title: Deep shaving and transanal disc excision in large endometriosis of mid and lower rectum: the Rouen technique.
abstract: Colorectal resection is performed in a majority of patients presenting with large endometriosis of mid and lower rectum; however, it may negatively and irreversibly impact postoperative rectal function. To avoid such unfavourable outcomes, we propose an original technique combining laparoscopic deep rectal shaving and transanal disc excision using a semi-circular stapler.
  
  
  
  The video presents the procedure performed in a 29-year-old nullipara referred with a large endometriotic nodule infiltrating the lower rectum on more than 30 mm length. The first step is laparoscopic and involves deep rectal shaving performed using exclusively the plasma energy. Then, transanal excision of shaved area is performed, by placing traction parachute sutures in the middle and outside the shaved area. Their traction induces the prolapse of shaved area that is resected using a semicircular stapler. Insufflating the rectum with air checks the integrity of the staple line.
  
  
  
  Operative time was 210 min. Immediate postoperative outcomes were uneventful, and bowel movements were normal beginning with day 6. Our technique is suitable in large rectal nodules located up to 10 cm above the anus, infiltrating the rectum on up to 6 cm length, and these parameters are preoperatively assessed using MRI and computed tomography. To date, it was successfully carried out in 29 women with large deep endometriosis of the mid and lower rectum. Rectovaginal fistula was recorded in one patient (3.6 %) and transitory bladder dysfunction in seven patients (25 %). Digestive function assessment using standardized questionnaires revealed an overall improvement, without de novo anal continence troubles. Postoperative pregnancy rate was 78 % with a majority of patients having conceived spontaneously.
  
  
  
  Based on our experience, we believe that our conservative technique is feasible and reproducible in large mid and lower rectal endometriosis and might avoid the risk of unfavourable outcomes related to low colorectal resection.
authors.affiliation: Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France. horace.roman@gmail.com.|Research Group EA 4308 'Spermatogenesis and Male Gamete Quality', Rouen University Hospital, Rouen, France. horace.roman@gmail.com.
authors.forename: Horace
authors.initials: H
authors.lastname: Roman
authors.affiliation: Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France.
authors.forename: Carole
authors.initials: C
authors.lastname: Abo
authors.affiliation: Department of Digestive Surgery, Rouen University Hospital, Rouen, France.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Huet
authors.affiliation: Department of Digestive Surgery, Rouen University Hospital, Rouen, France.|Digestive Tract Research Group EA3234/IFRMP23, Rouen University Hospital, Rouen, France.
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Tuech
mesh_terms: D055011:Ablation Techniques / Q000295:instrumentation / Q000379:methods*; D000328:Adult; D004715:Endometriosis / Q000601:surgery*; D005260:Female; D006801:Humans; D010535:Laparoscopy; D011351:Proctoscopy; D012002:Rectal Diseases / Q000601:surgery*; D012007:Rectum / Q000601:surgery; D013528:Surgical Staplers; D017792:Surgical Stapling / Q000295:instrumentation / Q000379:methods*; D013536:Suture Techniques
keywords: Colorectal endometriosis; Colorectal resection; Deep endometriosis; Disc excision; Full thickness excision; Transanal stapler