Novel Techniques for Deeply Infiltrated Endometriosis in the Rectum and Parametrium Via Robotic Notes

Abstract

<h3>Study Objective</h3> To demonstrate novel techniques for the proper utilization of the Robotic assisted transvaginal Natural Orifice Transluminal Endoscopy Surgery (NOTES) technique for safely surgical managing deeply infiltrated endometriosis (DIE) <h3>Design</h3> Stepwise demonstration with narrated video footage. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> A 38-year-old G3P3, NSVDx1 and CSx1 for twin pregnancy with severe chronic pelvic pain. Previous history of laparoscopic ablation of endometriosis 10 years ago. Adenomyosis, deeply infiltrated endometriosis and intrapelvic adhesions was demonstrated on the MRI. <h3>Interventions</h3> Robotic transvaginal NOTES hysterectomy has been demonstrated to be feasible and safe in the surgical management of benign gynecology disease compared to traditional NOTES hysterectomy; however, it can be technically challenging to perform, particularly in managing of additional deep infiltrated endometriosis removal surgery after hysterectomy. The research indicates that robotic vNOTES surgeries are feasible in complex benign gynecologic procedures such as endometriosis and sacrocolpopexy. The robotic wristed instruments with 3-D visualization resulting in delicate tissue dissection and uncomplicated suturing and knot typing, are constructive to surgeons for overcoming the cumbersome surgical techniques in transvaginal NOTES complete endometriosis removal. Integration of robotic transvaginal single site surgery and resection of DIE is an innovative alternative minimally invasive route that is more cosmetic and less pain. <h3>Measurements and Main Results</h3> The procedure was successfully completed in approximately 200 minutes with an unevenly postoperative recovery. Patient was discharge home same day. Her pain level was 7/10 in first week, 5/10 in second week, 2/10 in third week. Pathology confirmation of adenomyosis, right ureteral, right uterine artery pedicle and rectal endometriosis involving muscularis propria. <h3>Conclusion</h3> Robotic transvaginal NOTES for deeply invasive endometriosis is challenging but feasible in patients with parametrial and rectal involvement. The advantage of articulating instrumentation and 3-D visualization are especially pivotal in complex transvaginal NOTES surgery.