V12 - Discoid Excision of Rectal Deep Infiltrating Endometriosis Using Powered EEA Stapler

Purpose/Background: We present the case of 43-year-old female that presented to gynecology for evaluation of endometriosis. She presented with symptoms of menorrhagia, dysmenorrhea, dyspareunia, LLQ pain, and back pain exacerbated by menstruation. She reported dyschezia but denied hematochezia and melena. She was prescribed oral contraceptives to manage her menstrual pain, which initially helped but later led to irregular bleeding. Pelvic MRI was obtained and demonstrated deep infiltrating endometriosis with involvement of the anterior proximal rectum and bilateral ovaries. Due to deep infiltrating rectal involvement, patient was referred to colorectal surgery for assistance with surgical resection.

Methods/Interventions: She was taken to the operating room for robotic excision of endometriosis. Gynecology started with initial pelvic dissection and performed total abdominal hysterectomy and bilateral salpingectomy and oophorectomy. Intra-operative robotic integrated ultrasound was performed and revealed a 2.3cm endometriotic nodule invading the rectosigmoid colon. Decision was made to perform discoid resection of lesion. A 31mm black load EEA Circular stapler with 4-4.5-5.0 mm open staple heights was inserted into the rectum via the anus and fired uneventfully. Repeat intra-operative ultrasound was performed and demonstrated complete excision of endometrial nodule. Flexible sigmoidoscopy was performed was inserted and the rectum was distended while the pelvis was irrigated and there was no evidence of air leak.

Results/Outcomes: Patient had an uneventful post-operative course and was discharged home on post-operative day 2. Final surgical pathology demonstrated benign colon with mucosal involvement by deep infiltrating endometriosis without evidence of dysplasia or malignancy.

Conclusion/Discussion: The powered EEA circular stapler is an innovative technology for discoid excision of deep infilitrating rectal endometriosis. The stapler measures tissue thickness as it closes to avoid firing on tissue that is too thick for the staple load. Furthermore, the powered EEA circular stapler delivers graduated compression with three rows of varied height, which generates less stress on tissue and allows greater perfusion to the staple line relative to the standard manual stapler closure.