Treatment of Endometriosis of Uterosacral Ligament and Rectum through the Vagina: Description of a Modified Technique

O. Camara; J. Herrmann; A. Egbe; A. Kavallaris; H. Diebolder; M. Gajda; I.B. Runnebaum


Hum Reprod. 2009;24(6):1407-1413. 

In This Article

Abstract and Introduction


Background: Endometriosis is common in women of childbearing age, whereas involvement of the rectosigmoid requiring resection is rare. Laparoscopy has become a standard procedure in the management of endometriosis. The optimum way to diagnose endometriosis is by direct visualization of the implants. Usually for the removal of the specimen, an additional larger abdominal incision is needed.
Methods: Here we report on cases of four patients with a uterosacral ligament and rectal endometriosis who were successfully treated with combined laparovaginal resection, using a modification of an existing technique. They had been complaining of rectal bleeding and lower abdominal pain in relation to their menstrual cycle. The aim of this technique is to achieve a careful and margin-free resection of the area involved. This can be done without any large incisions of the abdominal wall. The hypogastric nerves remain preserved on both sides.
Results: The intra- and post-operative courses were uneventful. No blood transfusions were needed. Haemoglobin decrease was usually ≤ 1 mmol/l. The average tumour diameter was 3.5 cm.
Conclusions: Our technique circumvents a larger abdominal incision. This combined laparoscopic–transvaginal approach, avoiding the extension of port-site incisions, represents a viable option for the treatment of bowel endometriosis.


Endometriosis is one of the most common gynaecological diseases that affect women of childbearing age (Redwine et al., 1996; Anaf et al., 2000).

The most frequent locations of endometriosis are the ovaries and the pelvic peritoneum (Anaf et al., 2000). The presence of bowel involvement has been reported to be between 3.8 and 37% (Beltran et al., 2006; Leconte et al., 2007). Endometriosis of the sigmoid and rectum is rare, but can give rise to severe gastrointestinal and pelvic symptoms (Houtmeyers et al., 2006). Surgical treatment of bowel endometriosis remains, however, controversial. Recurrence is a common finding in women who undergo surgery for endometriosis (Vignali et al., 2005; Busacca et al., 2006; Brouwer and Woods, 2007). In terms of improvements in pain control and quality of life, surgical treatment achieves good results (Chapron et al., 2001; Chapron et al., 2004; Vercellini et al., 2006; Darai et al., 2007). Moderate bowel involvement requires partial or en-bloc excision (Woods et al., 2003). Deeper lesions are treated with segmental resection (Redwine et al., 1996; Breitenstein et al., 2006; Langebrekke et al., 2006; Lyons et al., 2006; Ribeiro et al., 2006; Brouwer and Woods, 2007). Laparoscopy has become a standard procedure in managing endometriosis (Redwine et al., 1996; Anaf et al., 2000; Chapron et al., 2001; Chapron et al., 2004; Angioni et al., 2006; Langebrekke et al., 2006; Ribeiro et al., 2006; Sakamoto et al., 2006; Brouwer and Woods, 2007). Low anterior resection is common in rectal endometriosis (Brouwer and Woods, 2007).

Previously, 50 patients at the University Hospital Jena with the triad of intestinal pain, palpable disease in the rectovaginal septum and laparoscopic diagnosis of endometriosis of the cul-de-sac and/or rectosigmoid colon underwent combined laparoscopic with or without vaginal en-bloc resection of the cul-de-sac, with partial resection of the posterior vaginal wall and rectum with re-anastomosis by mini-laparotomy (Kavallaris et al., 2003).

We now describe a hybrid Natural Orifice Translumenal Endoscopic Surgery (N.O.T.E.S.) as a modification of the technique previously published in Kavallaris et al. (2003) for the treatment of endometriosis in four patients without mini-laparotomy.


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