When should the bowel surgeon get involved with endometriosis involving the bowel?
The answer seems simple. The bowel surgeon should be involved early in the process. I agree. The bowel surgeon should ideally have the seen the patient in a pre-operative consultation to discuss the planned procedure, results and potential complications. The intra-operative timing is the critical thing. If the gynaecologist has minimal surgical skills then invariably the bowel surgeon will be involved earlier. If that occurs, then the patient will receive a colo-rectal procedure, usually a segmental resection because that is what most bowel surgeons do since they are treating cancers. Unfortunately this will be too aggressive for most endometriosis patients who would have been adequately treated with either a shave or a disk excision. Segmental resection has significant long term functional effects and I believe should be avoided if at all possible.
A recent series describes an impressive 750 cases of segmental bowel resection for endometriosis. Unfortunately the series involved no disks or shaves and I believe it is highly likely that many of these patients did not require segmental resection.
If the gynaecologist has the appropriate skills then I believe the endometriosis should be removed from the side walls, the ureters should be exposed and then the bowel mobilised and shaved. At that point the bowel surgeon should be asked to consult and the issue then becomes what is the best procedure for that patient – shave, disk or segment.
Early recourse to the assistance of bowel surgeons often due to inexperienced gynaecological endometriosis surgeons is likely to result in more segmental resections than should occur.