Laparoscopic Reverse Technique in Excision Surgery for Deep Endometriosis: Natural Orifice Specimen Extraction Surgery (NOSES) (Video Article)

This video article presents a surgical technique and clinical case video demonstrating the “Reverse Technique” in laparoscopic surgery for deep endometriosis excision, combined with the “Natural Orifice Specimen Extraction Surgery” (NOSES) technique for intestinal resection. We demonstrate both techniques through the case of a 25-year-old patient with a BMI of 20, nulligravida, diagnosed with deep infiltrating endometriosis involving the bowel. The patient presented with severe dysmenorrhea, dyschezia, hematochezia, and bowel inflammation, with MRI findings indicating intestinal involvement. The application of the above methods reduced the operating time to 150 minutes, with an EBL of 50cc, compared to an average of four hours and higher blood loss for similar segmental intestinal resections (1). The surgery was completed without complications, and the patient had an optimal recovery, being discharged 48 hours postsurgery.

Learning objective of the Case Report: This video article aims to demonstrate the effectiveness of combining the Reverse Technique with NOSES in the laparoscopic treatment of DIE with bowel involvement. This innovative approach optimizes surgical time, reduces complications, and enhances precision in the treatment of deep infiltrating endometriosis with intestinal involvement. This video article presents a case of a 25-year-old patient with DIE involving the bowel, accompanied by symptoms such as dysmenorrhea, dyschezia, and hematochezia. Through this case, we demonstrate the application of the NOSES technique combined with the Reverse Technique, which effectively reduces OT and enhances surgical outcomes. As advanced pelvic laparoscopic and endometriosis surgeons, it is important for us to introduce innovative techniques that not only demonstrate resection surgeries for DIE but also provide fertility-preserving approaches for patients with complex cases involving rectal involvement. We believe this submission is highly relevant due to its innovative approach and potential to improve surgical outcomes in complex endometriosis cases, significantly contributing to the field of gynecological surgery.

DIE is characterized by the presence of endometrial- like tissue infiltrating beyond the superficial peritoneum. This condition can cause significant anatomical changes, invading critical structures such as the bowel, ureters, and nerves, leading to severe pain and functional impairment. Surgical procedures in such cases carry a high risk of complications, with rates as high as 10-22% when intestinal resection is required. For this reason, these surgeries should be performed by highly trained surgeons with extensive knowledge of pelvic anatomy. Two main surgical techniques are described for this type of surgery: the Reverse Technique and the classical laparoscopic approach, which have distinct methodologies. Unlike the traditional technique, which involves identifying and removing the diseased areas first, the Reverse Technique begins with the separation of the healthy from the affected tissues, moving toward the diseased regions (2,3). The final step in Reverse Technique involves dissection of the affected tissues and rectal nodules, allowing the surgeon to establish clean surgical planes (4). Traditional laparoscopic approaches for intestinal involvement can be time- consuming and prone to complications. The combination of NOSES and the Reverse Laparoscopic Technique provides a novel and more effective approach to improving outcomes in complex endometriosis cases.

We present a case of a 25-year-old patient with severe endometriotic symptoms, including severe dysmenorrhea, dyschezia, and hematochezia, and abdominal pain that clearly intensified with menstrual cycle. Mandatory presurgical endometriosis mapping was realized, and the pelvic MRI findings revealed a 38mm nodular plaque involving the uterine torus and extending towards the rectum, compromising 40% of its lumen, located 10cm from the recto anal junction.

OT, compared to traditional methods. Postoperative pain and recovery time. Preservation of critical anatomical structures. Cosmetic outcome.

Surgery lasted 150 minutes. The patient was monitored during hospitalization with procalcitonin and C-reactive protein levels, as a parameter of colorectal anastomosis dehiscence, which remained normal. She was discharged from the hospital with adequate tolerance to a general anti-inflammatory diet after the second day of hospitalization, with no further complications. The patient showed significant improvement of symptoms one month after surgery. Pathology report revealed colonic mucosa with chronic inflammation and edema, associated with a fibromuscular tissue nodule with extensive endometriosis, measuring a total of five centimeters.

The NOSES technique provides significant advantages by using the anus as a natural entry point, eliminating the need for large abdominal incisions (5,6). This minimizes unnecessary tissue manipulation, accelerates the surgery, and reduces the need for patient repositioning during the procedure (6). The absence of extensive external incisions decreases the risk of complications such as infections and hernias, while also offering a cosmetic benefit, as no visible scars are left. Patients typically experience less postoperative pain, leading to faster recovery and an earlier return to normal activities. In the Reverse Technique, used in laparoscopic surgery for endometriosis, healthy tissue is lateralized while the diseased tissue is medialized. This method helps separate key structures, such as the hypogastric nerves and ureters, from the central area affected by the disease (7,8). The reverse approach consists in performing the dissection of the pelvic anatomy in a reverse order as compared to traditional methods. By starting the dissection in less affected areas, the surgeon gains better visibility and access to deeper regions, reducing the risk of injury to vital structures. In contrast, starting from the more severely affected areas in standard techniques can lead to accidental damage due to poor visibility or complex anatomical distortions. Both techniques present a significant advancement in the management of complex deep infiltrating endometriosis with bowel involvement. OT was reduced to 2 hours and 30 minutes, compared to the typical 4 hours for standard segmental intestinal resection procedures (8-10).

The combination of NOSES and the Reverse Technique significantly improves surgical efficiency and patient outcomes in cases of deep infiltrating endometriosis with bowel involvement. This approach reduces operative time, enhances the safety of the procedure, minimizes postoperative complications, and improves cosmetic outcomes. Further studies are recommended to explore the broader applicability of this technique in other complex surgical cases.