ダグラス窩癒着を認める症例で腹腔鏡下子宮全摘術を行う際に直腸Ｓ状結腸損傷を避けるための工夫

抄録

Purpose

　Rectosigmoid colon injury is one of the complications of total laparoscopic hysterectomy (TLH). During TLH, when incising the vaginal wall, a blind incision into the posterior vaginal wall may have to be made, depending on the position of the camera port. If the rectum/sigmoid colon, which should be elevated outside the pelvis, is present in the pouch of Douglas, the risk of rectosigmoid colon injury increases.

　We report a surgical strategy to prevent rectosigmoid colon injury in patients suspected of pouch of Douglas adhesions preoperatively or intraoperatively at our institution.

Methods

　First, we incise the supporting tissue to expose the entire cervical fascia, and insert a vaginal pipe when an incision of the vaginal wall is possible. Next, we incise the ventral vaginal wall and insert the forceps through the hole of the vaginal pipe. Finally, we grasp the cervix at 12 o'clock with the forceps and lift the entire uterus ventrally.

　This makes a space between the pouch of Douglas and the posterior vaginal wall, which enable us to treat the posterior vaginal wall while maintaining the distance from the rectum/sigmoid colon. Using this method, we can securely lift the entire uterus from the vaginal side to the cranial, thus creating sufficient work space between the posterior uterus and the rectum even in cases with pouch of Douglas adhesions.

Results

　We completed the operations safely without any damage due to this ingenuity.

Conclusion

　Using this technique, we have been able to prevent rectosigmoid colon injury in cases with pouch of Douglas adhesions at our institution.

　We hope that this report will encourage more laparoscopists to use this method in cases with pouch of Douglas adhesions observed before or during surgery.