Tips and Tricks for Nerve-Sparing Modified Radical Hysterectomy for Deep Endometriosis with Firefly Technology

Abstract

<h3>Study Objective</h3> To show tips and tricks for our nerve-sparing modified radical hysterectomy (NS-mRH) for deep endometriosis (DE) and provide perioperative outcomes of the procedure. <h3>Design</h3> Stepwise demonstration of this method with narrated video footage. <h3>Setting</h3> An urban general hospital. NS-mRH is known for its benefits as a definitive treatment for severe endometriosis. Furthermore, robotic surgery has become available worldwide and two meta-analyses have confirmed that robotic surgery is safe and feasible in the treatment of endometriosis, especially in advanced cases. However, reports which showed the surgical technique of robotic nerve-sparing hysterectomy for DE were limited. <h3>Patients or Participants</h3> 30 patients presented with DE and complex pelvic pathology. <h3>Interventions</h3> Our NS-mRH was performed using following 8 steps with da Vinci Xi: Step 0, observing peritoneal endometriotic lesions; Step 1, adhesiolysis and adnexal surgery; Step 2, separation of the pelvic autonomic nerve plane; Step 3, dissection of the ureter; 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; Step 7, checking for rectal injury using air leakage test and tissue perfusion; and Step 8, barrier agents for adhesion prevention. <h3>Measurements and Main Results</h3> 30% of patients had history of previous surgeries for endometriosis. 53% of patients presented with complete cul-de-sac obliteration and 87% of patients presented with ENZIAN B2 or B3 lesions which were predictive factors for postoperative voiding dysfunction. All procedures included NS-mRH, uterosacral ligament resection and posterior compartment peritonectomy. Mean operative time was 127 min and blood loss was 31 ml. The mean VAS score significantly decreased after surgery. No patients developed perioperative complications, including postoperative bladder, rectal, and sexual dysfunctions. <h3>Conclusion</h3> Our NS-mRH for DE using FireFly technology is safe and feasible technique with excellent outcomes. Application of ICG with NIR fluorescence appears potentially useful, not only to remove DE, but also to improve nerve-sparing.