ABSTRACT
The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long-term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5-8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short- and long-term complications.
Subject(s)
Digestive System Surgical Procedures/methods , Endometriosis/surgery , Intestinal Diseases/surgery , Anal Canal/surgery , Conservative Treatment , Contraceptives, Oral, Combined/therapeutic use , Danazol/therapeutic use , Endometriosis/diagnostic imaging , Endometriosis/drug therapy , Endosonography , Estrogen Antagonists/therapeutic use , Female , Humans , Intestinal Diseases/diagnostic imaging , Intestinal Diseases/drug therapy , Laparoscopy , Leuprolide/therapeutic use , Magnetic Resonance Imaging , Ovulation Inhibition , Pelvic Pain , Postoperative Complications/prevention & control , Progestins/therapeutic use , Rectal Diseases/diagnostic imaging , Rectal Diseases/drug therapy , Rectal Diseases/surgery , UltrasonographyABSTRACT
BACKGROUND: Cesarean delivery adhesions, during laparoscopic hysterectomy, can present surgical challenges, including distortion of anatomy, prolonged operating time, and inadvertent injury to nearby structures. TECHNIQUE: At the time of laparoscopic hysterectomy, in patients with significant adhesions from prior cesarean deliveries, we use a reverse inferior to superior vesicouterine fold dissection to mobilize the scarred bladder. We use this as an alternative to the commonly practiced technique of mobilizing the bladder in a superior to inferior fashion at the time of laparoscopic hysterectomy. EXPERIENCE: Fifty-two patients with a median age of 42.5 years are presented. Forty-eight patients were discharged within 3-6 hours postoperatively. Sixteen patients were discharged with Foley catheters, because they were unable to void within the protocol for a fast-track discharge. The catheters were removed between postoperative days 1 and 5. There were no gastrointestinal or genitourinary complications. One patient experienced a delayed vaginal cuff abscess and bleeding, which were managed conservatively. CONCLUSION: Reverse vesicouterine fold dissection is a useful alternative technique for laparoscopic hysterectomy in women with a history of prior cesarean deliveries.
