Improving accuracy of intraoperative diagnosis of endometriosis: Role of firefly in minimal access robotic surgery

Abstract

Endometriosis continues to be a major primary gynecologic etiology of chronic pelvic pain. The symptom profile, which includes cyclic pelvic pain, dysmenorrhea, and dyspareunia or dyschezia, is nonspecific and does not correlate with the extent or severity of disease. Trans-vaginal or trans-rectal ultrasound, as well as magnetic resonance imaging, can help visualize endometriomas and deeply infiltrating endometriosis. Additionally, there have been no serum marker tests available so far. However, even intraoperatively, the diagnosis may be missed, leading to under diagnosis and delayed or noninitiation of treatment. There are thought to be three distinct endometriotic lesions of the pelvis that are seen laparoscopically. The first is that which is visible on the pelvic peritoneal surface or the surface of the ovary, which is commonly termed peritoneal endometriosis. Second, endometriotic lesions that occur within the ovary and form cysts that are often lined with endometrioid mucosa are termed endometriomas. Lastly, rectovaginal endometriomas are endometriotic lesions that contain a mixture of adipose and fibrous tissue located between the rectum and vagina. All of these lesions can be singular or multiple and the pelvis may contain one or all three types of lesions. The shared histologic feature with all three lesions is the presence of endometrial epithelial cells or endometrial stroma. During a diagnostic procedure, the da-Vinci robot and its firefly mode allow for three dimensional visualization and seven degrees of instrument articulation for meticulous dissection of fibrotic areas of peritoneum that may contain deep infiltrating lesions of endometriosis. This case report describes a relatively new and innovative technique for effectively diagnosing and successfully treating endometriosis when other less invasive methods have failed.

Keywords: Da-Vinci robot; endometriosis; firefly; peritoneal stripping; recto-vaginal endometriosis.

Figure 1

Normal three-dimensional mode on the da-Vinci Si, the posterior culdisac appears endometriosis free

Figure 2

Posterior cul-de-sac lesion using firefly mode, there is clear area surrounding the dark vascular lesion, which represents fibrovascular tissue around islands of endometrial tissue

Figure 3

Peritoneal stripping of the involved area revealed fibrous tissue with foci of endometriosis

Figure 4

A low-power view of pelvic sidewall tissue showing endometriosis. There is fibrous tissue and smooth muscle with a focus of endometriosis near the surface. A small amount of hemorrhage is present (×40)

Figure 5

A minute focus of endometriosis on the surface of the tissue, present in a small fold. The cilia of the endometrial cells showing tubal metaplasia are focally prominent. Note the flat mesothelium lining the surface of the tissue directly opposite the endometrial epithelium (×400)