Step-By-Step Vaginal Anvil Insertion and Specimen Extraction for Rectosigmoidectomy in Endometriosis

Abstract

Study Objective

To present a safe step-by-step technique for minimally invasive vaginal insertion and totally intracorporeal placement of the circular stapler anvil used in rectosigmoidectomy procedures for endometriosis treatment.

Design

Didactic video demonstrating the step-by-step standardization of the vaginal insertion technique of the anvil and its application to the proximal bowel stump for intestinal anastomosis.

Setting

Laparoscopic procedure using a four-port French technique, 4K imaging system, and a 31mm circular stapler.

Patients or Participants

A 31-year-old patient with symptomatic bilateral parametrium endometriosis, chronic pelvic pain, tenesmus, and diarrhea. Rectosigmoid involvement was identified by magnetic resonance imaging.

Interventions

En bloc excision of endometriosis affecting the parametrium and pelvic somatic nerves was performed using neuropelveology techniques. A rectosigmoidectomy was conducted to resect the diseased bowel segment, which was missed during a prior surgery two years earlier, with persistent symptoms. The anvil of the circular stapler was introduced vaginally without exteriorization of the proximal bowel, achieving fully intracorporeal positioning. The procedure was preceded by bowel preparation using a combination of oral monobasic sodium phosphate dihydrate and dibasic sodium phosphate heptahydrate solution the night before surgery, plus two rectal doses (8 and 2 hours preoperatively). The resected bowel specimen was also removed transvaginally.

Measurements and Primary Results

Postoperative outcomes at immediate, 6-month, and 1-year follow-up were completely suitable, with no infection, full resolution of pelvic pain, and release of the parametrium confirmed on physical examination. Bowel function normalized to 1–3 daily evacuations initially, then stabilized at one per day without tenesmus. The technique proved to be feasible and reproducible.

Conclusion

Vaginal introduction of the anvil is a safe and reproducible technique when performed step-by-step. Adequate bowel preparation is essential. Vaginal specimen extraction offers a truly minimally invasive approach with uterine preservation and no need for abdominal wall incision.