Surgical procedures
CDH, endometriosis, fecal spillage
ENDOMETRIOSIS, PNEUMOPERITONEUM, STERILE, CAVITY, VAGINA, PELVIC ADHESIONS
The primary objective of surgery was to achieve visibly complete elimination of all endometriotic lesions, regardless of the technique used. The team included two gynecological surgeons with extensive experience in endometriosis surgery. Nerve-sparing and vessel-sparing techniques were used to preserve the inferior hypogastric plexus, hypogastric nerves, and splanchnic nerves on at least one side.All patients were placed in the modified dorsal lithotomy position. Pneumoperitoneum was induced by inserting a Veress needle (Karl Storz, Tuttlingen, Germany) into the umbilicus. A 4-port approach was used. Subsequently, the patient was placed in the steep Trendelenburg position. During the procedures, adhesiolysis was implemented for mobilization of the rectum and sigmoid colon in cases of pelvic adhesions. The ureters were dissected at the level of the uterine arteries. Limited tubular resection in a mesosparing manner close to the bowel was used to preserve the branches of the inferior hypogastric plexus.During the complete intra-abdominal NOSE procedure, after skeletonization and isolation of the affected rectum, the rectum was tied off laparoscopically proximally and distally to the DE nodule with a nonabsorbable suture (Dafilon 0; B Braun AG). A laparoscopic atraumatic temporary intestinal clamp (Aesculap) was placed to decrease the chance of fecal spillage, cephalad to the resection line. A transverse colostomy was performed in healthy tissue using a harmonic scalpel to deliver the anvil from a circular stapler (Proximatew ILS CDH 29, Ethicon Endo-Surgery) introduced through the anus using a sterile laparoscopic camera sleeve (folded laparoscopic camera sleeve; 3M, St Paul). With the use of a camera sleeve for anvil introduction into the abdominal cavity, the possibility of peritoneal cavity contamination was reducedA completely transected specimen was extracted transrectally through the camera sleeve in a specimen retrieval bag. The proximal part of the anastomosis was created by suturing the anvil in place with the purse-string of a monofilament laparoscopic suture (PDS 2.0; Ethicon, Inc.). The intestinal clamp was removed. The distal rectum was closed by using an endoscopic linear stapler. End-to-end anastomosis was performed by using a circular stapler.With conventional segmental bowel resection, dissection was continued towards the pelvic floor distally to the affected segment. The rectum was then skeletonized using a vessel-sealing device (Harmonic Scalpel ACE; Ethicon Endo-Surgery) laterally and anteriorly, entering the rectovaginal septum and preserving the posterior wall of the vagina. The distal rectum was closed using an endoscopic linear stapler (Echelon Flex Endopath, Ethicon Endo-Surgery). The mobilized rectum with the specimen was retrieved through a small suprapubic incision. The anvil of a conventional circular stapler was introduced into the proximal colon following the placement of a purse-string suture (PDS 2.0; Ethicon, Inc.). Circular stapled colorectal end-to-end anastomosis was then performed (Proximatew ILS CDH 29).At the end of both procedures, extensive saline irrigation was performed, and the integrity of the suture line at the distal rectum was verified using the Michelin test. A drain was conventionally left in place in the pouch of DouglasThe perioperative care was similar in patients from both arms of the study as the participants received the same medication and nursing technique.