bowel endometriosis occurs in approximately 10% of all patients with endometriosis   and usually arises from the rectum and sigmoid colon at a rate of approximately 80% .
conservative treatment with hormonal therapy is usually performed . however , if the patient hopes to become pregnant , an alternative to long - term hormonal therapy must be found .
we report a case of lower rectal endometriosis performed using laparoscopically assisted low anterior resection of the lower rectum .
a 34-year - old woman presented with pain during menstruation and was diagnosed with endometriosis of the lower rectum . despite treatment with an lh - rh agonist
, she was unable to become pregnant and surgical removal of her endometriosis was recommended . on admission ,
tumor markers such as cea , ca-125 and ca-19 - 9 were 1.7 ng / ml , 31.9 u / ml and < 2.0 u / ml , respectively . on lower gastrointestinal series , poor extensibility of the lower rectum with irregular elevation and mucosal irregularity was observed .
the portion of the rectum involved with endometriosis was approximately 35 mm from the anal verge ( fig .
colonoscopic findings showed tumor - like submucosal tumor in the anterior wall of the lower rectum ( fig .
2 ) . abdominal computed tomography findings revealed a 2-cm mass without contrast enhancement in the lower rectum .
concerning abdominal magnetic resonance imaging ( mri ) , a mass which was slightly enhanced and demonstrated mass effect on the surrounding organs was shown on gadolinium - enhanced t1-weighted images ( fig .
there were adhesions to the right lower abdominal cavity , and a small amount of ascites was found in the pouch of douglas .
exfoliation was started from the presacral region to the right side of the rectum and the rectococcygeus ligament was cut .
exfoliation was continued to the levator ani muscle and mobilization of the left side of the rectum was performed . in front of the rectum , exfoliation was performed from the posterior wall of the vagina , but because the layer of exfoliation was unclear and tissue was solid around the tumor , the exfoliation was difficult . since the left hypogastric nerve was involved by inflammation surrounding the tumor , the nerve was cut , and subsequently the left lateral ligament was cut .
after the inferior border of the tumor was confirmed by colonoscopy , the rectum was cut 1 cm distal to the inferior border of the tumor .
then a 3-cm skin incision was made in the lower abdomen , the specimen was pulled up and the rectum was cut 5 cm distal to the superior border of the tumor .
postoperatively , a rectovaginal fistula occurred on the 9th postoperative day , and an ileostomy was performed .
after that , the patient 's postoperative course was uneventful and she left the hospital on the 25th postoperative day ; 4 months later the ileostomy was closed .
endometriosis affects approximately 15 - 20% of women of child - bearing age , and bowel endometriosis occurs in 5% of all endometriosis cases .
athmanathan et al .   reported that 80% of the cases of bowel endometriosis arise from the rectum and sigmoid colon .
symptoms of rectal endometriosis include dysmenorrhea in 57 - 85.3% of patients , dyspareunia in 55 - 57% , rectal pain in 41.2% , rectal bleeding in 14% , and tenesmus in 8.8% . in our case , the patient had rectal pain during menstruation .
physical examination , computed tomography , mri and endorectal sonographic evaluation are useful in making the diagnosis .
however , the sensitivity of mri for the diagnosis of colorectal endometriosis is much higher , at between 80 and 92.6% with a positive predictive value of approximately 89% .
endorectal sonographic evaluation is noninvasive and its sensitivity and positive predictive value are both 100% .
endorectal sonography was indicated in our case due to its high feasibility and lower cost compared to mri .
significant resistance to the surgical treatment of colorectal endometriosis currently exists because of major complications such as colo- or rectovaginal fistulae .
reported that rectovaginal fistulae occurred in 10.3% of patients . on the other hand , fleisch et al .   reported the utility of surgical treatment for patients with persistent pain and found that 21 ( 91.3% ) of 23 patients reported improvement in their symptoms . for patients who desire to become pregnant ,
long - term hormonal therapy for endometriosis is contraindicated ; therefore , surgery is needed .
bailey et al .   reported that the pregnancy rate following surgery was 49% , strongly supporting the surgical treatment of rectal endometriosis .
reported that all the items on the sf-36 health status and quality of life scores were significantly improved after laparoscopic colorectal resection for endometriosis .
reported that the probability of requiring further surgery was 36% in patients with deep endometriosis , and furthermore , 38.6% of patients had residual or recurrent endometriosis .
reported that the incidence of adhesion - related obstruction after laparoscopic colorectal surgery was 1.3% , which was lower than for open laparotomy ; therefore , laparoscopic surgery for colorectal endometriosis is recommend if further surgery is needed .
for patients whose lesions are located on the lower part of the rectum , exfoliation is needed up to the levator ani muscle ; therefore , the laparoscopically assisted approach is more useful in providing a good operative field compared to open laparotomy . in our case ,
a rectovaginal fistula occurred on the 9th postoperative day and ileostomy was required , but intraabdominal adhesions were mild and ileostomy was performed easily using a laparoscopic approach . in conclusion , for patients with lower rectal endometriosis for whom hormonal therapy is contraindicated , laparoscopically assisted low anterior resection is recommended for its visual amplification effect , minimal invasiveness and palliation of symptoms .
 a 34-year - old woman presented with pain during menstruation and was diagnosed with endometriosis of the lower rectum . despite treatment with an lh - rh agonist 
 , she was unable to become pregnant and surgical removal of her endometriosis was recommended . 
 preoperative magnetic resonance imaging revealed endometriosis localized between the neck of the uterus and rectum with indentation and scuffing . 
 laparoscopically assisted low anterior resection was performed . 
 exfoliation was started from the right side of the rectum to the presacral and retrorectal space , and the rectococcygeus ligament was transected . 
 exfoliation of the retrorectal space was continued to the levator ani muscle and mobilization of the right side of the rectum was performed . in front of the rectum , 
 exfoliation was started posterior to the wall of the vagina , but layers became unclear near the tumor as the tissue was solid in this region . 
 the left hypogastric nerve close to the tumor was inflamed and it was cut . 
 the layer of the exfoliation was connected to the right side of the rectum , the tumor was isolated from the vagina , and the lower rectum was transected at a point 1 cm distal to the tumor with a 60-mm linear stapler . 
 reconstruction with a 31-mm circular stapler was performed using the double stapling technique . 
 operative time was 520 min with a blood loss of 320 ml . 
 on the 9th post operative day , a rectovaginal fistula occurred , and ileostomy was performed . 
 the patient was discharged from the hospital on the 25th postoperative day , and 4 months later , stoma closure was performed . 