International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
Tailoring Surgical Strategy of Bowel Endometriosis - Mario Malzoni, MD
Hi everyone. Thanks to Endometriosis Foundation of America for the opportunity to share my experience in tailoring the surgical strategy for bowel endometriosis and how the currency of imaging can help the surgeon in order to take the most conservative choice. This sometimes call it invisible disease that at the level of the bowel needs many information for a correct management of bowel and starting from colorectal analysis, skilled imaging indication for clinical management and then canceling with the patients and if needed, surgical approach. The bowel for endometriosis, usually we start with the medical treatment and if the medical treatment is not effective, not tolerated or contraindicated, we go to surgical treatment or we go directly to surgical treatment in case of previous sub occlusion or stenosis with the risk of occlusion or for infertility with no compliance for IVF or after two or more failure of IVF. Surgical treatment could be a shaving OID or segmental resection.
The preparatory cap is based on ultrasound or MRI. We never perform colonoscopy or double contrast cinema. And the key question is to have all the information from the imaging speaking the same language with sonographer and with radiologists. The role of preoperative ultrasound is very clear. This is the international conceptual statements that was published in 2024 from different society with European Society, European SSIS League, ra, international Society, a I and Urogenital Radiology Society of Europe. So with the level of evidence, one, a grade of statements A, the imaging with the transvaginal ultrasound is recommended to detect the presence and the deep of infiltration at the level of the sigmoid and the rectum. So with the Aztec new classification, 2021 of Anson, the C compartment is the infiltration of the rectum, which C one, two, or three depends from the sides of the nole, less than one between one and three or model three centimeters and intestinum.
If there is a localization inside the bowel in the sigmoid or in the right colon or IAC valve, the surgeons in consensus four shall be as complete as possible in order to have at least a visual disease-free margin during the surgery, it's better to avoid to dissect the nerve if there is at the same time of the bowel. A bilateral infiltration on the parametria consider to leave some disease on one side in order to avoid neurological complications and unnecessary dissection of the nerve should be avoided. Always try to be as conservative as possible on the bowel, but if needed, the perform a segmental bowel resection and remove all the fibrotic that fibrosis that seems to be a part of the disease, inner part of the bowel. So the indication for the different kind of surgery from shaving to the co sub segmental resection is based on the sides of the nole, the car sites, the infiltration dipped, the number of the lesion, the circumference of bowel involvement, the distance from the verge and the percentage of stenosis.
These are the picture that we need from ultrasound. Picture A is the chronic cytes that follow the cure of the bowel In picture B is the transverse sites. In C is the circumferential involvement of the bowel. And in picture D, probably the most important evaluation is the dip of infiltration, the maximum infiltration depth of deletions we published in 2020 on gix. Our data regarding the resection, segmental by resection and the indication that we call the EM rule the rule of infiltration of muscularis. So we consider not only the three centimeters in size, less or more, but we consider the seven millimeter like cutoff, the seven millimeter of infiltration in the muscularis. So all the lesions with the infiltration, less than seven millimeter can be treated by a conservative shaving technique and all the nole with infiltration more than seven millimeter in the muscular.
If the site is less than three centimeters, we can do a disclosure resection. If the site is more than three centimeters with infiltration more than seven, the indication is clear for segmental bowel resection. So with this clear preoperative indication, we can reduce the number and the percentage of segmental resection and we can increase the percentage of conservative shaving technique. So the segmented resection we published at our classical technique in 2020 during the classical technique, there is a mini lapar atomic approach in the fire part to perform the fire part of the surgery and then we come back in laparoscopy to perform the end-to-end anastomosis. But we decided to change. This was the complication on the first 720 segmental bowel resection that we performed in our department in the last 15 years. We had 7.3% of grade three complication with 3% of rectal bleeding, 0.7% of rectal degener fistula, 1.6% of leakage, and 1.3% of stenosis.
Then we decided run two years ago to change from an abdominal mine lap proteomic approach to perform the last part of the segmental bowel resection to a totally laparoscopic resection with inor poly anastomosis and the natural orifice specimen extraction. The so-called nose technique start starting from the consideration of colorectal surgeon and the previous randomized trials, systematic review and meta-analysis that support that no should be preferred to transabdominal mineral lap proteomic approach for specimen extraction for a lower rate of postoperative pain, infection and incisional area, shorter time of gas passage after surgery. Of course better cosmetic results and decrease of hospital stay. The main criticism at the beginning was the implantation tumor and specimen extraction site during the nose for colorectal cancer in the previous study, but the results was totally different in terms of recurrence, local total disease-free survival and overall survival. The same for the second criticism regarding the risk of bacteria contamination for opening of the rectum during the surgery.
But the infection and the ileus was totally the same. So no difference in stem in terms of infection, comparing all the technique with the mini laparotomy and the new one with the nose. And so we publish in 2021 our proposal of modified nose technique that I will show you in the video. So this is the rectal nole, bigger than three centimeter with an infiltration, very deep more than seven, and the preparation starts on the left side with the identification of the landmarks in the retroperitoneal era. Of course the external IAC artery and vein, the common iliac artery vein, the ureter of course the IP ligament, the left hypogastric nerves. And now we are opening the media paral space going in the AYA space. Then we stay very close to the rectum. So compared with the classical technique with news, you stay very, very close to the bowel.
We don't need the big dissection and less mobilization of the bowel, so we respect better the vascularization of the bowel. Now we are opening the rec general septum and then we move on the right side to open the gray vascular space at the level of the protium. Then we identify the right typo gastric nerves and we stay mely to the right typo gastic nerve and to all the hypogastric branches. And we stay medially and we push very gently the branches of the right hypogastric nerves laterally, and we stay medially in the area without nerves. Then we evaluate the area of the resection, and now we start the difference with the classical technique, the preparation of the bowel with ultrasound instruments and now with ultrasound instrument with harmonic, we cut completely the rectum, then we cut the proximal rectal part and completely after the complete resection, the specimen is removed through the anus to the rectum.
So the transrectal extraction of the specimen and through the rectum we insert the Anil with the green spike, the spike go in theran part of the rectum. And then with this movement or rotation, the Amil stay inside. And with the 12 millimeter port on the right side, we introduced the linear stapler in order to perform the closer of the lateral part of the rectum. Then we close with another linear stapler, the cal part of the rectum, and with a SL stapler we go to perform the classical rare assmosis. And this is the file results that we can see in the file picture. This is the nole inside very, very, very deep and bigger. And this is the sides of the nole with the inner infiltration at the level of the mucosa. We published in 2024, the simultaneous total laparoscopic double segmental resection with the same technique, the nose technique for the destruction of the specimen with the right colon resection, so right amy colectomy.
And the same time the resection of the OID and rectum for double nole infiltrating the ileocecal valve and the rectum. And this is the technique that we use. So the same four strokes, two five millimeter, one 10 millimeter, one 12 millimeter. This is the iios cycle valve nodule with stenosis. This is the rectal endometrioid nole. The mobilization starts on the right side, mobilization on the right colon until the flexor very up cran at the level of the transversal colon. This mobilization is mandatory in order to reduce the tension at the level of the rare anastomosis. Then we open the peritoneum laterally at the level of the right IP ligament and the right ureter. This is the area of the ureter of our AM vessel common artery. Then we identify the IAL mass with the ilio colic vessel, that if we can prepare a vessel by vessel and we can treat the small one with ultrasound instruments.
The IAL vessel are treated with clips when they are a little bit bigger and LOC in order to close. And then we can cut and then we can arrive at the all of the I resection. The ilio colic vascular axis is with the idio colic. Artery and vein are evaluated and using the same clips, the loc, we can close the vessel of the artery in the vein, the bigger one, and then we cut with ultrasound. And then we use from the right side thelina separate to resect the ilio and to resect the right colon of the chen and colon. Then the area of the right colon after hemic colectomy is removed inside the bag through the rectum, open it for the resection of the rectum, and then we perform the anastomosis between the ilio and the right colon. So the two branch of the linear StopRA go inside the ilio and inside the right colon we perform the resection and the anastomosis.
And then we close the open part of the right colon using two line of garbage shoot. This is the final resection results and picture of iliosacral valve stenosis for the nole and the other nole of the sigmoid and rectum. We published the trend results, it's database of our department with at the moment, the biggest area published never publish, published either on the nose technique with 81 cases of patients treated in our center to evaluate the complication, the conversion to conventional technique or to open surgery, the evaluation of endometriosis, free bowel resection margins and evaluation of the recurrence. And to assess the interoperative blood loss, operative time and gastrointestinal functional recovery duration of hospital stay and outcomes eligibility criteria for age more than 18, presence of nodal infiltrating more than seven millimeter, not eligible patients with the concomitant hysterectomy. At the same time for OSIS and not eligible patients with transvaginal nose, it was only 81 cases of transrectal nose.
So this is the preparative preparation. So 12 hours before surgery, metro needles or 500 milligrams at the time of the surgery, one hour before cefazolin, two grams and ole 500 milligrams and 12 hours after surgery, cefazolin one grams and ole 500 milligrams. This was the characteristics at the preoperative ultrasound evaluation of the patients. And the results on the 81 patients was very good. 0%. So zero of residual endometriosis conversion to traditional open technique, zero, no intraoperative complication, no protective stoma. We had seven cases of double resection, six cases involving the IOC cycle valve. At the same time of the rectal SMO nodule, we had 3.7% of grade three complication. One op peroneus, one ureteral lesions, one rectal bleeding, so no leakage. And the one ureteral lesions was related to the parametal excision, so to the ectomy and not to the bowel surgery in the territory.
The, if compare our data with the other very few paper in Tator, you see the conversion rate, the postoperative complication, the percentage of free margin, the recurrence and surgical time and hospital stay very good results. So complication rate very similar to the territory, but complication rate is lower 1.2% if we consider only the bowel complication. So in conclusion, for no technique, we can say that starting for this study is the largest series of patients treated and published it, a hundred percent of endometrial free margin at the histological evaluation, low complication rate and the fast postoperative recovery and good, very good surgical outcomes. But probably more studies are necessary in order to validate the technique. The conclusion for bowel surgeon in general, we can say that imaging is mandatory skill at ultrasound or skill the MRI in order to manage the disease with medical therapy or surgical treatment. In case of surgery, the surgical surgery is mandatory and is mandatory to centralize the patients in the reference center. So thank you so much for your attention.
