Bowel shaving, ureteral re-anastomosis and vaginal nodule removal

This is a case of a 30-year-old patient presenting with severe endometriosis and suffering from severe dysmenorrhea, dyspareunia, dyschezia and back pain. The MRI showed a severe reaction with rectovaginal nodule and fibrosis obliterating completely the cul-de-sac, left pararectal fossa, invading the bowel wall and the vagina, and also causing ureteral obstruction.

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Bowel shaving, ureteral re-anastomosis and vaginal nodule removal

Authors

A Wattiez, P Trompoukis, J Nassif, B Gabriel

Abstract

This is a case of a 30-year-old patient presenting with severe endometriosis and suffering from severe dysmenorrhea, dyspareunia, dyschezia and back pain. The MRI showed a severe reaction with rectovaginal nodule and fibrosis obliterating completely the cul-de-sac, left pararectal fossa, invading the bowel wall and the vagina, and also causing ureteral obstruction.

Classification

tips and tricks

Keywords

Bowel shaving, ureteral re-anastomosis, vaginal nodule removal

Media type

Surgical video

Duration

07'18''

Publication

2011-02

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E-publication

WeBSurg.com, Feb 2011;11(02).
URL: http://www.websurg.com/doi-vd01en3144.htm

Bowel shaving, ureteral re-anastomosis and vaginal nodule removal

1. Picture 00'28''

The operation started with extensive adhesiolysis between the uterus and the bowel, identification of ureters, entry to both pararectal fossae, identification and exposure of adnexa and dissection of rectovaginal septum. The procedure was continued with bowel mucosal skinning, ureteral anastomosis and vaginal node removal.

2. Mucosal skinning or bowel shaving 00'56''

This technique consists in completely detaching the endometriotic nodule from the bowel wall. It can also be called bowel shaving. After dissecting the rectovaginal septum and freeing the bowel, attempts are made to detach the endometriotic nodule from the bowel wall. It is very useful to try to grasp the nodule with a toothed forceps, apply tension, and, with the scissors parallel to the bowel wall, the nodule is cut away so deep as to be resected completely with the less possible damage to the wall. Of course, sometimes the opening of the bowel wall is inevitable. If the bowel is stenosed or in case of large nodules causing obstruction of the intestinal lumen, one has to be more radical and proceed with discoid resections or bigger resections and anastomosis. However, the tendency nowadays is to be radical with the disease while preserving normal tissues as much as possible and avoiding large resections. The rectal probe can also be used to identify the cutting limits. At the end, the integrity of the bowel can be tested using air insufflation per rectum and detecting the bubbles after filling the pelvis with water, or by injecting methylene blue per rectum. We should keep in mind that this procedure is a combination of visual and tactile information and experience.

3. Ureter resection and re-anastomosis 05'08''

Sometimes in cases of endometriosis of ureter and obstruction, the ureter has to be resected completely and an anastomosis has to be performed. In this case, if a double J catheter is not already in place, a cystoscopy has to be performed and the double J catheter has to be inserted inside the ureter. The diseased part of the ureter is then resected completely. A helpful tip during the resection is to leave a small piece of the disease in contact with the two parts to be anastomosed. This will help to ease off the tension during the anastomosis, and then this small piece can be cut away completely. Also, one should always be careful to resect sufficiently enough for better approximation of the two parts and good healing. For the anastomosis, Prolene sutures 5/0 or 6/0 are routinely used, and between 4 or 5 knots are placed. Intracorporeal sutures are used. In this case, normal 5mm instruments are used. However, this is more surgically demanding, and for easier suturing, the 3mm micro-instruments can alternatively be used. This is a good technique to remove the disease and leave behind normal tissue that will heal normally, allowing normal ureteral function. Postoperatively, a Foley catheter is left in placed for a few days and six weeks after the intervention, the double J catheter is removed cystoscopically under local anesthetic.

4. Vaginal nodule resection 12'28''

This patient was also suffering from dyspareunia. For this reason, the portion of the nodule invading the vaginal wall had to be removed. Here, the clinical examination during the examination is really important in order to identify the limits between the pathologic hard tissue and the normal vaginal mucosa. The resection is performed by means of the monopolar hook with caution not to touch and traumatize the surrounding tissues. Tension can again be applied to the nodule by the assistant so that the nodule can be identified and resected more easily. The resected specimens are removed from the open vagina and the procedure is continued with suturing. Vicryl or Monocryl 2/0 suture is used. Depending on the size of the defect, one can suture in sagittal or perpendicular planes taking extra caution to avoid vaginal stenosis. The healthy tissue heals fast and six weeks afterwards, the patient can enjoy a normal sexual life without dyspareunia or other similar symptoms.