Laparoscopic Purse-String Suture Technique for Total Intracorporeal Rectosigmoid End-to-End Anastomosis After Segmental Bowel Resection

Objective: Bowel endometriosis affects 8–12% of women with infiltrating endometriosis, mostly involving the rectum and sigmoid1. Surgery is preferred when medical therapy fails or is contraindicated. Although segmental resection has shown good outcomes, it carries significant risks of perioperative complications1-3, partially due to the mini-laparotomy required for specimen retrieval and bowel anastomosis (post-operative pain, wound-related issues, blood loss, hernias). Total intracorporeal laparoscopic anastomosis may reduce them4,5. While promising, experience with this technique is limited, and there is no consensus on its use. This video showcases our technique for total intracorporeal end-to-end anastomosis using a purse-string suture after bowel resection for endometriosis. Design: Case report and video-description of the surgical technique Setting: Tertiary level academic hospital Intervention: A 32-year-old woman with severe, symptomatic endometriosis unresponsive to hormone therapy was referred to our hospital. Preoperative evaluation identified a 5cm nodule involving the anterior rectal wall, recto-sigmoid junction, and right utero-sacral ligament, located 10cm from the anal verge. After obtaining informed consent, surgery was scheduled. The recto-sigmoid colon was mobilized using a nerve-sparing approach1-3,5, followed by resection of the affected segment. The specimen was exteriorized from the right ancillary trocar site, and a total intracorporeal end-to-end colorectal anastomosis was performed without the need for a suprapubic mini-laparotomy, using a circular stapler and a monofilament purse-string suture to secure the anvil. Bowel integrity and residual vascular assessment with near-infrared indocyanine green were performed, and the patient experienced an uneventful recovery, with significant clinical improvement at follow-up. Conclusion: In our experience total intracorporeal anastomosis technique improves minimally invasive surgery for deep endometriosis, avoiding the drawbacks of mini-laparotomy and requires less sigmoid mobilization. The most threatening complication after full-thickness bowel resection is anastomotic leakage, often due to poorly supplied residual horns. Our technique using a purse-string suture during intracorporeal anastomosis, preventing formation of residual horns, can provide greater anvil stability for a secure anastomosis seal.