Robotic Multidisciplinary Management of Extensive Deep Endometriosis

Study Objective To demonstrate a robotic multidisciplinary technique for extensive deep endometriosis ranging from Douglas pouch obliteration, rectal endometriosis and ureteral and appendiceal endometriosis. Design Case report. Setting Gynecology and Obstetrics department of a general hospital. Patients or Participants A 46-year-old para 3-1-2-2 woman who presented with severe dysmenorrhea and difficulty in defecation with right flank pain for 3 years. Interventions Robotically assisted hysterectomy with bilateral salpingo-oophrecetomy followed by LAR, appendectomy and urinary tract resection and reconstruction using psoas hitch, and appendectomy was performed on this patient early 2022. As the patient suffered from Douglas pouch obliteration, during hysterectomy we dissected the Douglas pouch and removed the deep endometriosis surrounding the sacral uterine ligament. Low anterior resection was performed using a double stapling technique. The bowel was transected below the pathologic site using a linear stapler. The oral stump of the bowel was extracted through the extended (to 3cms) left iliac port-site and outside the body, the pathologic segment was resected and the anvil for stapling was placed. The bowel was anastomosed using a circular stapler. Perfusion of the anastomotic site is confirmed via ICG firefly technology. Then the appendectomy was performed. After dissection of the mesoappendix, the appendix was transected at the base using a linear stapler. Finally, the lower segment of the ureter which became stenotic due to ureteral endometriosis was resected. Ureteroneocystostomy was performed using the psoas hitch. All of the procedure was caried out using the double bipolar technique, where the left Maryland forceps are used for coagulation and hemostasis and the right are used only for cutting. Measurements and Main Results The duration of the surgery was 4h4m. Estimated blood loss was 100mL. The postoperative course was completely benign. Conclusion Even complex procedures can be managed safely using robotic technology and multidisciplinary techniques. To demonstrate a robotic multidisciplinary technique for extensive deep endometriosis ranging from Douglas pouch obliteration, rectal endometriosis and ureteral and appendiceal endometriosis. Case report. Gynecology and Obstetrics department of a general hospital. A 46-year-old para 3-1-2-2 woman who presented with severe dysmenorrhea and difficulty in defecation with right flank pain for 3 years. Robotically assisted hysterectomy with bilateral salpingo-oophrecetomy followed by LAR, appendectomy and urinary tract resection and reconstruction using psoas hitch, and appendectomy was performed on this patient early 2022. As the patient suffered from Douglas pouch obliteration, during hysterectomy we dissected the Douglas pouch and removed the deep endometriosis surrounding the sacral uterine ligament. Low anterior resection was performed using a double stapling technique. The bowel was transected below the pathologic site using a linear stapler. The oral stump of the bowel was extracted through the extended (to 3cms) left iliac port-site and outside the body, the pathologic segment was resected and the anvil for stapling was placed. The bowel was anastomosed using a circular stapler. Perfusion of the anastomotic site is confirmed via ICG firefly technology. Then the appendectomy was performed. After dissection of the mesoappendix, the appendix was transected at the base using a linear stapler. Finally, the lower segment of the ureter which became stenotic due to ureteral endometriosis was resected. Ureteroneocystostomy was performed using the psoas hitch. All of the procedure was caried out using the double bipolar technique, where the left Maryland forceps are used for coagulation and hemostasis and the right are used only for cutting. The duration of the surgery was 4h4m. Estimated blood loss was 100mL. The postoperative course was completely benign. Even complex procedures can be managed safely using robotic technology and multidisciplinary techniques.