Robot-Assisted Nerve-Sparing Eradication of Deep Endometriosis

Abstract

Study Objective To demonstrate anatomical and technical highlights of a robot-assisted nerve-sparing surgery for deep endometriosis (DE). Design Stepwise demonstration of the technique. Setting An urban general hospital. Laparoscopic nerve-sparing techniques represented by the Negrar method have been described as resulting in lower rates of postoperative bladder, rectal, and sexual dysfunctions than classical approaches. However, few papers have shown the surgical technique for this procedure using a robotic approach in DE. Patients or Participants N/A Interventions Robot-assisted nerve-sparing excision of DE was performed using the following 8 steps: Step 1, adhesiolysis and adnexal surgery; Step 2, checking the ureteral course; Step 3, separation of the nerve plane [Step 3-1, dissection of the avascular layer below the hypogastric nerve, between the prehypogastric nerve fascia and presacral fascia); and Step 3-2, dissection of the avascular layer above the hypogastric nerve, between the prehypogastric nerve fascia and the fascia propria of the rectum]; Step 4, reopening of the pouch of Douglas; Step 5, complete removal of DE lesions while avoiding injury to the nerve plane; Step 6, hysterectomy (if the patient desires non-fertility-sparing surgery); Step 7, checking for rectal injury using an air leakage test; and Step 8, barrier agents for adhesion prevention. Measurements and Main Results No patients developed postoperative bladder, rectal, and sexual dysfunctions after the surgery. This nerve-sparing method is a modification of the technique of total mesorectal excision (TME) and total mesometrial resection (TMMR). We considered that this nerve-sparing technique is also applicable to segmental bowel resection and radical hysterectomy. Conclusion Robot-assisted nerve-sparing eradication of DE is as technically feasible as the conventional laparoscopic approach. The step-by-step technique should help perform each part of the surgery in a logical sequence, making the procedure easier and safer to complete.