Robot-Assisted Laparoscopic Management of Vascular Entrapment of the Sacral Nerve Roots Causing Motor Deficit

Abstract

Study Objective To demonstrate the robot-assisted laparoscopic decompression approach to treat aberrant vessels entrapping the sacral nerves causing motor deficit. Design Video presentation of two cases. Setting Tertiary unit specializing in advanced gynecologic surgery and neuropelveology. Patients or Participants Case 1: A 23-year-old virgin female patient presented with right lower extremity weakness, which had progressed into a limp over the past year and dysmenorrhea with a VAS (visual analog scale) score of 10. Gynecological examination revealed a 2 cm endometrioma on the right ovary. Under neurological examination hypoesthesia on right peroneal and right tibial nerve-dermatomes and chronic denervation of the muscles innervated by L5-S1 were observed. Case 2: A 46-year-old gravidity 3 parity 3 female patient presented with non-menstrual left sciatic pain, which caused difficulties while wearing socks and high heels and climbing up stairs. Magnetic resonance imaging (MRI) revealed dilated vessels on the left sacral nerve roots. Interventions Robot-assisted laparoscopic sacral nerve decompression Measurements and Main Results Patients were evaluated at 3rd and 6th month postoperatively. First patient's electromyography (EMG) result was normal at the 3rd month control. Motor deficit of both patients were eliminated and they both recovered fully. Conclusion Motor deficit or pain radiating (i.e. sciatica) to lower extremities are usually caused by spinal cord problems. However, these symptoms could arise by anatomic structures obstructing the nerves travelling to target organs or by nerve injuries. Since lumbosacral plexus is located over the sacral bone, it can be compressed easily by abnormal vessels crossing over the plexus. Accessing to the sacral plexus between lateral iliac vessels and iliopsoas muscle is crucial and stable instruments are crucial during surgery. Robotic-assisted laparoscopy allows this stability and decrease the possibility of complications. The robotic technique offers, three-dimensional vision, improved maneuverability and enhanced ergonomics in the deepest parts of the pelvis.