Advertisement

Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection?

  • Olivier Donnez
    Correspondence
    Reprint requests: Olivier Donnez, M.D., Ph.D., Institut du Sein et de Chirurgie Gynécologique, d'Avignon, Polyclinique Urbain V (Groupe Elsan), Chemin du Pont des Deux Eaux 95, Avignon F-84000, France.
    Affiliations
    Institut du sein et de Chirurgie gynécologique d’Avignon, Polyclinique Urbain V (Elsan Group), Avignon, France, and Pôle de recherche en gynécologie, IREC institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
    Search for articles by this author
  • Horace Roman
    Affiliations
    Expert Center in Diagnosis and Management of Endometriosis, Department of Gynecology and Obstetrics and Research Group EA 4308 Spermatogenesis and Male Gamete Quality, Rouen University Hospital, Rouen, France
    Search for articles by this author
      Deep endometriosis (DE) remains the most difficult endometriotic entity to treat. Medical treatment for DE can reduce symptoms but does not cure the disease, and surgical removal of the lesion is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions. Although several surgical techniques such as laparoscopic bowel resection, disc excision, and rectal shaving have been described, there is no consensus regarding the choice of technique or the timing of surgery. Our review of publications reporting results and complications of surgery for rectovaginal DE reveals a relatively higher complication rate after bowel resection compared with shaving and disc excision, especially for rectovaginal fistulas, anastomotic leakage, delayed hemorrhage, and long-term bladder catheterization. Data show that shaving is feasible even in advanced disease. The risk of immediate complications after shaving and disc excision is probably lower than after colorectal resection, allowing for better functional outcomes. The presumed higher risk of recurrence related to shaving has not been demonstrated. For these reasons, surgeons should consider rectal shaving as a first-line surgical treatment of rectovaginal DE, regardless of nodule size or association with other digestive localizations. When the result of rectal shaving is unsatisfactory (rare cases), disc excision may be performed either exclusively by laparoscopy or by using transanal staplers. Segmental resection may ultimately be reserved for advanced lesions responsible for major stenosis or for several cases of multiple nodules infiltrating the rectosigmoid junction or sigmoid colon.

      Key Words

      To read this article in full you will need to make a payment

      References

        • Giudice L.C.
        • Kao L.C.
        Endometriosis Lancet. 2004; 364: 1789-1799
        • Nisolle M.
        • Donnez J.
        Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities.
        Fertil Steril. 1997; 68: 585-596
        • Donnez J.
        • Squifflet J.
        Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.
        Hum Reprod. 2010; 25: 1949-1958
        • Donnez J.
        • Jadoul P.
        • Colette S.
        • Luyckx M.
        • Squifflet J.
        • Donnez O.
        Deep rectovaginal endometriotic nodules: perioperative complications from a series of 3,298 patients operated on by the shaving technique.
        Gynecol Surg. 2013; 10: 31-40
        • Vercellini P.
        • Buggio L.
        • Berlanda N.
        • Barbara G.
        • Somigliana E.
        • Bosari S.
        Estrogen-progestins and progestins for the management of endometriosis.
        Fertil Steril. 2016; 106: 1552-1571
        • Setúbal A.
        • Sidiropoulou Z.
        • Torgal M.
        • Casal E.
        • Lourenço C.
        • Koninckx P.
        Bowel complications of deep endometriosis during pregnancy or in vitro fertilization.
        Fertil Steril. 2014; 101: 442-446
        • Daraï E.
        • Cohen J.
        • Ballester M.
        Colorectal endometriosis and fertility.
        Eur J Obstet Gynecol Reprod Biol. 2017; 209: 86-94
        • Jacques M.
        • Freour T.
        • Barriere P.
        • Ploteau S.
        Adverse pregnancy and neo-natal outcomes after assisted reproductive treatment in patients with pelvic endometriosis: a case-control study.
        Reprod Biomed Online. 2016; 32: 626-634
        • Borghese B.
        • Sibiude J.
        • Santulli P.
        • Lafay Pillet M.C.
        • Marcellin L.
        • Brosens I.
        • et al.
        Low birth weight is strongly associated with the risk of deep infiltrating endometriosis: results of a 743 case-control study.
        PLoS One. 2015; 10: e0117387
        • Abrão M.S.
        • Podgaec S.
        • Dias Jr., J.A.
        • Averbach M.
        • Silva L.F.
        • Marino de Carvalho F.
        Endometriosis lesions that compromise the rectum deeper than the inner muscularis layer have more than 40% of the circumference of the rectum affected by the disease.
        J Minim Invasive Gynecol. 2008; 15: 280-285
        • Goncalves M.O.
        • Podgaec S.
        • Dias Jr., J.A.
        • Gonzalez M.
        • Abrao M.S.
        Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis, defining surgical strategy.
        Hum Reprod. 2010; 25: 665-671
        • Koninckx P.R.
        • De Cicco C.
        • Schonman R.
        • Corona R.
        • Betsas G.
        • Ussia A.
        The recent article “Endometriosis lesions that compromise the rectum deeper than the inner muscularis layer have more than 40% of the circumference of the rectum affected by the disease”.
        J Minim Invasive Gynecol. 2008; 15: 774-775
        • Meuleman C.
        • Tomassetti C.
        • D’Hoore A.
        • Van Cleynenbreugel B.
        • Penninckx F.
        • Vergote I.
        • et al.
        Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.
        Hum Reprod Update. 2011; 17: 311-326
        • Roman H.
        FRIENDS group (French Colorectal Infiltrating Endometriosis Study group). A national snapshot of the surgical management of deep infiltrating endometriosis of the rectum and colon in France in 2015: a multicenter series of 1135 cases.
        J Gynecol Obstet Hum Reprod. 2017; 46: 159-165
        • Malzoni M.
        • Di Giovanni A.
        • Exacoustos C.
        • Lannino G.
        • Capece R.
        • Perone C.
        • et al.
        Feasibility and safety of laparoscopic-assisted bowel segmental resection for deep infiltrating endometriosis: a retrospective cohort study with description of technique.
        J Minim Invasive Gynecol. 2016; 23: 512-525
        • Reich H.
        • McGlynn F.
        • Salvat J.
        Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis.
        J Reprod Med. 1991; 36: 516-522
        • Donnez J.
        • Nisolle M.
        • Casanas-Roux F.
        • Bassil S.
        • Anaf V.
        Rectovaginal septum, endometriosis or adenomyosis: laparoscopic management in a series of 231 patients.
        Hum Reprod. 1995; 10: 630-635
        • Donnez J.
        • Nisolle M.
        • Gillerot S.
        • Smets M.
        • Bassil S.
        • Casanas-Roux F.
        Rectovaginal septum adenomyotic nodules: a series of 500 cases.
        Br J Obstet Gynaecol. 1997; 104: 1014-1018
        • Donnez J.
        • Squifflet J.
        Laparoscopic excision of deep endometriosis.
        Obstet Gynecol Clin North Am. 2004; 31: 567-580
        • Donnez J.
        • Nisolle M.
        • Squifflet J.
        Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules.
        Fertil Steril. 2002; 77: 32-37
        • Koninckx P.R.
        • Timmermans B.
        • Meuleman C.
        • Penninckx F.
        Complications of CO2-laser endoscopic excision of deep endometriosis.
        Hum Reprod. 1996; 11: 2263-2268
        • Jerby B.L.
        • Kessler H.
        • Falcone T.
        • Milsom J.W.
        Laparoscopic management of colorectal endometriosis.
        Surg Endosc. 1999; 13: 1125-1128
        • Redwine D.B.
        • Wright J.T.
        Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection.
        Fertil Steril. 2001; 76: 358-365
        • Duepree H.J.
        • Senagore A.J.
        • Delaney C.P.
        • Marcello P.W.
        • Brady K.M.
        • Falcone T.
        Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement.
        J Am Coll Surg. 2002; 195: 754-758
        • Varol N.
        • Maher P.
        • Healey M.
        • Woods R.
        • Wood C.
        • Hill D.
        • et al.
        Rectal surgery for endometriosis—should we be aggressive?.
        J Am Assoc Gynecol Laparosc. 2003; 10: 182-189
        • Fedele L.
        • Bianchi S.
        • Zanconato G.
        • Bettoni G.
        • Gotsch F.
        Long-term follow-up after conservative surgery for rectovaginal endometriosis.
        Am J Obstet Gynecol. 2004; 190: 1020-1024
        • Mohr C.
        • Nezhat F.R.
        • Nezhat C.H.
        • Seidman D.S.
        • Nezhat C.R.
        Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis.
        JSLS. 2005; 9: 16-24
        • Jatan A.K.
        • Solomon M.J.
        • Young J.
        • Cooper M.
        • Pathma-Nathan N.
        Laparoscopic management of rectal endometriosis.
        Dis Colon Rectum. 2006; 49: 169-174
        • Slack A.
        • Child T.
        • Lindsey I.
        • Kennedy S.
        • Cunningham C.
        • Mortensen N.
        • et al.
        Urological and colorectal complications following surgery for rectovaginal endometriosis.
        Br J Obstet Gynecol. 2007; 114: 1278-1282
        • Brouwer R.
        • Woods R.J.
        Rectal endometriosis: results of radical excision and review of published work.
        ANZ J Surg. 2007; 77: 562-571
        • Kondo W.
        • Bourdel N.
        • Tamburro S.
        • Cavoli D.
        • Jardon K.
        • Rabischong B.
        • et al.
        Complications after surgery for deeply infiltrating pelvic endometriosis.
        Br J Obstet Gynecol. 2011; 118: 292-298
        • Seracchioli R.
        • Ferrini G.
        • Montanari G.
        • Raimondo D.
        • Spagnolo E.
        • Di Donato N.
        Does laparoscopic shaving for deep infiltrating endometriosis alter intestinal function? A prospective study.
        Aust N Z J Obstet Gynaecol. 2015; 55: 357-362
        • Afors K.
        • Centini G.
        • Fernandes R.
        • Murtada R.
        • Zupi E.
        • Akladios C.
        • et al.
        Segmental and discoid resection are preferential to bowel shaving for medium-term symptomatic relief in patients with bowel endometriosis.
        J Minim Invasive Gynecol. 2016; 23: 1123-1129
        • Roman H.
        • Moatassim-Drissa S.
        • Marty N.
        • Milles M.
        • Vallée A.
        • Desnyder E.
        • et al.
        Rectal shaving for deep endometriosis infiltrating the rectum: a 5-year continuous retrospective series.
        Fertil Steril. 2016; 106: 1438-1445
        • Roman H.
        • Milles M.
        • Vassilieff M.
        • Resch B.
        • Tuech J.J.
        • Huet E.
        • et al.
        Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis.
        Am J Obstet Gynecol. 2016; 215: 762.e1-762.e9
        • Marty N.
        • Touleimat S.
        • Moatassim-Drissa S.
        • Millochau J.C.
        • Vallee A.
        • Stochino Loi E.
        • et al.
        Rectal shaving using plasma energy in deep infiltrating endometriosis of the rectum: four years of experience.
        J Minim Invasive Gynecol. 2017 Jun 30; ([Epub ahead of print])https://doi.org/10.1016/j.jmig.2017.06.019
        • Roman H.
        • Darwish B.
        • Bridoux V.
        • Chati R.
        • Kermiche S.
        • Coget J.
        • et al.
        Functional outcomes after disc excision in deep endometriosis of the rectum using transanal staplers: a series of 111 consecutive patients.
        Fertil Steril. 2017; 107: 977-986
        • Woods R.J.
        • Heriot A.G.
        • Chen F.C.
        Anterior rectal wall excision for endometriosis using the circular stapler.
        ANZ J Surg. 2003; 73: 647-648
        • Landi S.
        • Pontrelli G.
        • Surico D.
        • Ruffo G.
        • Benini M.
        • Soriano D.
        • et al.
        Laparoscopic disk resection for bowel endometriosis using a circular stapler and a new endoscopic method to control postoperative bleeding from the stapler line.
        J Am Coll Surg. 2008; 207: 205-209
        • Fanfani F.
        • Fagotti A.
        • Gagliardi M.L.
        • Ruffo G.
        • Ceccaroni M.
        • Scambia G.
        • et al.
        Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study.
        Fertil Steril. 2010; 94: 444-449
        • Koh C.
        • Juszcsyk K.
        • Cooper M.J.W.
        • Solomon M.J.
        Management of deeply infiltrating endometriosis involving the rectum.
        Dis Colon Rectum. 2012; 55: 925-931
        • Possover M.
        • Diebolder H.
        • Plaul K.
        • Schneider A.
        Laparascopically assisted vaginal resection of rectovaginal endometriosis.
        Obstet Gynecol. 2000; 96: 304-307
        • Darai E.
        • Thomassin I.
        • Barranger E.
        • Detchev R.
        • Cortez A.
        • Houry S.
        • et al.
        Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis.
        Am J Obstet Gynecol. 2005; 192: 394-400
        • Fleisch M.C.
        • Xafis D.
        • De Bruyne F.
        • Hucke J.
        • Bender H.G.
        • Dall P.
        Radical resection of invasive endometriosis with bowel or bladder involvement—long-term results.
        Eur J Obstet Gynecol Reprod Biol. 2005; 123: 224-229
        • Keckstein J.
        • Wiesinger H.
        Deep endometriosis, including intestinal involvement—the interdisciplinary approach.
        Minim Invasive Ther Allied Technol. 2005; 14: 160-166
        • Dubernard G.
        • Piketty M.
        • Rouzier R.
        • Houry S.
        • Bazot M.
        • Darai E.
        Quality of life after laparoscopic colorectal resection for endometriosis.
        Hum Reprod. 2006; 21: 1243-1247
        • Mereu L.
        • Ruffo G.
        • Landi S.
        • Barbieri F.
        • Zaccoletti R.
        • Fiaccavento A.
        • et al.
        Laparoscopic treatment of deep endometriosis with segmental colorectal resection: short-term morbidity.
        J Minim Invasive Gynecol. 2007; 14: 463-469
        • Darai E.
        • Ackerman G.
        • Bazot M.
        • Rouzier R.
        • Dubernard G.
        Laparoscopic segmental colorectal resection for endometriosis: limits and complications.
        Surg Endosc. 2007; 21: 1572-1577
        • Seracchioli R.
        • Poggioli G.
        • Pierangeli F.
        • Manuzzi L.
        • Gualerzi B.
        • Savelli L.
        • et al.
        Surgical outcome and long-term follow up after laparoscopic rectosigmoid resection in women with deep infiltrating endometriosis.
        Br J Obstet Gynecol. 2007; 114: 889-895
        • Minelli L.
        • Fanfani F.
        • Fagotti A.
        • Ruffo G.
        • Ceccaroni M.
        • Mereu L.
        • et al.
        Laparoscopic colorectal resection for bowel endometriosis: feasibility, complications, and clinical outcome.
        Arch Surg. 2009; 144: 234-239
        • Ferrero S.
        • Anserini P.
        • Abbamonte L.H.
        • Ragni N.
        • Camerini G.
        • Remorgida V.
        Fertility after bowel resection for endometriosis.
        Fertil Steril. 2009; 92: 41-46
        • Dousset B.
        • Leconte M.
        • Borghese B.
        • Millischer A.E.
        • Roseau G.
        • Arkwright S.
        • et al.
        Complete surgery for low rectal endometriosis. Long-term results of a 100-case prospective study.
        Ann Surg. 2010; 251: 887-895
        • Ruffo G.
        • Scopelliti F.
        • Scioscia M.
        • Ceccaroni M.
        • Mainardi P.
        • Minelli L.
        Laparoscopic colorectal resection for deep infiltrating endometriosis: analysis of 436 cases.
        Surg Endosc. 2010; 24: 63-67
        • Meuleman C.
        • Tomassetti C.
        • D’Hoore A.
        • Buyens A.
        • Van Cleynenbreugel B.
        • Fieuws S.
        • et al.
        Clinical outcome after CO2 laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis.
        Hum Reprod. 2011; 26: 2336-2343
        • Wolthuis A.M.
        • Meuleman C.
        • Tomassetti C.
        • D’Hooghe T.
        • Fieuws S.
        • Penninckx F.
        • et al.
        Laparoscopic sigmoid resection with transrectal specimen extraction: a novel technique for the treatment of bowel endometriosis.
        Hum Reprod. 2011; 26: 1348-1355
        • Ruffo G.
        • Scopelliti F.
        • Manzoni A.
        • Sartori A.
        • Rossini R.
        • Ceccaroni M.
        • et al.
        Long-term outcome after laparoscopic bowel resections for deep infiltrating endometriosis: a single-center experience after 900 cases.
        Biomed Res Int. 2014; 2014: 463058
        • Belghiti J.
        • Ballester M.
        • Zilberman S.
        • Thomin A.
        • Zacharopoulou C.
        • Bazot M.
        • et al.
        Role of protective defunctioning stoma in colorectal resection for endometriosis.
        J Minim Invasive Gynecol. 2014; 21: 472-479
        • Akladios C.
        • Messori P.
        • Faller E.
        • Puga M.
        • Afors K.
        • Leroy J.
        • et al.
        Is ileostomy always necessary following rectal resection for deep infiltrating endometriosis?.
        J Minim Invasive Gynecol. 2015; 22: 103-109
        • Milone M.
        • Vignali A.
        • Milone F.
        • Pignata G.
        • Elmore U.
        • Musella M.
        • et al.
        Colorectal resection in deep pelvic endometriosis: surgical technique and post-operative complications.
        World J Gastroenterol. 2015; 21: 13345-13351
        • Abo C.
        • Roman H.
        • Bridoux V.
        • Huet E.
        • Tuech J.J.
        • Resch B.
        • et al.
        Management of deep infiltrating endometriosis by laparoscopic route with robotic assistance: 3-year experience.
        J Gynecol Obstet Hum Reprod. 2017; 46: 9-18
        • Nezhat C.
        • Nezhat F.
        • Pennington E.
        • Nezhat C.H.
        • Ambroze W.
        Laparoscopic disk excision and primary repair of the anterior rectal wall for the treatment of full-thickness bowel endometriosis.
        Surg Endosc. 1994; 8: 682-685
        • Roman H.
        • Abo C.
        • Huet E.
        • Bridoux V.
        • Auber M.
        • Oden S.
        • et al.
        Full thickness disc excision in deep endometriotic nodules of the rectum. A prospective cohort.
        Dis Colon Rectum. 2015; 58: 957-966
        • Bridoux V.
        • Roman H.
        • Kianifard B.
        • Vassilieff M.
        • Marpeau L.
        • Michot F.
        • et al.
        Combined transanal and laparoscopic approach for the treatment of deep endometriosis infiltrating the rectum.
        Hum Reprod. 2012; 27: 418-426
        • Roman H.
        • Abo C.
        • Huet E.
        • Tuech J.J.
        Deep shaving and transanal disc excision in large endometriosis of mid and lower rectum: the Rouen technique.
        Surg Endosc. 2016; 30: 2626-2627
        • Roman H.
        • Darwish B.
        • Schmied R.
        • Remorgida V.
        • Tuech J.J.
        Combined vaginal-laparoscopic-transanal approach for reducing bladder dysfunction after conservative surgery in large deep rectovaginal endometriosis.
        J Gynecol Obstet Biol Reprod. 2016; 45: 546-548
        • Darwish B.
        • Roman H.
        Regarding pillars for surgical treatment of bowel endometriosis.
        J Minim Invasive Gynecol. 2016; 23: 1201-1203
        • Roman H.
        • Puscasiu L.
        • Lempicki M.
        • Huet E.
        • Chati R.
        • Bridoux V.
        • et al.
        Colorectal endometriosis responsible for bowel occlusion or subocclusion in women with pregnancy intention: is the policy of primary in vitro fertilization always safe?.
        J Minim Invasive Gynecol. 2015; 22: 1059-1067
        • Thiels C.A.
        • Shenoy C.C.
        • Ubl D.S.
        • Habermann E.B.
        • Kelley S.R.
        • Mathis K.L.
        Rates, trends, and short-term outcomes of colorectal resections for endometriosis: an ACS-NSQIP review.
        Int J Surg. 2016; 31: 5-9
        • Nezhat C.
        • Nezhat F.
        • Pennington E.
        Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser.
        Br J Obstet Gynecol. 1992; 99: 664-667
        • Maytham G.D.
        • Dowson H.M.
        • Levy B.
        • Kent A.
        • Rockall A.
        Lapraoscopic excision of rectovaginal endometriosis: report of a prospective study and review of the literature.
        Colorectal Dis. 2010; 12: 1105-1112
        • Roman H.
        • Bridoux V.
        • Tuech J.J.
        • Marpeau L.
        • da Costa C.
        • Savoye G.
        • et al.
        Bowel dysfunction before and after surgery for endometriosis.
        Am J Obstet Gynecol. 2013; 209: 524-530
        • Emmertsen K.J.
        • Laurberg S.
        Low anterior resection syndrome score. Development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer.
        Ann Surg. 2012; 255: 922-928
        • Knowles C.H.
        • Eccersley A.J.
        • Scott S.M.
        • Walker S.M.
        • Reeves B.
        • Lunniss P.J.
        Linear discriminant analysis of symptoms in patients with chronic constipation. Validation of a new scoring system (KESS).
        Dis Colon Rectum. 2000; 43: 1419-1426
        • Nieveen van Dijkum E.J.M.
        • Terwee C.B.
        • Oosterveld P.
        • van der Meulen J.H.P.
        • Gouma D.J.
        • de Haes J.C.J.M.
        Validation of the gastrointestinal quality of life index for patients with potentially operable periampullary carcinoma.
        Br J Surg. 2000; 87: 110-115
        • Jorge J.M.
        • Wexner S.D.
        Etiology and management of fecal incontinence.
        Dis Colon Rectum. 1993; 36: 77-97
        • Mabrouk M.
        • Ferrini G.
        • Montanari G.
        • Di Donato N.
        • Raimondo D.
        • Stanghellini V.
        • et al.
        Does colorectal endometriosis alter intestinal functions? A prospective manometric and questionnaire-based study.
        Fertil Steril. 2012; 97: 652-656
        • Riiskjaer M.
        • Greisen S.
        • Glavind-Kristensen M.
        • Kesmodel U.S.
        • Forman A.
        • Seyer-Hansen M.
        Pelvic organ function before and after laparoscopic bowel resection for rectosigmoid endometriosis: a prospective, observational study.
        Br J Obstet Gynecol. 2016; 123: 1360-1367
        • Roman H.
        • Hennetier C.
        • Darwish B.
        • Badescu A.
        • Csanyi M.
        • Aziz M.
        • et al.
        Bowel occult microscopic endometriosis in resection margins in deep colorectal endometriosis specimens has no impact on short-term postoperative outcomes.
        Fertil Steril. 2016; 105: 423-429
        • Abrão M.S.
        • Petraglia F.
        • Falcone T.
        • Keckstein J.
        • Osuga Y.
        • Chapron C.
        Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management.
        Hum Reprod Update. 2015; 21: 329-339
        • Shiomi A.
        • Ito M.
        • Maeda K.
        • Kinugasa Y.
        • Ota M.
        • Yamaue H.
        • et al.
        Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis of 1,014 consecutive patients.
        J Am Coll Surg. 2015; 220: 186-194
        • Chapron C.
        • Jacob S.
        • Dubuisson J.B.
        • Vieira M.
        • Liaras E.
        • Fauconnier A.
        Laparoscopically assisted vaginal management of deep endometriosis infiltrating the rectovaginal septum.
        Acta Obstet Gynecol Scand. 2001; 80: 349-354
        • Matthiessen P.
        • Hallböök O.
        • Rutegård J.
        • Simert G.
        • Sjödahl R.
        Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial.
        Ann Surg. 2007; 246: 207-214
        • Matsuzaki S.
        • Houlle C.
        • Botchorishvili R.
        • Pouly J.L.
        • Mage G.
        • Canis M.
        Excision of the posterior vaginal fornix is necessary to ensure complete resection of rectovaginal endometriotic nodules of more than 2 cm in size.
        Fertil Steril. 2009; 91: 1314-1315
        • Roman H.
        • Vassilieff M.
        • Gourcerol G.
        • Savoye G.
        • Leroi A.M.
        • Marpeau L.
        • et al.
        Surgical management of deep infiltrating endometriosis of the rectum: pleading for a symptom-guided approach.
        Hum Reprod. 2011; 26: 274-281
        • Vassilieff M.
        • Suaud O.
        • Collet-Savoye C.
        • Da Costa C.
        • Marouteau-Pasquier N.
        • Belhiba H.
        • et al.
        Computed tomography-based virtual colonoscopy: an examination useful for the choice of the surgical management of colorectal endometriosis.
        Gynecol Obstet Fertil. 2011; 39: 339-345
        • Roman H.
        • Bourdel N.
        Against the systematic use of segmental resection in colorectal endometriosis: do not replace the pain by unpleasant digestive symptoms!.
        Gynecol Obstet Fertil. 2009; 37: 358-362
        • Payá V.
        • Hidalgo-Mora J.J.
        • Diaz-Garcia C.
        • Pellicer A.
        Surgical treatment of rectovaginal endometriosis with rectal involvement.
        Gynecol Surg. 2011; 8: 269-272
        • Kupelian A.S.
        • Cutner A.
        Segmental bowel resection for deep infiltrating endometriosis.
        Br J Obstet Gynecol. 2016; 123: 1368
        • Roman H.
        • Vassilieff M.
        • Tuech J.J.
        • Huet E.
        • Savoye G.
        • Marpeau L.
        • et al.
        Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum.
        Fertil Steril. 2013; 99: 1695-1704
        • Roman H.
        • Loisel C.
        • Resch B.
        • Tuech J.J.
        • Hochain P.
        • Leroi A.M.
        • et al.
        Delayed functional outcomes associated with surgical management of deep rectovaginal endometriosis with rectal involvement: giving patients an informed choice.
        Hum Reprod. 2010; 25: 890-899
        • Anaf V.
        • El Nakadi I.
        • De Moor V.
        • Coppens E.
        • Zaeleman M.
        • Noel J.C.
        Anatomic significance of a positive barium enema in deep infiltrating endometriosis of the large bowel.
        World J Surg. 2009; 33: 822-827
        • Badescu A.
        • Roman H.
        • Aziz M.
        • Puscasiu L.
        • Molnar C.
        • Huet E.
        • et al.
        Mapping of bowel occult microscopic endometriosis implants surrounding deep endometriosis nodules infiltrating the bowel.
        Fertil Steril. 2016; 105: 430-434
        • Remorgida V.
        • Ragni N.
        • Ferrero S.
        • Anserini P.
        • Torelli P.
        • Fulcheri E.
        How complete is full thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study.
        Hum Reprod. 2005; 20: 2317-2320
        • Donnez O.
        • Orellana R.
        • Van Kerk O.
        • Dehoux J.P.
        • Donnez J.
        • Dolmans M.M.
        Invasion process of induced deep nodular endometriosis in an experimental baboon model: similarities with collective cell migration?.
        Fertil Steril. 2015; 104: 491-497
        • Orellana R.
        • García-Solares J.
        • Donnez J.
        • van Kerk O.
        • Dolmans M.M.
        • Donnez O.
        Important role of collective cell migration and nerve fiber density in the development of deep nodular endometriosis.
        Fertil Steril. 2017; 107: 987-995