What is the best course of action for a 30-year-old female patient with suspected Deep Infiltrating Endometriosis (DIE), Ehlers-Danlos Syndrome (EDS), and a history of bowel adhesions if bowel involvement is encountered during endometriosis excision?

Surgical Management of Bowel Endometriosis: Multidisciplinary Approach Required

The surgeon's plan to abort and reschedule with colorectal surgery is outdated and potentially harmful—current evidence strongly supports simultaneous multidisciplinary laparoscopic surgery with both gynecologic and colorectal surgeons present from the start when bowel involvement is suspected. 1, 2, 3

Why the Current Plan is Problematic

Aborting surgery upon discovering bowel involvement subjects this patient to:

• Unnecessary repeat anesthesia exposure and surgical risks 3
• Prolonged pain and disability from untreated disease 4
• Increased adhesion formation from incomplete surgery, complicating the second procedure 5, 2
• Higher overall morbidity from staged procedures versus single-stage complete excision 3

The Evidence-Based Approach

Preoperative Planning is Critical

MRI pelvis should have been performed before any surgery to map the full extent of disease, particularly bowel involvement. 6, 7

• MRI demonstrates 92.4% sensitivity and 94.6% specificity for detecting intestinal endometriosis 6, 8
• Preoperative imaging reduces morbidity by decreasing incomplete surgeries requiring reoperation 7
• The rectosigmoid anterior wall and sigmoid colon are the most common sites of bowel involvement 8

Multidisciplinary Surgery is Standard of Care

Multidisciplinary laparoscopic treatment has become the standard of care for deep infiltrating endometriosis with bowel involvement. 1, 3

• Both gynecologic and colorectal surgeons should be present from the start of surgery 2, 3
• The colorectal surgeon performs full-thickness disc excision or segmental resection as needed based on lesion size and location 1, 3
• This approach allows complete disease excision in a single operation 2, 4

Surgical Techniques Available

The colorectal surgeon has three options depending on findings: 9, 4

• Rectal shaving for superficial involvement
• Anterior discoid resection for focal full-thickness disease
• Segmental resection for extensive involvement (rarely needed except for sigmoid lesions) 4

Bowel resection should be avoided when possible, but full-thickness excision is often necessary and can be performed safely. 4

Special Considerations for This Patient

Ehlers-Danlos Syndrome Complicates Management

The vascular form of EDS (Type IV) presents extreme surgical risk with tissue fragility, hemorrhage tendency, and poor wound healing. 6

• However, most patients with joint hypermobility have hypermobile EDS (hEDS), not vascular EDS 6
• hEDS patients represent one-third of tertiary neurogastroenterology referrals and have poorer quality of life 6
• Tissue fragility is NOT a feature of hEDS or hypermobile spectrum disorders 6
• Vascular EDS requires pledgeted sutures and careful tissue handling, but successful surgery is achievable 6

History of Bowel Adhesions

Previous adhesions increase surgical complexity but do not contraindicate complete excision. 5

• Adhesions account for 55-75% of small bowel obstructions and are the most common cause 5
• Despite severe adhesions after deep endometriosis surgery, 50% of women conceive spontaneously 4
• Laparoscopic approach remains feasible even with significant adhesive disease 2

Outcomes with Proper Multidisciplinary Approach

Long-term outcomes following bowel resection for severe endometriosis are excellent: 1, 3

• Pain relief is excellent in >95% of cases 4
• Pregnancy rate of 50% despite often severe post-surgical adhesions 1, 3, 4
• Anastomotic complications occur in approximately 1% of cases 3
• Recurrence of deep endometriosis is rare 4

Recommended Action Plan

Request immediate consultation with colorectal surgery BEFORE the scheduled procedure to establish a coordinated surgical plan. 2, 3

1. Obtain MRI pelvis without IV contrast to map disease extent and confirm bowel involvement 6, 7
2. Schedule single-stage surgery with both gynecologic and colorectal surgeons present from incision 2, 3
3. Ensure colorectal surgeon has laparoscopic expertise in endometriosis excision techniques 1, 3
4. Clarify EDS subtype (hypermobile vs vascular) as this affects surgical planning and tissue handling 6
5. Consent for full range of procedures including disc excision or segmental resection 9, 4

Critical Pitfalls to Avoid

• Do not proceed with surgery without preoperative imaging when deep infiltrating endometriosis is suspected 7
• Do not accept staged procedures when simultaneous multidisciplinary surgery is feasible and safer 2, 3
• Do not assume all EDS patients have tissue fragility—only vascular EDS (Type IV) has this complication 6
• Do not delay definitive treatment—incomplete surgery increases adhesions and complicates subsequent procedures 5, 2