[Frontiers in Bioscience E5, 316-332, January 1, 2013]

Surgery for deep infiltrating endometriosis: Technique and rationale

William Kondo1,2, Nicolas Bourdel1, Monica T. Zomer2, Karem Slim3, Revaz Botchorischvili1, Benoit Rabischong1, Gérard Mage1, Michel Canis1

1Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie Aubrac, 63003 Clermont-Ferrand, France, 2Department of Gynecology, Sugisawa Medical Center, Av. Iguaçu 1236, Curitiba, Parana, Brazil, 3Department of Digestive Surgery, CHU Estaing, 1 Place Lucie Aubrac, 63003 Clermont-Ferrand, France


1. Abstract
2. Introduction
3. Ergonomy
3.1.Positioning of the patient
3.2. Placement of the trocars
3.3. Uterine manipulation
4. Principles of surgery
4.1. Exposition and adhesiolysis
4.2. Precise and careful dissection
4.3. Respect the healthy tissue
5. Surgical steps
5.1. Inspection of the abdominal cavity
5.2. Treatment of lesions in the anterior pelvic compartment (anterior cul-de-sac, vesico-uterine septum and bladder)
5.3. Treatment of the ovarian endometrioma
5.3.1. Anatomy
5.3.2. Surgical Procedure
5.3.3. Surgical steps of ovarian cystectomy
5.4. Treatment of lesions in the posterior pelvic compartment
5.4.1. Dissection of the healthy tissue: mobilization of the sigmoid colon and identification of the ureter
5.4.2. Ureteral dissection
5.4.3. Transection of the utero-sacral ligament and identification of the pararectal space
5.4.4. Identification of the lateral borders of the nodule and the posterior vaginal fornix
5.4.5. Separation of the nodule from the anterior rectal wall Traditional technique Reverse technique
5.4.6. Vaginal suture repair
5.5. Final checklist
7. References


The surgical treatment of deep infiltrating endometriosis is challenging and complex. Currently, the gold standard for patient care is the referral to tertiary centers with a multidisciplinary team including gynecologists, colorectal surgeon and urologist with adequate training in advanced laparoscopic surgery. The surgical technique is essential to adequately manage the disease and to minimize the risk of complications; however, the technique is rarely taught and described in details. This paper reviews our current technique and all the tricks to allow the reproduction and even the improvement of this technique by other surgeons.