Has the Challenge Become Routine? Robotic Approach to Deep Pelvic Endometriosis

Abstract

Study Objective

To demonstrate that a procedure once considered highly challenging can become simpler and safer when performed in a systematic manner, guided by anatomical knowledge and supported by advanced surgical technology.

Design

Edited surgical video with narration, describing the stepwise systematization of a robotic-assisted deep endometriosis surgery, with emphasis on key anatomical landmarks.

Setting

The procedure was performed at a tertiary care hospital with access to a robotic platform. The patient was placed in lithotomy position, with lateral docking of the robot. Two robotic trocars were positioned in the iliac fossae bilaterally, and one 11 mm laparoscopic assistant trocar was placed in the right flank.

Patients or Participants

A 36-year-old woman with a two-year history of infertility, severe chronic pelvic pain, and deep dyspareunia. Imaging studies revealed deep endometriosis involving the posterior vaginal wall, rectum, and proximity to the hypogastric nerves, in addition to a solid ovarian mass.

Interventions

A systematic approach for complete excision of endometriotic lesions and right oophoroplasty:

• 1.
  Excision of peritoneal lesions in the vesicouterine fold
• 2.
  Right oophoroplasty
• 3.
  Access to pararectal spaces, ureterolysis, and nerve-sparing peritonectomy of the posterior compartment
• 4.
  Dissection of the rectovaginal space with rectal mobilization
• 5.
  Rectal discoid resection
• 6.
  Review of anatomical structures and hemostasis

Measurements and Primary Results

Complete excision of endometriotic lesions was achieved without complications related to bowel resection or bladder function. The patient was discharged on postoperative day 3, having progressed to a light diet. She experienced significant pain relief and was cleared for pregnancy two months after surgery.

Conclusion

The systematic surgical approach, combined with the precision of robotic assistance, allows highly complex procedures to be performed in a safer, more standardized, and reproducible manner.