颈后病变（28 × 10 × 27 毫米）深浸润，导致道格拉斯囊完全闭塞。直肠结节浸润肌层，距肛缘 9 cm，狭窄程度估计为 35%。进行了 3 维腹腔镜检查。在直肠松动和直肠阴道间隙开放后，肠结节在其整个周围被隔离。33 mm经肛门圆形吻合器经肛门插入直肠，用于椎间盘切除和直肠壁缝合。总手术时间为55分钟。未发生术中并发症。实现了子宫内膜异位症的完全切除。估计失血量为 10 毫升。手术结束时未放置腹腔内引流管并拔除导尿管。患者术后 3 天出院，未出现术后并发症。在新鲜标本上测量的肠道子宫内膜异位结节的直径为 20 × 7 × 13 毫米。结论需要先进的腹腔镜手术技能来进行有效和安全的直肠盘状切除术。亚专业化和充分的术前评估对于适当规划针对肠内异位症的治疗策略至关重要。估计失血量为 10 毫升。手术结束时未放置腹腔内引流管并拔除导尿管。患者术后 3 天出院，未出现术后并发症。在新鲜标本上测量的肠道子宫内膜异位结节的直径为 20 × 7 × 13 毫米。结论需要先进的腹腔镜手术技能来进行有效和安全的直肠盘状切除术。亚专业化和充分的术前评估对于适当规划针对肠内异位症的治疗策略至关重要。估计失血量为 10 毫升。手术结束时未放置腹腔内引流管并拔除导尿管。患者术后 3 天出院，未出现术后并发症。在新鲜标本上测量的肠道子宫内膜异位结节的直径为 20 × 7 × 13 毫米。结论需要先进的腹腔镜手术技能来进行有效和安全的直肠盘状切除术。亚专业化和充分的术前评估对于适当规划针对肠内异位症的治疗策略至关重要。在新鲜标本上测量的肠道子宫内膜异位结节的直径为 20 × 7 × 13 毫米。结论需要先进的腹腔镜手术技能来进行有效和安全的直肠盘状切除术。亚专业化和充分的术前评估对于适当规划针对肠内异位症的治疗策略至关重要。在新鲜标本上测量的肠道子宫内膜异位结节的直径为 20 × 7 × 13 毫米。结论需要先进的腹腔镜手术技能来进行有效和安全的直肠盘状切除术。亚专业化和充分的术前评估对于适当规划针对肠内异位症的治疗策略至关重要。

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Laparoscopic technique for discoid resection of rectal endometriotic nodules

OBJECTIVE To show the surgical steps used to perform rectal disc excision in a context of deep infiltrating endometriosis characterized by contiguity between intestinal lesion and retrocervical region. DESIGN Step-by-step video demonstration of the technique. SETTING Although surgical options for the management of rectosigmoid endometriosis have increasingly been investigated, there is no consensus regarding patient eligibility for shaving, discoid or segmental resection. In our practice, candidates for rectosigmoid disc excision are considered women with nodules large ≤3 cm and deep >7 mm [1]. Such a patients' selection, together with the adoption of a standardized surgical technique, has allowed us to maximize the chance of successful discoid resection, minimizing the complications potentially derivable from this surgical procedure. INTERVENTIONS The patient was a 30-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia and chronic pelvic pain unresponsive to hormonal therapies. Preoperative ultrasonography showed complete obliteration of the Douglas' pouch due to a rectal endometriotic nodule (21 × 7 × 12 mm) in contiguity with a deeply infiltrating retrocervical lesion (28 × 10 × 27 mm). The rectal nodule resulted to infiltrate the tunica muscularis with a distance from the anal verge of 9 cm and an estimated stenosis of 35%. A 3-dimensional laparoscopy was performed. After rectal mobilization and rectovaginal space opening, the intestinal nodule was isolated in its entire circumference. A 33 mm transanal circular stapler was inserted into the rectum via the anus and used to perform disc excision and suture of the rectal wall. The overall operative time was 55 minutes. No intraoperative complication occurred. Complete excision of endometriosis was achieved. The estimated blood loss was 10 mL. Intra-abdominal drain was not placed and urinary catheter was removed at the end of surgery. The patient was discharged 3 days after surgery and did not experience post-operative complications. Diameters of bowel endometriotic nodule, measuring on fresh specimen, were 20 × 7 × 13 mm. CONCLUSIONS Advanced laparoscopic surgical skills are needed to perform an effective and safe rectal discoid resection. Sub-specialization and an adequate pre-operative evaluation are of utmost importance to appropriately plan the treatment strategy against bowel endometriosis.

更新日期：2021-01-01

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