Resection of Ischiorectal Endometriosis and Martius Flap Reconstruction

Study Objective

To describe the surgical management of ischiorectal endometriosis with a primary excision and secondary Martius flap reconstruction.

Design

A stepwise demonstration of surgical technique and key anatomic landmarks with the use of an educational video.

Setting

Ischiorectal endometriosis is rare and can be associated with vaginal deliveries and birth trauma. The intervention was carried out at tertiary care academic institution.

Patients or Participants

We present the case of a 34-year-old patient who presents with a 10-year history of progressively worsening perineal pain after childbirth. An MRI confirmed an endometriosis nodule in the ischiorectal fossa involving the superficial and deep perineal muscles, and the external anal sphincter.

Interventions

In this video, we have described an approach to resection using a trans-ischiorectal fossa approach and subsequent reconstruction with a Martius flap. Rotational grafts such as the Martius flap have been used for fistula repair and are less invasive when compared to gluteal or gracilis flaps. The patient did well post-operatively from the graft reconstruction and remains pain free.

Measurements and Main Results

We describe a two-step approach as a feasible strategy to avoid an invasive rotational flap. This video aims to provide a step-by-step approach to both resection and reconstruction while providing an overview of perineal anatomy.

Conclusion

Ischioanal endometriosis is a rare presentation, typically associated with perineal birth trauma. We describe a trans-ischiorectal approach to the resection of this lesion along with a secondary Martius flap reconstruction.