SEGMENTAL RESECTION OF THE SIGMOID RECTUM WITH SURGICAL SPECIMEN EXTRACTION VIA VAGINAL ROUTE (NOSES) COMBINED WITH PAN-HYSTERECTOMY. STEP-BY-STEP LAPAROSCOPIC TECHNIQUE

This work aims to demonstrate the step-by-step surgical treatment of deep endometriosis involving the recto-sigmoid via video laparoscopy, with surgical specimen extraction through a natural orifice, utilizing the vaginal opening during hysterectomy. It concerns a 53-year-old patient who complained of changes in bowel habits, thinning of stools, and no hematochezia for about 2 years. She had an incomplete colonoscopy performed at another facility, whose report showed a fixed angulation and possible obstruction approximately 15-20 cm from the anal margin. She has one daughter, vaginal delivery 20 years ago, and is widowed. A transvaginal ultrasound with bowel preparation was requested, which found: a right retrouterine ovary, adhered to the right uterosacral ligament, with a 15.5 cm³ endometrioma. Deep endometriosis lesions in both uterosacral ligaments. The vagina appeared normal. Three lesions in the recto-sigmoid, the most distal about 9 cm from the anal margin, the second 12 cm from the anal margin, and the most proximal located about 18 cm from the anal margin, occupying about 50% of the sigmoid circumference, with a size of 4.5 cm. Given these findings, surgery was proposed, and the procedure performed was laparoscopic pan-hysterectomy with treatment of the endometriosis lesions and segmental resection of the rectum and sigmoid, encompassing the 3 lesions, removing the surgical specimen via the vagina (NOSES). The illustrative video shows the step-by-step of the surgery for deep endometriosis with intestinal involvement, when there are multiple intestinal lesions and sigmoid obstruction. The video will show the cavity inventory, protection of nerves and ureters, release of the rectum and sigmoid, pan-hysterectomy, removal of the vaginal specimen, sectioning of the rectum with a laparoscopic linear stapler with a single load, preservation of the mesorectum, removal of the bowel via the vagina, creation of the purse-string suture, passage of the circular stapler’s anvil, new pneumoperitoneum, creation of the anastomosis with double stapling, integrity test of the anastomosis, and vaginal closure by laparoscopy.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025