Combined robotic transanal transection single-stapled technique (TTSS) in ultra-low rectal endometriosis involvement associated with parametrial and vagina infiltration.

OBJECTIVE: To describe a combined robotic and trans-anal technique used to treat ultra-low rectal endometriosis in a 36-years-old patient with multiple pelvic compartments which was responsible for infertility, dyspareunia, left sciatic pain and severe dyschezia.

DESIGN: Surgical video article.

SETTING: The achievement of a perfect bowel anastomosis in patients with low rectal endometriosis could be challenging due to technical and anatomical limitations [1]. By allowing a right angle rectotomy with a single-stapled anastomosis, the TTSS technique overcomes these technical difficulties ensuring a good quality anastomosis with an easier correction of postoperative anastomotic leakage when it occurs [2,3].

INTERVENTIONS: The surgery starts by splitting the nodule in three components according to different anatomical structures involved (parametrium, vagina and rectum). Parametrial and vaginal fragments are excised as previously described [4]. The rectal involvement is approached following several steps: isolation and cut of inferior mesenteric vessels (IMA, IMV) and left colic artery in order to obtain a proper colon mobilization; transanal rectotomy immediately below the lower limit of the nodule; extraction of the specimen through the anus; proximal bowel segment transection 1 cm above the upper limit of the nodule; introduction of circular stapler anvil into the sigmoid colon; placement of two pursestring to secure the anvil and at distal rectal cuff, respectively; connection of the anvil to the shoulder of circular stapler; stapler closing and firing with coloanal anastomosis formation; stapled line reinforcement by stitching and integrity anastomosis test. No preventive diverting stoma was performed according with our policy [5].

CONCLUSIONS: Although no data are yet available in patients with endometriosis, the use of TTSS technique may be an interesting approach in patients with very low rectal endometriosis involvement.