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COMMENTARY
A Surgery on Deep Infiltrating Endometriosis Involving the

Rectum: A Debate Started 100 Years Ago between Cullen and

Sampson

John L Yovich

AbstrAct
A recent randomized control trial reports at the 5 years postoperative stage for limited vs extended surgery involving the rectovaginal septum.
For those gynecologists with advanced laparoscopy skills who have been reluctant to embrace the idea of complete bowel resections with
reanastomosis, the study provides comfort in showing no difference in long-term outcomes between nodule excision and rectal resection.
However, the study perpetuates the idea that all medical procedures have to be subjected to this type of statistical analysis, without any
reference to the pioneers whose ideas formed the basis of current procedures as well as providing an understanding of the pathogenesis of the
underlying disorder. The two gynecologists who first reported on the surgical management of this condition 100 years ago projected different
ideas on pathogenesis as well as the appropriate surgical method to apply. Thomas Cullen and John Sampson should be acknowledged in any
consideration of determining the appropriate procedure for this challenging disorder.
Keywords: Adenomyosis, Advanced laparoscopic surgery, Bowel resection, Deep infiltrating endometriosis involving rectum DIER, Endometriosis.
World Journal of Laparoscopic Surgery (2020): 10.5005/jp-journals-10033-1400

IntroductIon PIVET Medical Centre, Perth Western Australia, Australia
A recently reported randomized controlled study (RCT) regarding Corresponding Author: John L Yovich, PIVET Medical Centre, Perth
surgery for deep infiltrating endometriosis involving the rectum Western Australia, Australia, Phone: +61419906953, e-mail: jlyovich@
(DIER) showed no significant difference in long-term outcomes pivet.com.au
1
between nodule excision vs rectal resection. The impressive study How to cite this article: Yovich JL. A Surgery on Deep Infiltrating
is reporting at the 5 years postoperative stage but has not actually Endometriosis Involving the Rectum: A Debate Started 100 Years Ago
advanced either the understanding of the underlying disorder nor between Cullen and Sampson. World J Lap Surg 2020;13(2):94–96.
its proper management. In part, this is due to a failure to consider Source of support: Nil

historical aspects related to the two gynecologists who first Conflict of interest: None
reported on this disease, namely, Thomas Stephen Cullen (1868–
1953) and John Albertson Sampson (1873–1946) and who expressed
different views on its surgical management 100 years ago. With respect to the specific surgical procedure for DIER,

thomAs cullen Cullen stated “The removal of an extensive adenomyoma of the
rectovaginal septum is infinitely more difficult than a hysterectomy
Cullen graduated in Medicine in Toronto, Canada, in 1890, thereafter for carcinoma of the cervix”. In tackling this disease, Cullen believed
training as a gynecologist at the Johns Hopkins University 1891 but that gynecologists should be trained as fully competent abdominal
also spending time working as a pathologist in Gottingen, Germany, surgeons. He stated: “Where the lumen of the bowel is greatly
3,4
before returning to Johns Hopkins in 1893. However, the senior narrowed, a complete segment of the rectum should be removed
surgical position he had expected with Howard Kelly was deferred; with the uterus, and an anastomosis should be made.” In such cases
hence he established a pathology laboratory, becoming the first “surgeons should perform a “preliminary permanent colostomy…
Gynecological Pathologist in North America, while also practising later the pelvic structures can be removed en bloc”. 4,5
as a gynecologist in private practice. He eventually gained the However, despite Cullen’s anatomical knowledge and surgical
position as Head of Gynecology in 1919 after the retirement of Kelly expertise, especially that involving bowel anastomoses, 3–5
and had the title of Professor of Clinical Gynecology, a position he he described some unpleasant complications that included
held until retirement in 1939. Between 1894 and 1909, Cullen wrote vesicovaginal and rectovaginal fistulas. In this pre-antibiotic era,
four books on gynecological diseases that married histopathology despite the advanced sterile surgical techniques practiced at the
with clinical symptoms and signs, one of which was adenomyoma Johns Hopkins Hospital, most of the women who had complications
2
of the uterus. Subsequently, in 1914, he published on the specific died. 4,6
3
subject of adenomyosis of the rectovaginal septum as well
as an accumulated experience in 2020 of his findings of extra- John sAmpson

uterine adenomyosis, detailing 10 sites that he had personally
4
documented. However, the worst cases were those involving the Sampson’s experience overlaps with Cullen in that he graduated
rectovaginal septum, numbering 19 in total, and which led to its from Johns Hopkins in 1899 then proceeded into residency in
eponymous title “Cullen’s Disease”. gynecology under Howard Kelly through to 1906, a period when
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