Multidisciplinary, robotic-assisted approach to treatment of ovarian remnant syndrome involving retrograde instillation of indocyanine green fluorescence

Our objective here is to demonstrate multidisciplinary teamwork in complex gynecological cases. To this end, we report a complicated case of ovarian remnant tissue after oophorectomy in the context of advanced-stage endometriosis. A 35-year-old G1P1001 woman with previous hysterectomy and bilateral salpingo-oophorectomy (BSO) presented with recurrence of pelvic pain less than one year after Da Vinci single-incision laparoscopic surgery (SILS) for resection of stage IV endometriosis. A multidisciplinary team of surgeons including minimally invasive gynecology, gynecologic oncology, urology and colorectal surgery was assembled to work collaboratively on this case. The patient underwent robotic-assisted removal of ovarian remnant tissue and endometriosis with bowel resection and ureterolysis. A novel technique involving indocyanine green fluorescence imaging was applied retrograde through cystoscopy guidance into ureters bilaterally to facilitate challenging dissections. The postoperative course was notable for development of a pelvic abscess leading to pleural effusion. Although recovery was prolonged, the patient has been disease-free to date after discharge. The breadth of surgical expertise allowed for the thorough removal of remnants.