Robot-Assisted Exploration of Somatic Nerves in the Pelvis and Transection of the Sacrospinous Ligament for Alcock Canal Syndrome

Abstract

<h3>Study Objective</h3> To describe the anatomical and technical highlights of robotic exploration of the somatic nerves in the pelvis and transection of sacrospinous ligament (nerve decompression) for the patient with Alcock canal syndrome. <h3>Design</h3> Stepwise demonstration of a technique. <h3>Setting</h3> An urban general hospital. <h3>Patients or Participants</h3> A 48-year-old woman was referred for severe sitting pain, cyclic pelvic pain, gluteal and perineal pain, all of which were resistant to medication therapy. MRI revealed adenomyosis with neither deep endometriosis nor vascular entrapment. Based on neuropelveological evaluation, the patient was suspected to be suffering from Alcock canal syndrome due to compression of the pudendal nerve (and posterior cutaneous nerve of the thigh) by the sacrospinous ligament. <h3>Interventions</h3> Excluding the step for hysterectomy, the procedure was performed using the following 9 steps with the da Vinci Xi: Step 1, opening the peritoneum along external iliac artery; Step 2, exposure of the external iliac artery; Step 3, development of the lumbosacral space; Step 4, identification of the lumbosacral trunk; Step 5, identification of the superior gluteal nerve; Step 6, identification of the sciatic nerve; Step 7, identification of the inferior gluteal nerve; Step 8, identification of the pudendal nerve; and Step 9, transection of the sacrospinous ligament. <h3>Measurements and Main Results</h3> The surgery was successfully completed without any complications and the postoperative course was uneventful. On follow-up visits, the patient reported a gradual decreased in pain in postoperative 1st and 3rd months, and the neuralgia was finally completely resolved in the 6th month. Neuropelveologic evaluation still continues every 6 months. <h3>Conclusion</h3> When needed, minimally invasive techniques are applied for exploration and treatment with neuropelveological assessment. Robot-assisted transection of the sacrospinous ligament is a feasible, safe technique for selected patients with Alcock canal syndrome. Laparoscopic exploration of the pelvic nerves should be performed for further diagnosis and therapy before prematurely labeling the patient as refractory to the treatment.