V81 - Shave, Disc, Resect. Redefining Approaches in Deep infiltrative Endometriosis involving the Bowel

Purpose/Background: Bowel endometriosis is a debilitating, life-altering disease marked by chronic pelvic pain, dyschezia, and bowel symptoms, with a substantial burden on infertility. In cases refractory to medical management, surgery is indicated for persistent symptoms, obstructive disease, infertility, or extensive bowel involvement. We present a video demonstrating three robotic, lesion-directed, organ and fertility preserving approaches to bowel endometriosis: shaving, disc excision, and segmental resection.

Methods/Interventions: This video demonstrates a lesion-directed robotic approach to bowel endometriosis, with technique selection based on depth and circumferential extent. Patients with serosal/seromuscular implants are amenable to shaving. The implant can be excised with cold scissors and judicious energy to preserve bowel integrity. Disc (full-thickness) excision is applied to isolated nodules; the defect is then closed intracorporeally, the luminal caliber is evaluated by flexible sigmoidoscopy and the specimen is retrieved via natural-orifice extraction. Finally, segmental resection is reserved for multifocal, deeply infiltrating, or stenosing disease; key steps include preservation of the superior rectal vessels when feasible, controlled rectal transection, and the NICE technique (natural-orifice intracorporeal extraction and anastomosis) with transrectal anvil placement and a robotic purse-string, followed by indocyanine-green fluorescence perfusion assessment and endoscopic leak testing.

Results/Outcomes: Across all approaches, dissection prioritizes organ- and fertility-sparing principles, meticulous hemostasis, and tension-free reconstruction conferring good outcomes. This video highlights the technical feasibility of a minimally invasive approach to endometriosis despite the extent of bowel involvement. This allows for precise lesion localization, safe dissection, organ preservation and full-thickness management options for intracorporeal resection and fertility preservation.

Conclusion/Discussion: Using a structured selection algorithm shaving, disc excision, or segmental resection surgeons can achieve effective symptom control while prioritizing organ and fertility preservation and maintaining excellent safety.