{"paper_id":"85e3b324-8226-42ba-bafe-2f3a696e3bac","body_text":"Abstract\nFor symptomatic deep infiltrating endometriosis, surgery is often required to achieve symptom relief and restore fertility. A minimally invasive approach using laparoscopy is considered the gold standard. However, specific limitations of the laparoscopic approach deep in the pelvis keep challenging even surgeons with a solid experience with minimally invasive techniques. Robotic surgery has the potential to compensate for technical drawbacks inherent in conventional laparoscopic surgery, such as limited degree of freedom, two-dimensional vision, and the fulcrum effect. In the present report, we aim at demonstrating the central role of robotic surgery for deep infiltrating endometriosis, with special emphasis in the ability to practice organ (rectal) preservation. A 45-year-old white female with a 4-month history of chronic pelvic pain, dyschezia, and dysmenorrhea, refractory to hormonal therapy was referred to our unit. MRI findings were diagnostic of deep infiltrating endometriosis (retrocervical and rectovaginal) extending to the anterior rectal serosal layer (partial-thickness rectal invasion). Using a fully robotic approach, appropriate dissection of the rectovaginal septum and of the extraperitoneal rectum followed by complete excision of the endometriotic rectal nodule with organ (rectal) preservation was undertaken. It is our belief that using a robotic approach, the potential to boost rectal preservation might be established. Moreover, it is possible that in many cases, a robotic operation may allow the surgeon to perform the intervention with greater accuracy and comfort. As a result, more patients with deep infiltrating endometriosis may benefit from rectal sparing procedures.\nReferences\nBalasch J, Creus M, Fábregues F, Carmona F, Ordi J, Martinez-Román S et al (1996) Visible and non-visible endometriosis at laparoscopy in fertile and infertile women and in patients with chronic pelvic pain: a prospective study. Hum Reprod Oxf Engl 11:387–391\nLeibson CL, Good AE, Hass SL, Ransom J, Yawn BP, O’Fallon WM et al (2004) Incidence and characterization of diagnosed endometriosis in a geographically defined population. Fertil Steril 82:314–321\nRevised American Fertility Society classification of endometriosis (1985) Fertil Steril 43:351–352\nRuffo G, Sartori A, Crippa S, Partelli S, Barugola G, Manzoni A et al (2012) Laparoscopic rectal resection for severe endometriosis of the mid and low rectum: technique and operative results. Surg Endosc 26:1035–1040. doi:10.1007/s00464-011-1991-8\nVercellini P, Pietropaolo G, De Giorgi O, Pasin R, Chiodini A, Crosignani PG (2005) Treatment of symptomatic rectovaginal endometriosis with an estrogen–progestogen combination versus low-dose norethindrone acetate. Fertil Steril 84:1375–1387\nAbrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C (2015) Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update 21:329–339. doi:10.1093/humupd/dmv003\nErcoli A, D’asta M, Fagotti A, Fanfani F, Romano F, Baldazzi G et al (2012) Robotic treatment of colorectal endometriosis: technique, feasibility and short-term results. Hum Reprod 27:722–6. doi:10.1093/humrep/der444\nNezhat C, Lewis M, Kotikela S, Veeraswamy A, Saadat L, Hajhosseini B et al (2010) Robotic versus standard laparoscopy for the treatment of endometriosis. Fertil Steril 94:2758–2760. doi:10.1016/j.fertnstert.2010.04.031\nSiesto G, Ieda N, Rosati R, Vitobello D (2014) Robotic surgery for deep endometriosis: a paradigm shift. Int J Med Robot 10:140–146. doi:10.1002/rcs.1518\nSeracchioli R, Manuzzi L, Mabrouk M, Solfrini S, Frascà C, Manferrari F et al (2010) A multidisciplinary, minimally invasive approach for complicated deep infiltrating endometriosis. Fertil Steril 93(1007):e1–e3\nDuffy JMN, Arambage K, Correa FJS, Olive D, Farquhar C, Garry R et al (2014) Laparoscopic surgery for endometriosis. Cochrane Database Syst Rev 4:CD011031. doi:10.1002/14651858.CD011031.pub2\nDaraï E, Ballester M, Chereau E, Coutant C, Rouzier R, Wafo E (2010) Laparoscopic versus laparotomic radical en bloc hysterectomy and colorectal resection for endometriosis. Surg Endosc 24:3060–3067. doi:10.1007/s00464-010-1089-8\nGoldberg JM, Falcone T (2003) Laparoscopic microsurgical tubal anastomosis with and without robotic assistance. Hum Reprod 18:145–147\nPellegrino A, Damiani GR, Trio C, Faccioli P, Croce P, Tagliabue F et al (2015) Robotic shaving technique in 25 patients affected by deep infiltrating endometriosis of the rectovaginal space. J Minim Invasive Gynecol 22:1287–1292. doi:10.1016/j.jmig.2015.06.002\nBush SH, Apte SM (2015) Robotic-assisted surgery in gynecological oncology. Cancer Control 22:307–313\nAuthor information\nAuthors and Affiliations\nCorresponding author\nEthics declarations\nConflict of interest\nSEAA, VES, RMM, and MTVG declare that they have no potential (financial and no financial) conflict of interest.\nEthical approval\nThe present study was approved by the IRB at our Hospital. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\nInformed consent\nWritten informed consent was obtained from the patient for publication of this Case Report and the two accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\nRights and permissions\nAbout this article\nCite this article\nAraujo, S.E.A., Seid, V.E., Marques, R.M. et al. Advantages of the robotic approach to deep infiltrating rectal endometriosis: because less is more. J Robotic Surg 10, 165–169 (2016). https://doi.org/10.1007/s11701-016-0586-8\nReceived:\nAccepted:\nPublished:\nIssue date:\nDOI: https://doi.org/10.1007/s11701-016-0586-8","source_license":"CC0","license_restricted":false}