Treatment of rectosigmoid endometriosis by laparoscopic reverse submucosal dissection (LRSD): The Sydney partial thickness discoid excision technique.

BACKGROUND: Laparoscopic reverse submucosal dissection (LRSD) is a standardised surgical technique for removal of rectosigmoid endometriosis which optimises the anatomical dissection plane for excision of endometriotic nodules. AIM: This cohort study assesses the outcomes of the first cohort of women treated by LRSD, for deeply infiltrating rectosigmoid endometriosis. MATERIALS AND METHODS: Primary outcomes assessed were complication rate as defined by the Clavien-Dindo system, and completion of the planned LRSD. Secondary outcomes include mucosal breach, specimen margin involvement, length of hospital admission, and a comparison of pre-operative and post-operative pain, bowel function and quality of life surveys. These included the Endometriosis Health Profile Questionnaire (EHP-30), the Knowles-Eccersley-Scott Symptom Questionnaire (KESS) and the Wexner scale. RESULTS: Of 19 patients treated, one required a segmental resection. The median length of hospital admission was two days (range 1-5) and no post-operative complications occurred. Median pain visual analogue scales (scale 0-10) were higher prior to surgery (dysmenorrhoea 9.0, dyspareunia 7.5, dyschezia 9.0, pelvic pain 6.0) compared to post-surgical median scores (dysmenorrhoea 5.0, dyspareunia 4.0, dyschezia 2.0, pelvic pain 4.0) at a median of six months (range 4-32). Quality of life studies suggested improvement following surgery with pre-operative median EHP-30 and KESS scores (EHP-30: 85 (5-106), KESS score 9 (0-20)) higher than post-operative scores (EHP-30: 48.5 (0-80), KESS score: 3 (0-19)). CONCLUSION: This series highlights the feasibility of LRSD with low associated morbidity as a progression of partial thickness discoid excision (rectal shaving) for the treatment of rectosigmoid deep infiltrating endometriosis.

Fostering interdisciplinary colorectal and gynaecology surgery networks during training is crucial to maximise expertise and innovate patient care.

The importance of interdisciplinary collaboration between specialties has gained significant recognition in recent years, and rightly so with notable benefits to skills acquisition and patient outcomes. Due to the scope of overlapping procedures and clinical scenarios, developing trustable networks between colorectal and gynaecology surgeons must be encouraged as a focus of trainee education. This article highlights the benefits, challenges, and recommendations for fostering such networks.

Obstetric cholestasis: A case report on rapid bile acid elevation.

Obstetric cholestasis is a pregnancy-specific liver disorder which most commonly develops in the second or third trimester. It typically presents with generalised pruritus, often worst on the hands and feet, and no rash. Diagnosis is made on the basis of clinical presentation and elevated bile acid levels. Whilst obstetric cholestasis usually has no significant maternal adverse outcomes, aside from decreased quality of life from pruritus, it can lead to significant foetal complications, including stillbirth. There are no treatments for obstetric cholestasis, which resolves only following delivery. Thus, depending on the severity of obstetric cholestasis, early induction of labour may be recommended. As symptoms may precede bile acid elevation, repeat testing after a week is usually recommended when initial levels are normal. This report describes a case where a 35-year-old pregnant woman presented with pruritus but a normal bile acid level of 3 µmol/L. On repeat testing the following day the level had risen to 62, diagnosing obstetric cholestasis, and resulting in an urgent induction of labour at 38 weeks and 2 days of gestation. The patient gave birth to a healthy girl. This highlights the importance of close monitoring and consideration of early repeated blood tests where clinical suspicion is high, and/or a diagnosis of obstetric cholestasis would have significant management implications, to prevent adverse foetal outcomes.

Endometriosis Involving the Sciatic Nerve: A Case Report of Isolated Endometriosis of the Sciatic Nerve and Review of the Literature.

Endometriosis is a common gynecological condition which affects 5-10% of women of reproductive age and up to 50% of women with pelvic pain and infertility. The most commonly affected areas are the pelvic peritoneum, ovaries and rectovaginal septum. Isolated endometriosis of the sciatic nerve is very rare. Our patient suffered from worsening right hip and buttock pain with severe exacerbation during menstruation. Several different imaging modalities (ultrasound of her pelvis and right hip, as well as X-rays and computed tomography scans of her right hip and lumbosacral spine) failed to identify any pathology. Magnetic resonance imaging scans of her pelvis revealed a 3.5 cm endometriotic lesion over the pelvic segment of her right sciatic nerve. Following a multidisciplinary discussion, the patient underwent laparoscopic excision of endometriosis. The patient recovered well from her surgery. She successfully conceived with in vitro fertilization 3 years after her surgery, following a failed course of Clomid (Clomiphene citrate) for ovulatory dysfunction.

Laparoscopic Myomectomy of a 4.2 kg Fibroid with Assistance of a Minilaparotomy.

The improved cosmesis and recovery from minimally invasive techniques has seen a dramatic rise in its popularity. Unfortunately, the laparoscopic myomectomy for large fibroids presents a unique challenge to the surgeon. It is reputed to be difficult and time consuming, with a high risk of conversion to laparotomy. As laparoscopic techniques improve, the laparoscopic myomectomy for larger fibroids is becoming more feasible. This article outlines the case of laparoscopic removal of a 4.2 kg fibroid with the assistance of a minilaparotomy.