Surgical Endoscopy

, Volume 22, Issue 4, pp 995–1001 | Cite as

Combined vaginal–laparoscopic–abdominal approach for the surgical treatment of rectovaginal endometriosis with bowel resection: a comparison of this new technique with various established approaches by laparoscopy and laparotomy

  • Rosanna Zanetti-Dällenbach
  • Julia Bartley
  • Christine Müller
  • Achim Schneider
  • Christhardt Köhler



A new combined vaginal–laparoscopic–abdominal approach for rectovaginal endometriosis allows intraoperative digital bowel palpation to assess bowel infiltration and prevents unnecessary bowel resections. This technique was compared to various established approaches where bowel resection was indicated by clinical symptoms and imaging results only.


Patients operated for rectovaginal endometriosis with endometriotic bowel involvement between March 2002 and April 2006 at the gynecological department Charité, Berlin, Germany were included. Bowel involvement was suspected by clinical symptoms, clinical examination, and/or results of imaging techniques.

The study group (SG) was operated by the combined vaginal–laparoscopic–abdominal approach (n = 30) and the control group (CG) (n = 18) by laparoscopy (n = 4), laparotomy (n = 3), laparoscopy followed by laparotomy for bowel resection (n = 8) or laparoscopy followed by vaginal bowel resection (n = 3). In all cases histopathology was performed.


The study group and the control group were comparable regarding age, body mass index, symptoms, American Society for Reproductive Medicine (ASRM) classification, colorectal operative procedures, operating times, length of the resected bowel specimen, and concomitant surgical procedures. However, only in the CG were protective stomas required (p = 0.047). There were significantly less complications in the SG (p = 0.027). No patient experienced leakage of anastomosis. Bowel involvement by endometriosis was confirmed by histopathology in the SG in all cases whereas in the CG only in 16/18 (88.9%) cases. Hospitalization time was significantly shorter in the SG. Rehospitalizations were necessary only in the CG to repair one rectovaginal fistula and to reverse three stomas.


With the presented technique of a combined vaginal–laparoscopic–abdominal surgical procedure for rectovaginal endometriosis, we showed that the complication rate, rehospitalization rate, and hospitalization time were significantly lower than in the patients of the CG. Furthermore, the combined vaginal–laparoscopic–abdominal technique allowed better evaluation of the invasiveness of the endometriotic lesion and avoided unnecessary bowel surgery.


Rectovaginal endometriosis Combined vaginal laparoscopic abdominal approach Complications Bowel resection 


  1. 1.
    Dubernard G, Piketty M, Rouzier R, Houry S, Bazot M, Darai E (2006) Quality of life after laparoscopic colorectal resection for endometriosis. Hum Reprod 21:1243PubMedCrossRefGoogle Scholar
  2. 2.
    Darai E, Thomassin I, Barranger E, Detchev R, Cortez A, Houry S, Bazot M (2005) Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis. Am J Obstet Gynecol 192:394PubMedCrossRefGoogle Scholar
  3. 3.
    Ford J, English J, Miles WA, Giannopoulos T (2004) Pain, quality of life and complications following the radical resection of rectovaginal endometriosis. Bjog 111:353PubMedGoogle Scholar
  4. 4.
    Martin DC, Batt RE (2001) Retrocervical, retrovaginal pouch, and rectovaginal septum endometriosis. J Am Assoc Gynecol Laparosc 8:12PubMedCrossRefGoogle Scholar
  5. 5.
    Kavallaris A, Kohler C, Kuhne-Heid R, Schneider A (2003) Histopathological extent of rectal invasion by rectovaginal endometriosis. Hum Reprod 18:1323PubMedCrossRefGoogle Scholar
  6. 6.
    Koninckx PR, Timmermans B, Meuleman C, Penninckx F (1996) Complications of CO2-laser endoscopic excision of deep endometriosis. Hum Reprod 11:2263PubMedGoogle Scholar
  7. 7.
    Jerby BL, Kessler H, Falcone T, Milsom JW (1999) Laparoscopic management of colorectal endometriosis. Surg Endosc 13:1125PubMedCrossRefGoogle Scholar
  8. 8.
    Weed JC, Ray JE (1987) Endometriosis of the bowel. Obstet Gynecol 69:727PubMedGoogle Scholar
  9. 9.
    Macafee CH, Greer HL (1960) Intestinal endometriosis. A report of 29 cases and a survey of the literature. J Obstet Gynaecol Br Emp 67:539PubMedGoogle Scholar
  10. 10.
    Fedele L, Bianchi S, Zanconato G, Raffaelli R, Berlanda N (2004) Is rectovaginal endometriosis a progressive disease? Am J Obstet Gynecol 191:1539PubMedCrossRefGoogle Scholar
  11. 11.
    Koh CH, Janik GM (2002) The surgical management of deep rectovaginal endometriosis. Curr Opin Obstet Gynecol 14:357PubMedCrossRefGoogle Scholar
  12. 12.
    Vercellini P, Pietropaolo G, De Giorgi O, Pasin R, Chiodini A, Crosignani PG (2005) Treatment of symptomatic rectovaginal endometriosis with an estrogen–progestogen combination versus low-dose norethindrone acetate. Fertil Steril 84:1375PubMedCrossRefGoogle Scholar
  13. 13.
    Vercellini P, Pietropaolo G, De Giorgi O, Daguati R, Pasin R, Crosignani PG (2006) Reproductive performance in infertile women with rectovaginal endometriosis: Is surgery worthwhile? Am J Obstet GynecolGoogle Scholar
  14. 14.
    Angioni S, Peiretti M, Zirone M, Palomba M, Mais V, Gomel V, Melis GB (2006) Laparoscopic excision of posterior vaginal fornix in the treatment of patients with deep endometriosis without rectum involvement: surgical treatment and long-term follow-up. Hum Reprod 21:1629PubMedCrossRefGoogle Scholar
  15. 15.
    Garry R, Clayton R, Hawe J (2000) The effect of endometriosis and its radical laparoscopic excision on quality of life indicators. BJOG 107:44PubMedCrossRefGoogle Scholar
  16. 16.
    Urbach DR, Reedijk M, Richard CS, Lie KI, Ross TM (1998) Bowel resection for intestinal endometriosis. Dis Colon Rectum 41:1158PubMedCrossRefGoogle Scholar
  17. 17.
    Redwine DB, Wright JT (2001) Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection. Fertil Steril 76:358PubMedCrossRefGoogle Scholar
  18. 18.
    Coronado C, Franklin RR, Lotze EC, Bailey HR, Valdes CT (1990) Surgical treatment of symptomatic colorectal endometriosis. Fertil Steril 53:411PubMedGoogle Scholar
  19. 19.
    Chapron C, Jacob S, Dubuisson JB, Vieira M, Liaras E, Fauconnier A (2001) Laparoscopically assisted vaginal management of deep endometriosis infiltrating the rectovaginal septum. Acta Obstet Gynecol Scand 80:349PubMedCrossRefGoogle Scholar
  20. 20.
    Donnez J, Nisolle M, Gillerot S, Smets M, Bassil S, Casanas-Roux F (1997) Rectovaginal septum adenomyotic nodules: a series of 500 cases. Br J Obstet Gynaecol 104:1014PubMedGoogle Scholar
  21. 21.
    Anaf V, Simon P, El Nakadi I, Simonart T, Noel J, Buxant F (2001) Impact of surgical resection of rectovaginal pouch of Douglas endometriotic nodules on pelvic pain and some elements of patients’ sex life. J Am Assoc Gynecol Laparosc 8:55PubMedCrossRefGoogle Scholar
  22. 22.
    Redwine DB (1992) Laparoscopic en bloc resection for treatment of the obliterated cul-de-sac in endometriosis. J Reprod Med 37:695PubMedGoogle Scholar
  23. 23.
    Redwine DB, Koning M, Sharpe DR (1996) Laparoscopically assisted transvaginal segmental resection of the rectosigmoid colon for endometriosis. Fertil Steril 65:193PubMedGoogle Scholar
  24. 24.
    Jadoul P, Feyaerts A, Squifflet J, Donnez J (2007) Combined laparoscopic and vaginal approach for nephrectomy, ureterectomy, and removal of a large rectovaginal endometriotic nodule causing loss of renal function. Journal of Minimally Invasive Gynecology 14:256PubMedCrossRefGoogle Scholar
  25. 25.
    Martin DC (1988) Laparoscopic and vaginal colpotomy for the excision of infiltrating cul-de-sac endometriosis. J Reprod Med 33:806PubMedGoogle Scholar
  26. 26.
    Possover M, Diebolder H, Plaul K, Schneider A (2000) Laparascopically assisted vaginal resection of rectovaginal endometriosis. Obstet Gynecol 96:304PubMedCrossRefGoogle Scholar
  27. 27.
    Köhler C, Mangler M, Loddenkemper C, Ebert A, Schneider A (2005) eine neue Operationsmethode zur Therapie der rektovaginalen Endometriose auf der Basis histologischer Befunde. In: XIX. Akademische Tagung deutschsprechender Hochschullehrer in der Gynäkologie und Geburtshilfe. Basel, Switzerland: Geburtsh Frauenheilk, 66Google Scholar
  28. 28.
    Keckstein J, Ulrich U, Kandolf O, Wiesinger H, Wustlich M (2003) Laparoscopic therapy of intestinal endometriosis and the ranking of drug treatment. Zentralbl Gynakol 125:259PubMedCrossRefGoogle Scholar
  29. 29.
    Marpeau O, Thomassin I, Barranger E, Detchev R, Bazot M, Darai E (2004) Laparoscopic colorectal resection for endometriosis: preliminary results. J Gynecol Obstet Biol Reprod (Paris) 33:600Google Scholar
  30. 30.
    Tran KT, Kuijpers HC, Willemsen WN, Bulten H (1996) Surgical treatment of symptomatic rectosigmoid endometriosis. Eur J Surg 162:139PubMedGoogle Scholar
  31. 31.
    Köhler C, A S (2006) Rectovaginal endometriosis. In: fifty-sixth annual meeting of the society of pelvic surgeons. Philadelphia, USAGoogle Scholar
  32. 32.
    (1997) American Society for Reproductive Medicine (1997) Revised classification of endometriosis: 1996. Fertil Steril 67:817Google Scholar
  33. 33.
    Carbognin G, Girardi V, Pinali L, Raffaelli R, Bergamini V, Pozzi Mucelli R (2006) Assessment of pelvic endometriosis: correlation of US and MRI with laparoscopic findings. Radiol Med (Torino) 111:687CrossRefGoogle Scholar
  34. 34.
    Remorgida V, Ragni N, Ferrero S, Anserini P, Torelli P, Fulcheri E (2005) How complete is full thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study. Hum Reprod 20:2317PubMedCrossRefGoogle Scholar
  35. 35.
    Fedele L, Bianchi S, Zanconato G, Bettoni G, Gotsch F (2004) Long-term follow-up after conservative surgery for rectovaginal endometriosis. Am J Obstet Gynecol 190:1020PubMedCrossRefGoogle Scholar
  36. 36.
    Ford J, English J, Miles WF, Giannopoulos T (2005) A new technique for laparoscopic anterior resection for rectal endometriosis. JSLS 9:73PubMedGoogle Scholar
  37. 37.
    Abbott JA, Hawe J, Clayton RD, Garry R (2003) The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2–5 year follow-up. Hum Reprod 18:1922PubMedCrossRefGoogle Scholar
  38. 38.
    Duepree HJ, Senagore AJ, Delaney CP, Marcello PW, Brady KM, Falcone T (2002) Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement. J Am Coll Surg 195:754PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Rosanna Zanetti-Dällenbach
    • 1
    • 2
    • 3
  • Julia Bartley
    • 1
  • Christine Müller
    • 1
  • Achim Schneider
    • 1
  • Christhardt Köhler
    • 1
  1. 1.Department of GynecologyUniversitätsmedizin BerlinBerlinGermany
  2. 2.Department of Gynecology and ObstetricsUniversity Hospital BaselSwitzerlandGermany
  3. 3.Department of Gynecology and ObstetricsUniversity Hospital BaselBaselSwitzerland

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