Video Summary

To reduce surgical trauma, the NOSE technique (Natural Orifice Specimen Extraction) was chosen: lower postoperative morbidity, better aesthetic result, and shorter hospital stay. The surgery was performed without complications. Minimally invasive resection of the structures with transvaginal removal was utilized to avoid any new incisions, such as Pfannenstiel. Considering the patient selection, NOSE technique can provide advantages compared to the conventional approaches without compromising the execution of the procedures.

Video

Teaching Points

Patient Preparation

1. Low-residue diet 24 hours before surgery
2. Two phosphate-based enemas, the first one the night before and the second one 2 hours before surgery
3. Fasting for 8 hours before the procedure
4. Antibiotic prophylaxis during anesthesia induction (ceftriaxone and metronidazole)

Patient Position

Dorsal decubitus in a slight (20°) Trendelenburg position

Critical Steps

1. Port placement
2. Identify endometriotic lesions
3. Total hysterectomy with transvaginal extraction
4. Left paracolic gutter mobilization, followed by splenic flexure partial mobilization
5. Medial and posterior rectosigmoid dissection
6. Transvaginal extraction of the intestinal segment
7. Anastomosis, intraoperative air leak test, and closure

Technical Tips

1. Identification and dissection of the ureters (ureterolysis) and pelvic autonomic nerves (neurolysis), following anatomical spaces, such as pararectal and retrorectal, to avoid injuries.
2. No need for high ligation of the inferior mesenteric artery and complete mobilization of the splenic flexure (not an oncological surgery). In addition, dissection can be performed closer to the intestinal wall.

Potential Areas for Injury/Complication

1. Nerve injury (inferior hypogastric plexus, superior hypogastric plexus, and splanchnic nerves) during the dissection of structures and pelvic peritonectomy. Endometriosis is a benign disorder; therefore, it is important to preserve urinary, evacuatory, and sexual functions, especially in young patients.
2. Ureteral injury also in the dissection of structures and pelvic peritonectomy
3. Colorectal anastomosis. This is assessed intraoperatively by analyzing doughnuts for completeness and performing the air leak test.