Should colorectal surgery be on call for potential resection in a female patient of reproductive age with a history of ileus, left salpingectomy, and suspected stage four endometriosis undergoing robotic-assisted resection of endometriosis, possible chromotubation, and hysterectomy with Aveta?

Should Colorectal Surgery Be On Call for Suspected Stage IV Endometriosis?

Yes, colorectal surgery should absolutely be on call for this case given the suspected stage IV endometriosis, history of ileus, and planned robotic-assisted resection. The likelihood of bowel involvement requiring surgical expertise is substantial, and having colorectal surgery immediately available prevents delays, reduces operative time, and optimizes patient outcomes.

Rationale for Colorectal Involvement

Stage IV endometriosis frequently involves the bowel, with rectosigmoid involvement occurring in 5.3-12% of all endometriosis cases and representing approximately 80% of intestinal endometriosis. 1, 2, 3 The patient's history of ileus further suggests potential bowel complications or adhesive disease that increases the complexity of dissection.

• Deep infiltrating endometriosis (DIE) with colorectal involvement is one of the most aggressive forms of the disease and requires specialized surgical expertise for safe resection 2
• Intestinal endometriosis is notoriously difficult to diagnose preoperatively, with 56.6% of cases being misdiagnosed as other conditions including submucosal tumors or malignancies 4
• The inability to definitively rule out bowel involvement preoperatively (suspected but not confirmed stage IV) makes colorectal backup essential 4

Surgical Complexity Requiring Colorectal Expertise

Robotic-assisted treatment of DIE with colorectal involvement requires extensive ureterolysis (80% of cases), potential segmental resection, and complex pelvic dissection where colorectal surgical expertise is critical. 2

• Segmental colorectal resection may be necessary for nodules >30-35mm or when complete excision cannot be achieved by shaving techniques 1
• Extensive dissection near the rectum carries risk of inadvertent perforation, which requires immediate colorectal surgical management 1
• Torus resection and uterosacral ligament involvement often require dissection in close proximity to bowel structures 2
• Additional procedures such as partial vaginal resection (20% of cases) may involve the rectovaginal septum, necessitating colorectal expertise 2

Operative Efficiency and Patient Safety

Having colorectal surgery on call rather than available by delayed consultation significantly reduces operative time, prevents staged procedures, and minimizes anesthesia duration for the patient. 5

• Mean operative times for robotic DIE with bowel involvement range from 157-370 minutes, and delays for surgical consultation would substantially extend anesthesia time 2, 3
• Conversion to laparotomy should be avoided when possible, but requires immediate decision-making if bowel injury occurs 1
• The patient's history of ileus suggests potential adhesive disease that may complicate bowel mobilization and increase injury risk 5

Multidisciplinary Approach Standards

Guidelines emphasize that deep pelvic endometriosis with intestinal involvement requires close collaboration between gynecologists and colorectal surgeons, with multidisciplinary team involvement enabling better management. 5, 3

• Robotic-assisted laparoscopic colorectal resection for DIE should be performed in the context of immediate collaboration between gynecologic and colorectal surgical teams 3
• Prompt joint decision-making is essential to avoid unnecessary delays and optimize outcomes 5
• Surgical input at an early stage helps ensure appropriate management of unexpected findings 5

Risk of Complications Without Colorectal Backup

Post-operative complications specific to bowel involvement include rectovaginal fistula (10% in some series), anastomotic leak, and bowel obstruction, all of which require immediate colorectal surgical expertise. 2, 3

• Rectovaginal fistulae occurred in 10% of robotic DIE cases with bowel involvement in one series 3
• Small bowel obstruction requiring intervention occurred in reported cases, though most resolved with medical management 1
• The patient's history of ileus places her at higher risk for post-operative bowel complications 5

Common Pitfalls to Avoid

• Do not proceed without colorectal backup based on "suspected" rather than confirmed stage IV disease - intestinal endometriosis is frequently misdiagnosed preoperatively and discovered intraoperatively 4
• Do not assume that robotic assistance alone eliminates the need for colorectal expertise - the technology facilitates dissection but does not replace surgical judgment for bowel resection decisions 1, 2
• Do not delay colorectal consultation until intraoperative findings confirm bowel involvement - this extends operative time, increases anesthesia duration, and may compromise patient safety 5, 3
• Do not underestimate the complexity based on imaging alone - extensive ureterolysis and adhesiolysis may reveal more extensive bowel involvement than anticipated 2