Bowel Endometriosis Surgery in Uberlândia, Brazil

Endometriosis is the presence, outside the uterus, of tissue similar to the endometrium — the layer that lines the inside of the uterus. When this tissue forms nodules that infiltrate organs, it is called deep endometriosis; when the nodule reaches the muscular layer of the bowel wall, it is bowel endometriosis (lesions only on the surface of the bowel are considered peritoneal disease). Up to 37% of women with deep endometriosis are estimated to have bowel involvement, and the most affected segment is the rectosigmoid, followed by the distal small bowel. In a French national series of 1,135 women operated on for deep endometriosis of the rectum and sigmoid colon, the disease involved only the rectum in 56.8% of cases, the rectum and sigmoid in 36.3% and only the sigmoid in 6.9%; the cecum was also involved in 6.6% and the small bowel in 4.7%.

Symptoms tend to follow the menstrual cycle: pain on defecation (dyschezia), diarrhea or constipation during the period, bloating and, in some cases, rectal bleeding — on top of the severe period pain and pain during intercourse common to deep endometriosis. At a Brazilian referral center, pain on defecation and diarrhea during menstruation were associated with a higher likelihood of segmental bowel resection being indicated, where lesions were larger (median 3.1 cm versus 1.6 cm with shaving). Mapping is done by imaging with a dedicated protocol: in a meta-analysis of 30 studies (3,374 women), transvaginal ultrasound had a sensitivity of 89% and a specificity of 97% for rectosigmoid endometriosis, and MRI 86% and 96% — with the caveat that the studies were heterogeneous. With bowel preparation, ultrasound reaches 93% and 94% in a 2024 meta-analysis, and in a Brazilian study of 194 patients with suspected deep endometriosis it predicted infiltration of the submucosa or mucosa with a sensitivity of 83% and a specificity of 94% — information that helps choose the technique before surgery. Colonoscopy assesses the mucosa — the innermost layer — so it is not the test that maps endometriosis; it is used when other bowel diseases need to be ruled out.

Not every case of bowel endometriosis needs surgery. Initial treatment is usually hormonal: in a Brazilian study of 238 women with rectosigmoid endometriosis treated with hormones first, 60.1% remained on medical treatment, and major complications occurred in 9.2% of the surgical group versus 0.6% of the medical group. Surgery is reserved for pain that does not respond to hormonal treatment, lesion growth and suspected bowel sub-obstruction — and, when there is infertility, the decision is made together with reproductive medicine. The European ESHRE guideline (2022) considers that surgical removal of deep endometriosis may reduce pain and improve quality of life (weak recommendation) and recommends, as good practice, referring women with deep endometriosis to a center of expertise. Studies comparing the same patient before and after surgery show improvement: in a review that pooled 17 studies, women operated on for bowel endometriosis improved in all 8 quality-of-life domains assessed, most of all in the pain domain; and in a prospective study of 175 women who underwent bowel resection, every pelvic pain parameter fell, with the largest drop in pain on defecation — studies without a non-operated control group.

Dr. Solon Gonçalves is a digestive tract surgeon (RQE 60355) and general surgeon (RQE 44656) and performs the complete operation for deep endometriosis involving the bowel — from excision of the pelvic implants to the bowel stage, including, when indicated, hysterectomy and bilateral salpingo-oophorectomy — by laparoscopy or robotic surgery, at UMC Hospital and Mater Dei Santa Genoveva Hospital in Uberlândia, Brazil.

The 2020 joint recommendations of ESGE, ESHRE and WES (World Endometriosis Society) for the surgical treatment of deep endometriosis advise building the team according to the planned procedure: the gynecologist leads, and a bowel surgeon, a urologist or other specialists may need to take part; a multidisciplinary meeting before the operation may be helpful. If a stoma is anticipated, this should be discussed extensively with the patient, and the stoma site may be marked before surgery.

Dr. Solon performs the whole operation: excision of the deep endometriosis nodules in the pelvis — uterosacral ligaments, rectovaginal septum, vaginal wall and peritoneum —, hysterectomy and bilateral salpingo-oophorectomy when indicated, and the bowel stage: choosing, based on imaging and the operative findings, between shaving, disc resection or segmental resection; suturing the rectum or performing the anastomosis; assessing the need for a protective stoma; and examining the whole bowel — the same recommendations advise inspecting the appendix, small bowel, cecum and ileocecal valve, because the disease is multifocal —, as well as following the recovery. When the ureter or bladder is involved, a urologist joins the team.

In the United States, in a national database of 745 colorectal resections for endometriosis, 82.3% were performed by general or colorectal surgeons and 17.7% by gynecologists; after adjustment, the specialty of the operating surgeon was not associated with major complications, and the authors suggest considering a multidisciplinary or dual-surgeon team when bowel resection is needed. In the ENDORE randomized trial, the multidisciplinary teams included three gynecologic surgeons, each with at least 120 operations for colorectal endometriosis, and five general surgeons with at least 5 years of experience in colorectal surgery, who performed every procedure requiring a bowel suture; rectal shaving was done by the gynecologic surgeon alone.

Bowel endometriosis surgery can be performed entirely by laparoscopy or by robotic surgery — what changes is the instrument, not the bowel technique. In the French national series, conventional laparoscopy was used in 82.2% of operations, robotics in 9.7% and open surgery in 8.1%. The robotic platform offers magnified three-dimensional vision, articulated instruments and tremor filtering, which may make dissection in the deep pelvis — between the rectum, the vagina and the ureters — and suturing easier. The ESGE/ESHRE/WES recommendations say exactly this: robotic instruments may facilitate difficult steps, but several studies have shown results equivalent to, not better than, conventional laparoscopy in deep endometriosis.

The only randomized trial, LAROSE, compared the two approaches in women with suspected endometriosis scheduled for surgery (not specifically bowel disease): operative time was similar (106.6 vs 101.6 minutes) and there was no difference in blood loss, complications or conversion to open surgery. In the 2025 meta-analysis specific to colorectal endometriosis, robotics took about 21.5 minutes longer on average, with no difference in blood loss, length of stay, conversion or overall complication rate — and the authors regard laparoscopy as the gold standard, with robotics as a potential alternative. In the most recent meta-analysis, from 2026, laparoscopy was 22.2 minutes faster in the bowel subgroup (only 2 studies).

One signal in favor of robotics appeared in urinary function: in a meta-analysis of 10 studies (728 patients) of colorectal endometriosis surgery, postoperative voiding dysfunction was less frequent after robotics (4.4% vs 13.3%) — an association that still needs confirmation in randomized trials. Cost is higher: at a referral center, disposable material for colorectal resection cost 14% more with the robot. For the surgeon, there is an ergonomic gain, with lower physical load on some muscle groups and lower cognitive load in a review of 10 studies (not specific to endometriosis), with very low-certainty evidence and no demonstrated outcome for the patient.

In practice, Dr. Solon performs both approaches and discusses the choice with the team and with the patient, case by case, based on the extent of the disease, the need for deep pelvic dissection and the team's experience — without presenting the robot as a universal solution.