Robotic excision of deep endometriosis involving the superior gluteal nerve

Abstract

Objective: To present how robotic excision of deep endometriosis involving the superior gluteal nerve may be safely and efficiently performed using the robotic assistance.

Setting: Tertiary referral center.

Patients: A 45-year-old patient presenting with deep endometriosis responsible for recent left sciatica and palsy of the left gluteus minimus, gluteus medius and tensor fasciae latae muscles.

Intervention: The MRI revealed a small endometriosis nodule in contact with the left sciatic notch and atrophy of the three muscles innervated by the left superior gluteal nerve. Inspection of the pelvis found a small peritoneal dimple on the posterior leaf of the left broad ligament, the depth of the dimple indicating the tip of the endometriosis nodule. To excise this nodule, we followed the 10 steps employed to remove deep endometriosis nodules involving the sciatic nerve (1). The lumbosacral trunk was dissected following this approach, and the nodule was identified on its lateral border. The nodule is removed in small fragments, until the nerves are completely released, the pyriformis muscle in visible below the nerves and the ileum bone is clean. During this step, the stability of the view, the miniaturized tips of the robotic instruments, the six degrees of freedom of instruments with an additional seventh degree at the instrument tip may make the difference and reduce surgical trauma of nerves when compared to straight instruments used in conventional laparoscopy (2,3). Despite the lack of evidence, we employ anti-adhesion barriers with the goal of reducing the risk of adhesions of surrounding tissues to nerves. Histological examination of the specimen confirmed the endometriosis. One month after the surgery, there was a significant improvement in hip abduction and contraction of the gluteus minimus, gluteus medius and tensor fasciae latae muscles.

Conclusion: Deep endometriosis nodule may involve somatic nerves of the pelvis leading to palsy of muscles specifically innervated by these nerves. Nodule excision is feasible using robotic surgery, due to the specific advantages related to this technology, with good functional outcomes.

Keywords: endometriosis; robotic surgery; sciatic nerve; superior gluteal nerve.