Review
Michelle L. Matthews, M.D., Carolinas Medical Center

The objective of this study was to evaluate the feasibility, efficacy, and complications of laparoscopic segmental resection of colorectal endometriosis. This was a prospective study of 40 consecutive women with MRI and ultrasound evidence of colorectal endometriosis with preoperative and postoperative assessment of pain and digestive symptoms by questionnaire. All patients received gonadotropin-releasing hormone analogues for 3 months prior to surgery. The segmental resection was performed in a similar manner for all patients utilizing automated suturing and stapling devices. 

Four of the 36 patients (10%) required conversion to open surgery for either severe adhesions, ureter involvement or an incompletely stapled anastomosis. In addition to colorectal resection, additional procedures were performed in many patients including ovarian endometrioma resection (42.5%), uterosacral ligament resection (87.5%), ureterolysis (67.5%), partial vaginal resection (30%) and hysterectomy (10%). The mean duration of surgery was 6.3 hours and 15% of patients required a blood transfusion. 

The median follow-up after surgery was 15 months. The overall pain score improved in 95% of patients. Transient digestive and urinary symptoms occurred at a rate similar to that expected by laparotomy and most had improvement post-operatively. Complications requiring further surgery occurred in 10% of patients (3 rectovaginal fistulas, 1 pelvic abscess). The patients with rectovaginal fistulas also had vaginal resection in conjunction with the segmental colorectal resection. This rate of rectovaginal fistula formation is higher than in prior published reports with lapartomy (0-3%) although data on vaginal resection in these reports are limited. In conclusion, laparoscopic segmental resection of endometriosis is feasible and improves pain scores and digestive symptoms. However, it has a risk of major post-operative complications.

Comments 
Daniel B. Williams, M.D., Cincinnati, OH

This was a case series that examined the use of laparoscopic segmental colorectal resection for endometriosis. The authors performed a thorough diagnostic evaluation including MRI. They also treated patients preoperatively with a GnRH agonist for 3 months. They reported an overall improvement in pain scores of 95% post-surgery. It would have been interesting to know if there was any pain improvement from baseline using the GnRH agonist alone, prior to surgical intervention. The operative time was over 6 hours, even in presumably experienced hands. Also he complication rate was high, including the need for re-operation as well as blood transfusions. In conclusion, while this procedure can be done laparoscopically, a prospective trial comparing laparoscopy versus laparotomy would be necessary to define the advantage of laparoscopy in the treatment of such patients. As with most advanced laparoscopic procedures, the need for operator expertise cannot be overly stressed.

You may also want to visit Highlights from Fertility and Sterility taken from the ASRM medical journal and ASRM Journal Highlights to read summaries of current articles from other medical journals in the field of reproductive medicine. 

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