Treatment Should Not Be Worse Than the Disease: A Live Deep Endometriosis Case with a Colorectal Nodule

An endometrioma, a rectovaginal nodule, adenomyosis and eight years of infertility. Many would brace for a bowel resection. Dr Sanjay Patel reaches for a different plan: split the nodule, preserve the nerves and suture. Here is his reasoning.

The patient

A nulligravida in her early 40s presented with heavy bleeding, severe dysmenorrhea, chronic pelvic pain, dyschezia and eight years of infertility. One IVF cycle had yielded no good embryos. She was hypertensive and had taken elagolix for six months. MRI showed an adenomyotic uterus, a right endometrioma over 5 cm, a 1.5 cm colorectal nodule involving roughly 15% of the circumference, and rectovaginal and parametrial disease. Counselled for ovum donation, she consented to right tubo-ovarian mass excision.

Clear the space, find the plane

Dr Patel noted that six months of elagolix had left the tissue less elastic, making surgery harder. With donor oocytes planned and the left ovary healthy, he removed the right adnexal mass first to open the pelvis, rather than attempting cystectomy. He worked retroperitoneally, parallel to the ureter, entered the pseudocapsule for a clean cleavage plane, and designed the dissection so the hypogastric nerve was mobilised laterally rather than handled.

The Mayflower butterfly technique

For rectovaginal plate and uterosacral disease, he splits the nodule instead of shaving or resecting it. He dissects fibre to fibre until the tissue regains elasticity, the sign of a healthy margin, because residual disease invites recurrence. Explaining his shift after 2017, he said “treatment should not be worse than the disease.” His unit resects bowel in only one or two of 70–80 monthly cases. Perirectal fat is mobilised 360° first, since nodule size alone pushes surgeons toward resection

Closing the bowel

Here the muscularis was involved but the mucosa intact, so he used seromuscular V-Loc closure. He skips air or dye leak tests, which stretch the suture line, and checks with a rectal probe instead. If the mucosa opens, a two-layer transverse closure follows. Bowel prep omits polyethylene glycol, and clear liquids start within 8 hours, a protocol built with his GI surgeon, Dr Laxman Keria.

A candid course correction

Chairing the session, Dr PG Paul praised the nearly bloodless dissection. Late in the case, MRI suggested a small myoma near the cavity, and Dr Patel was tempted to remove it. Intraoperative transvaginal ultrasound showed it lay well away, so he left it, conceding that MRI alone had misled.

In deep endometriosis, the best resection is often the one avoided. Respect the plane, split rather than strip, confirm intraoperatively what imaging only suggests, and operate with a dedicated team.