Robot-Assisted Nerve-sparing Resection of Bilateral Parametrial Deep Infiltrating Endometriosis

OBJECTIVE:To demonstrate the surgical steps used to perform a robotic radical parametrectomy in a woman with deep infiltrating endometriosis. DESIGN:Description of the procedure using video. SETTING:University hospital, referral center for endometriosis and minimally invasive surgery. INTERVENTIONS:A 47-year-old woman, with a body mass index of 31 kg/m2, who had undergone a supracervical hysterectomy for fibromatosis 5 years earlier, presented for definitive surgical management of parametrial and rectal endometriosis-associated pain. Robot-assisted nerve-sparing eradication of endometriosis, trachelectomy, and rectal shaving were planned. On the right side, the retroperitoneum was opened to widely expose the ureter, and a right adnexectomy was performed, gently separating the ureter from the diffuse periadnexal fibrosis. Right medial pararectal space was developed, and after right partial uterolysis, a nerve-sparing resection of the posterior parametrial endometriosis was performed. On the left side, endometriotic infiltration penetrated into the lateral and anterior (cranial portion) parametrium, wrapping the left uterine artery and the ureter. Left paravesical and pararectal spaces were developed. The left uterine artery was clipped at its origin, and the resection of the lateral and anterior parametrial nodules was completed following the shape of the nodule, dividing the lesion in 2 parts, and following the plane of the deep uterine vein to avoid excision of the nerve branches from the left inferior hypogastric plexus. Rectal endometriosis was removed by shaving, and the surgery ended with trachelectomy and robotic suture of the vaginal cuff. CONCLUSION:Robot-assisted laparoscopy is a safe and effective technique for nerve-sparing resection of parametrial endometriosis.