Laparoscopic Purse-String Suture Technique for Total Intracorporeal Rectosigmoid End-to-End Anastomosis After Segmental Bowel Resection.

OBJECTIVE: Bowel endometriosis affects 8% to 12% of women with infiltrating endometriosis, mostly involving the rectum and sigmoid [1]. Surgery is preferred when medical therapy fails or is contraindicated. Although segmental resection has shown good outcomes, it carries significant risks of perioperative complications [1-3], partially due to the mini-laparotomy required for specimen retrieval and bowel anastomosis (postoperative pain, wound-related issues, blood loss, hernias). Total intracorporeal laparoscopic anastomosis may reduce them [4,5]. While promising, experience with this technique is limited, and there is no consensus on its use. This video showcases our technique for total intracorporeal end-to-end anastomosis using a purse-string suture after bowel resection for endometriosis.

DESIGN: Case report and video-description of the surgical technique.

SETTING: Tertiary level academic hospital.

INTERVENTION: A 32-year-old woman with severe, symptomatic endometriosis unresponsive to hormone therapy was referred to our hospital. Preoperative evaluation identified a 5cm nodule involving the anterior rectal wall, recto-sigmoid junction, and right uterosacral ligament, located 10cm from the anal verge. After obtaining informed consent, surgery was scheduled. The recto-sigmoid colon was mobilized using a nerve-sparing approach [1-3,5], followed by resection of the affected segment. The specimen was exteriorized from the right ancillary trocar site, and a total intracorporeal end-to-end colorectal anastomosis was performed without the need for a suprapubic mini-laparotomy, using a circular stapler and a monofilament purse-string suture to secure the anvil. Bowel integrity and residual vascular assessment with near-infrared indocyanine green were performed, and the patient experienced an uneventful recovery, with significant clinical improvement at follow-up.

CONCLUSION: In our experience total intracorporeal anastomosis technique improves minimally invasive surgery for deep endometriosis, avoiding the drawbacks of mini-laparotomy and requires less sigmoid mobilization. The most threatening complication after full-thickness bowel resection is anastomotic leakage, often due to poorly supplied residual horns. Our technique using a purse-string suture during intracorporeal anastomosis, preventing formation of residual horns, can provide greater anvil stability for a secure anastomosis seal.