Preoperative Ultrasound Indications Determine Excision Technique for Bowel Surgery for Deep Infiltrating Endometriosis: A Single, High Volume Center

ABSTRACT Study objective To identify bowel nodule features of deep infiltrating endometriosis (DIE) measured via preoperative ultrasound (US) that influence laparoscopic surgical strategy. Design A retrospective study Setting Malzoni Clinic – Endoscopica Malzoni Department, Center for Advanced Endoscopic Gynecological Surgery, Avellino - Italy Patients Patients undergoing laparoscopic surgery between January 1, 2014 and December 31, 2018 for clinically suspected DIE with previous US evaluation ≤ 1 month before intervention. Intervention Use of US measurements to determine laparoscopic excision technique (segmental bowel resection, discoid resection, shaving) for DIE with bowel involvement. Measurements and main results Of 5051 DIE surgeries, 4983 were included; 1494 (29.9%) bowel resections (512 bowel segmental resections and 982 nodulectomies [967 shaving and 15 discoid resections]) were performed, accounting for 34.3% and 65.7% of all bowel procedures, respectively. Preoperative US findings and surgical reports were collected. Sensitivity and specificity of preoperative ultrasound evaluation for all types of DIE lesions were calculated, and US measurements of bowel nodules and different surgical techniques were compared. According to US preoperative measurements, the majority of nodules excised by segmental resection had a longitudinal diameter of 3 to 7 cm, none 4 cm). All shaved nodules had thickness ≤7 mm. The 15 nodules excised by discoid resection (1.5% of nodulectomies) were Conclusions The need for segmental resection in DIE with bowel-infiltrating nodules depends on degree of muscular layer infiltration and corresponding thickness (muscularis-rule) in addition to nodule length and can be accurately identified by preoperative US evaluation.