International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
Between Too Much and Too Less: Extramucosal and Lateral Excision in Colorectal Endometriosis - Elvira Bratila, MD, PhD
The next speaker, which is Elvira Bratila, professor of Obstetric and gynecology, Carol Davila, university of Medicine and Pharmacy of Bucharest, Romania. The physician unites the professional abilities and surgeon expertise with the application and dedication to mentoring the future generation physicians by opening new horizons of knowledge in various fields and areas of competence. The professional activity of Professor Vera Batia reunites the whole spectrum of surgical techniques from classical vaginal surgery to minimally invasive surgery. Welcome
And thank you for invitation and from the opportunity to present our experience and our surgical approach in bowel endometriosis conditions that impact the quality of life of our patient and especially sometimes even after surgery. I represen present our approach in the last years because when we treat bowel endometriosis, we have to choose between three traditional techniques. Shaving that is not very well standardized at it's a technique unique to each team actually and it doesn't assure complete excision in all the cases. Another technique more radical is discoed excision report in the literature with a high rate of postoperative fistula between 3.7 and 7.4. This is an article meta analysis that report in my opinion, and high risk of complication after this procedure. The main issue of this procedure is tissue tension. It creates and the consequence it's ischemia and sometimes the risk of fistula ensure resection.
The most radical technique that you are choosing when you have big nodules, but we have to think about the risk of stenosis and some digestive symptoms after surgery. If you look in the literature, I choose only one review and metaanalysis published in 2020 and we can see the complication and the bowel perforation, rectovaginal, fistula and leakage. It's almost similar between this excision and the bowel segmental resection. On the other hand, if you look about relapse in the literature, you don't have a lot of article about risk of relapse. Relapse. It's a little bit high after shaving and even after this decision, the risk of relapse, it's high too.
To address this challenge between less shaving and too much, we introduced two techniques, extra mucosal excision of bowel, endometriosis and lateral rectal excision designed to offer a precise and effective alternative minimizing complication while assuring complete lesion excision. I will talk first about extra mucosal excision. The rational behind this technique is bowel endometriosis, a benign disease that almost always respects them. Causa and the given rectal anatomy. Anatomy that we meet in all the digestive tract between mucosa and sum mucosa exists the plan proper for dissection and you can use it when you treat deep endometriosis of the bowel.
The technique we inspire with this technique after Heller procedure for SIA and RA mucosal pmy and we propose this technique and detect in the plan. This is a video from sia. We detect between mucosa and sum mucosa and with this technique we allow a safe and controlled excision of the bowel endometriosis. The first step of the procedure is to change the S shape of the rectum into a straight shape. Pull out the rectum from the pelvis and sure we respect the principle of nurse bearing surgery with this step is very important because we rise the level of the nodule and it's more accessible if you want to do an extra mucosal excision of the nodule or even lateral rectal excision. This is a video with a step of the procedure. You use extra mucosal excision for C one and some C two bowel endometriosis. We start with excision of the lesion from the lateral side and then only with coal scissor. We are not using electricity because you don't want to burn the mucosa and have complication after surgery. This is a case with two nodules C one. After we excise the nodule, we check the integrity of the mucosa that is very well seen in the video and then we go to remove the other nodule testing against the mucosa.
And after the last step is to cover the mucosa with lateral part of the dissection area using running suture. Usually you are using PDS four zero. We consider that it's better don't use electricity because with suture all the bleeding is stopped and it's not necessary to, in most of the cases not necessary to use bipolar. Now we are using the technique even with the robot. We start to do this technique starting in 2024. It's a very fast technique. Short patient stay in the hospital only three days and we follow the patient even at the end of the surgery with rect oscopy and two months after surgery. And you are using this technique even for ELL lesion, special for multiple allele lesion. In this video you can see how you are doing and avoid the segmental excision of the small bowel. After we dissect the nodule in the plant between mucosa and submucosa, we suture with PDS in the running suture sometimes depends of the depths of the nodule because it's a three-dimensional actually volume of the bowel nodule.
When you check the integrity of the mucosa, we can see that we have a hole in this video. The hole, it's very small and it's enough to suture with PDS four zero because sure it is better to before with ultrasounds the depths of the nodule in the muscular layer, but I don't think it's very accurate. Comparing with we are finding during surgery, you can see we check the mucosa and when you check very carefully you see that we have a little hole that we are suture and the second layer that re approximate the margin of the tissue that was detected and then check again to see if the mucosa is very well suture. Here it's another case a little bit bigger nodule when we check the mucosa, but we have a biggest hole with suture, but it's not, the integrity of the mucosa is not satisfactory and we go to the other technique, lateral excision, you can see the hole in the mucosa here we finish to remove the bowel nodule sutures, the mucosa in a running suture and when we check with blue dye you see that it's not enough and we apply the other technique, lateral rectal resection, we the linear stapler and comparing with the discoid resection when the margin of the resection are inverted with linear stapler, you see the margin are averted.
We prefer to put a suture to cover the resection, lateral resection of the rectum. With linear stapler we can use for nodule classified like C two or in some cases C3 or we can avoid the double circular, double discoid excision the same. The S shape of the rectum and the deposition of the nodule are not proper to use the linear stapler. That's why we mobilize the rectum, depends how we are needed to do the technique, prepare the nodule and then excise it with linear stapler. The difference between lateral and disc excision is less tension with this technique and less ischemic area and sure that lead with less fistula and leakage. After this procedure, this is a video with this step, this is a nodule. We start to mobilize the rectum on the right side and then on the left side we can mobilize enough that is necessary to put it in a straight line.
Sometimes if the nodule lids big, you can go in a holy plane From the right to the left side depends how you need to put in a straight line. And after mobilize the rectum, we prepare, ands, dissect the margin of the nodule, and then we put a thread for attraction to put for a better exposure when we use the stapler and then we excise the nodule. But very important we put foche catheter in the rectum. It's very important to have a very good excision and on the other side with the foche catheter, especially if you do this technique robotically, put better the recal linear shape. Now for example, we have a case with multiple nodule on the aschen colon and we are using the same technique to avoid right hemi colectomy and we put more threads to expose better the nodule and do the right technique with mobilize the right colon and use the linear stapler to excise the nole.
To conclude the extra mucosal excision of bowel endometriosis is indicated for C one and C two bowel deep endometriosis. The two major advantages of this technique are complete excision and avoid unnecessary resection for some C two nodule, but require experience in colorectal surgery because when you have a hole in a mucosa, we can change the technique and you can do a technique like lateral excision and the lateral rectal resection for endometriosis is indicated for deepest nodule and bigger for C two or some cases with nodule over three centimeters. It's a very simple technique, fast technique, even if you are talking about extra mucosal excision or lateral recal excision, the bowel step is between 30 and 50 minutes with high reproducibility. Even for gynecologic surgeon, this is very important. I think we are not in a wild west, but in some cases it's better to refine our surgical strategy because we can enhance the quality of care of the patient with bowel endometriosis, ensuring first complete excision because we don't have enough data about the lesions that we are raised in place or the microscopic of endometriosis because 30% of this excision has positive margin and avoid and reducing complication and preserving.
Another important issue is to preserve intestinal function. Very important because a lot of our patient has digestive complaint after bowel surgery, but this technique and we will communicate our results, the patient are very well in recovery is very fast. Thank you very much for attention and this is my team. Thank you very much. Part of my team.
