The Role of Shaving Technique in the Treatment of Recto-Vaginal Endometriosis

Video Objective To demonstrate the rational use of shaving technique in the approach of endometriotic lesions of the recto-vaginal septum in selected cases. Setting Botucatu Medical School, Sao Paulo State University - FMB/UNESP. Tertiary public hospital, university teaching center. Interventions The procedure begins by characterizing the endometriotic lesion, by recognition of the pelvic anatomical structures and their relations with the disease. The physiological adherence of the sigmoid to the left pelvic wall is dissected, followed by identification of the ureters. Anatomic markers are used to guide dissection avoiding complications and inadvertent injury of noble structures. The retroperitoneal dissection begins on both sides from healthy tissue laterally towards the medial retro-uterine portion until it reaches the central portion of the lesion in the insertion of uterosacral ligaments. From this point on, the lesion is confined to the posterior portion of the uterus and anterior wall of the rectum. The endometriotic lesion is then isolated in the rectal wall using the reverse shaving technique. With the aid of a rectal probe, superficial resection of the endometriotic lesion is started, taking care not to deepen its dissection beyond the superficial sero-muscular layer. Finally, rigorous hemostasis is performed. When resection is very deep or very extensive it is advisable to check the integrity of the rectum-sigmoid wall with the aid of safety maneuvers. The vaginal touch is repeated at the end of the procedure to confirm that the entire initial lesion has been removed. Conclusion Despite its indication only for cases of superficial lesions the shaving technique presents as advantages: autonomy for the gynecologist, less tissue damage with preservation of the neuronal activity of the intestine, rapid recovery with early return of the daily life activity to the patient, being a great option for the treatment of rectum-vaginal endometriosis in duly selected cases.