Robot-assisted nerve-sparing eradication of deep endometriosis using the da Vinci SP.

Abstract

Objective: The evolution of nerve-sparing surgery has been supported by a growing body of literature on anatomic details, dissection techniques, and functional outcomes, suggesting that nerve-sparing surgery for deep endometriosis (DE) reduces postoperative pelvic organ dysfunction, including voiding and rectal dysfunction [1]. Recently, newer single-port robotic systems (da Vinci SP) have become available with articulating instruments and cameras that allow for intracorporeal triangulation, which may overcome some of the weaknesses of conventional single-port laparoscopic surgery [2]. Although such systems are believed to allow more complex surgeries than conventional single-port laparoscopic surgery, the scope of application remains unexplored. The objective of this video is therefore to demonstrate the anatomical and technical highlights of a complex intrapelvic procedure, nerve-sparing modified radical hysterectomy and complete removal of DE using the da Vinci SP (SP).

Setting: An urban general hospital. Stepwise demonstration of the technique with narrated video footage.

Participants: The patient was a 47-year-old woman who presented with chronic pelvic pain resistant to pharmacotherapy. Magnetic resonance imaging showed uterine adenomyosis and bilateral ovarian endometrioma with DE, involving the uterosacral ligament and surface of the rectum, with complete cul-de-sac obliteration.

Interventions: The surgical steps were completely identical to conventional multiport laparoscopic robotic surgery [3,4]. This suggests that conventional laparoscopic or robotic skills are highly transferrable to SP. SP offer several advantages, including high-resolution three-dimensional visualization, articulating instruments, and improved dexterity and range of motion. These advantages allow us to comfortably perform meticulous dissection and suturing even in difficult situations such as DE. The postoperative course was uneventful, with no perioperative complications, including no postoperative bladder or rectal dysfunction [5]. She was very satisfied with the invisible operative scar and low degree of postoperative pain.

Conclusion: Nerve-sparing eradication of DE using SP is technically safe and feasible, with cosmetic advantages and less pain.