Natural Conception Pregnancy after Vaginal Specimen Extraction in

Lower Anterior Resection Procedure for Managing Bowel Deep

Infiltrating Endometriosis: a Case Report
1
M. Luky Satria S Marwali, Florencia Wirawan
1. Endometriosis Center,Fatmawati General Hospital, Indonesia

ABSTRACT
INTRODUCTION:
Multidisciplinary laparoscopic treatment has become the standard of care for radical
treatment of deep infiltrating pelvic endometriosis (DIE) and to optimize outcome in female
patient during their reproductive years. In case of endometriosis infiltrating the rectosigmoid
colon, a laparoscopic rectosigmoid resection may be required. A laparoscopic sigmoid
resection with transvaginal specimen extraction, has the potential to decrease surgical
trauma to the abdomen, which lead to decrease surgical stress response, a faster return to
normal bowel function and diet, a decrease in post operative pain, fewer wound
complication and incisional hernia. Furthermore, some studies said that LAR procedure may
enhance conceive possibility.
OBJECTIVES: In this study, we wanted to share a successful conceive reproductive outcome
case after LAR with NOTES vaginal specimen extraction for uterosacral, rectovaginal and
bowel DIE.
METHODS:case report
CASE:P0, 34 years old with four years of primary infertility came with chief complains of
dysmenorrhea (VAS 8/10), dyspareunia (VAS 4/10) and dyschezia (VAS 6/10). A speculum
insertion was done and a nodule was visible at the posterior fornix. Rectovaginal nodule with
tenderness was palpable during rectovaginal toucher. Magnetic resonance imaging showed
a type III Diabolo-like rectovaginal noudle with bowel involvement. Thus, after a failed
hormonal therapy, the team decided to do a fertility-sparring surgical procedure. Gynecology
team responsible for adhesiolysis and rectovaginal DIE nodule resection meanwhile
colorectal surgeon team responsible for bowel egmental resection with transvaginal
specimen approach. Net operation time was 360 minutes with estimated blood loss 300 cc.
oral intake was introduced at post operative day 3 and patient was discharge at post
operative day 5 and continue to consume Dienogest for 3 months to prevent recurrence. A
follow up was done at the 45 th day post procedure, dysmenorrhea VAS score was lowered
(VAS 4/10) and normal bowel function was achieved. 4 months after the procedure, patient
was successfully conceived by natural intercourse without any assisted reproductive therapy
(ART).
CONCLUSION:Transvaginal specimen extraction technique was feasible to be done and we
found a similar operation time, blood loss, patient discharge and no complication which
were comparable with transabdominal specimen extraction technique. Reproductive
outcome was good as patient was able to conceive after procedure was done.