Endometriosis: Management of Deep Infiltrating Endometriosis of Rectum and Sigmoid
Mariam Alhilli
Hermann Kessler
Perioperative Considerations
Definition—Deep infiltrating endometriosis: solid mass deeper than 5 mm below peritoneal surface (Figs. 38-1 and 38-2)
 FIGURE 38-1 ▪ Deep infiltrating endometriosis involving rectovaginal septum, posterior uterine serosa, and pelvic sidewalls. |
 FIGURE 38-2 ▪ Deep infiltrating endometriosis involving right ovarian fossa and posterior pelvic peritoneum and rectum. |
Location within pelvis
Rectovaginal septum
Rectocervical space
Uterosacral ligaments
Vagina
Ovaries (endometrioma)
Rectum, mesorectum, sigmoid, or mesocolon (Figs. 38-3 and 38-4)
 FIGURE 38-3 ▪ A. Endometriotic implants involving ascending colon and cecum. B. Endometriotic plaque involving sigmoid colon and mesentery. |
 FIGURE 38-4 ▪ Magnetic resonance imaging of pelvis showing deep infiltrating endometriosis involving the rectovaginal septum and rectum. |
Indications for surgery
Extensive symptomatic endometriosis (pelvic/abdominal pain)
Infertility
Need to restore organ function
Surgical management
Conservative (shaving or disc excision)
Radical (segmental resection of rectum/sigmoid)
Laparoscopic approach is considered standard of care.
Interdisciplinary treatment involving Urology, Colorectal Surgery, Gynecology or Gynecologic Oncology
Symptom Assessment
Clinical Examination
Rectovaginal examination
Obliteration of rectovaginal septum
Thickening of uterosacral ligaments or nodularity
Fixation, retroversion, and immobility of uterus
Tenderness of vagina and posterior cul-de sac
Speculum examination—pigmented endometriosis vaginal lesions
Biopsy if superficial
Imaging
Magnetic resonance imaging: soft tissue evaluation to verify location and extent of disease (Fig. 38-5)
Computed tomography: pelvic mass evaluation, rule-out ureteral obstruction
Transvaginal ultrasound
Requires experienced sonographer and high level of radiologic expertise
Gastrograffin enema
Flexible sigmoidoscopy—to determine the thickness of lesions, extrinsic bowel compression, penetration of mucosa, and rule-out stricture (Fig. 38-6)
FIGURE 38-5 ▪ Endoscopic image of endometriosis involving rectal mucosa.
FIGURE 38-6 ▪ Dissection of pararectal and paravesical spaces to expose the ureter and uterine vessels.
Cystoscopy—to determine trigone involvement
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