{"paper_id":"a611db65-7d7f-45da-83f6-ec4181cf37ce","body_text":"149\n19Robotic Treatment of Colorectal \nEndometriosis\nElisa Bertocchi and Giacomo Ruffo\n19.1  Introduction\nDeep infiltrating endometriosis (DIE) is defined as endometriosis lesions infiltrating \nmore than 5-mm beneath the peritoneal layer [1]. The endometriosis nodules gener-\nally arise from the posterior portion of the uterine cervix and spread to the recto -\nvaginal septum, uterosacral and parametrial ligaments. This leads to a chronic \ninflammatory reaction and fibrosis that can provoke a distortion of normal pelvic \nanatomy, pain, and subsequent infertility [2]. Bowel endometriosis is a type of DIE \ndefined by the presence of ectopic endometrial glands and stroma outside the endo-\nmetrial cavity and infiltrating at least the muscularis propria of the intestinal wall \n[3]. Patients with bowel endometriosis may suffer pain, dyschezia, abdominal bloat-\ning, constipation or diarrhea, passage of mucus with the stools, cyclical rectal bleed-\ning, defecation urgency, a feeling of incomplete evacuation, and even bowel \nocclusion [2, 4]. Endometriosis prevalence varies from 7% to 10% among women \nof reproductive age rising to between 30% and 35% in infertile women. The per -\ncentage of bowel involvement ranges from 8% to 30% with high incidences in refer-\nral hospitals [ 4]. The main locations of intestinal endometriosis, in order of \nfrequency, are the rectum and the sigmoid (83%) followed by the appendix, the \nsmall bowel, the cecum and ileocecal junction [ 2, 4]. Endometriosis could be seen \nas the tip of an iceberg, with a large proportion of women having a misdiagnosed \nand incorrectly treated disease.\nSupplementary Information The online version contains supplementary material available at \nhttps://doi.org/10.1007/978- 3- 031- 33020- 9_19.\nE. Bertocchi (*) · G. Ruffo \nGeneral Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital,  \nNegrar di Valpolicella (Verona), Italy\ne-mail: elisa.bertocchi@sacrocuore.it; giacomo.ruffo@sacrocuore.it\n© The Author(s) 2024\nG. Ceccarelli, A. Coratti (eds.), Robotic Surgery of Colon and Rectum, Updates \nin Surgery, https://doi.org/10.1007/978-3-031-33020-9_19\n\n150\nHormonal therapies may improve the symptoms caused by bowel endometriosis. \nHowever, surgery is required in patients with occlusive or subocclusive symptoms, \nin those whose symptoms have not improved despite the use of hormonal treat -\nments, in those with contraindications to the use of hormonal therapies and also in \npatients hoping to conceive [ 5]. Nowadays a minimally invasive approach is the \nstandard of care in the surgical treatment of endometriosis [ 1, 2, 4, 5]. The robotic \napproach is a consolidated and developing technique that can lead to good surgical \nresults in this field. In this chapter the technical details of robotic surgery for bowel \nendometriosis are reported.\n19.2  Patients’ Preoperative Work-Up\nEndometriosis is staged according to the revised American Fertility Society \nClassification [6]. Preoperatively, all women are asked to define endometriosis-  \nrelated symptoms and their intensity using the Visual Analog Scale [ 2, 3, 5]. All \nwomen with suspected bowel endometriosis should undergo a clinical rectovaginal \nexamination, an abdominal and pelvic ultrasound scan and a double-contrast bar -\nium enema or magnetic resonance imaging to map deep endometriotic lesions \nwhich may affect the rectovaginal septum and the posterior compartment [2, 3, 5].\n19.3  Colorectal Surgery for Endometriosis\n19.3.1  Patient Positioning and Docking\nThe patient is placed in a lithotomic position on a specific pad which creates fric -\ntion. The arms are positioned alongside the trunk and the legs are bent/apart and \nabducted using specialized stirrups. A 30° Trendelenburg position and a right tilt are \nthe first movement to expose the pelvic operative field from the small bowel loops. \nA bladder catheter and a uterine manipulator are placed before starting the surgery. \nPneumoperitoneum is induced using the Veress needle in the Palmer’s point. The \n12-mm camera port can be placed infraumbilically with the aim of maintaining the \noperative field on the pelvis, focusing on the fundus of the uterus. Two or three \nadditional 8-mm robotic ports are then positioned for the robotic instruments, pay -\ning close attention to maintaining a distance of at least 10 cm (the breadth of four \nfingers) from one another to avoid collision of the robotic arms upon docking. We \nusually put two 8-mm robotic accesses on the two oblique lines that connect the \ncamera’s port and the anterior superior iliac spine bilaterally at 8–10 cm from the \ncamera port. A third robotic arm could be placed along the left side of the abdomen \nto create the correct traction in the complex pelvic field. In addition to the two \nrobotic 8-mm trocars, we usually put one 5-mm laparoscopic assistant port of about \n10 cm, in a lateral position to the camera port on the right. In cases of a rectal resec-\ntion, a 12-mm laparoscopic port is placed in the suprapubic position for the bowel \ntransection with the laparoscopic linear stapler. Docking could be performed by \nE. Bertocchi and G. Ruffo\n\n151\nplacing the robotic cart at a 45° angle to the operating table, or parallel to the opera-\ntive bed or between the patient’s legs. The gynecologists and the urologists use a 0° \ncamera, and the colorectal surgeons use a 30° camera. We usually utilize a monopo-\nlar hook/scissors on the robotic arm on the right side and a robotic bipolar grasper \non the robotic arm on the left side along the lines connecting the camera port and the \nanterior superior iliac spines.\n19.3.2  Gynecological Surgical Steps\nEradication of DIE is a multidisciplinary surgery involving gynecologists and often \ncolorectal surgeons and urologists. The first phase of this surgery, which is a nerve- \nsparing technique [5], is gynecological and involves the following main stages:\n• Performing adhesiolysis, ovarian surgery and removing the involved peritoneal \ntissues.\n• Opening the presacral spaces (Latzko’s and Okabayashi’s lateral and medial \npararectal spaces) and then isolating and preserving the pelvic sympathetic fibers \nof the inferior mesenteric plexus, the superior hypogastric plexus, the upper \nhypogastric nerves, the lumbosacral sympathetic trunk and ganglia.\n• Dissecting the parametrial planes, isolating the ureteral course, lateral paramet -\nrectomy and preserving the sympathetic fibers of posterolateral parametrium and \nlower mesorectum.\n• Performing posterior parametrectomy and if necessary, doing a surgical dissec -\ntion of Waldeyer’s presacral space and Heald’s retrorectal space.\n• Developing the rectovaginal septum and sparing the distal portion of the inferior \nhypogastric plexus. This step allows for the isolation of the endometriotic nodule \nof the rectovaginal septum and/or the rectal nodule. In the case of infiltration of \nthe vaginal wall, a portion of the wall is resected and the vaginal margins are \nsutured by laparoscopy or hand-sewn through the vagina.\n• Opening of the tunnel of the ureter to separate the medial vascular portion of the \nvesicouterine ligament from its lateral part, in which the nerves of the inferior \nhypogastric plexus run. When the anterior parametrium is involved a complete \nunroofing of the ureter to the bladder is performed.\n19.3.3  Type of Colorectal Surgery\nColorectal surgery for DIE is performed after both the gynecological and urologi -\ncal steps.\n19.3.3.1  Rectal Shaving\nRectal shaving is carried out in the case of the presence of rectal/sigmoid nodules \n≤3 cm with involvement up to the muscular layer of the viscera. This technique \ninvolves the removal of the endometriotic nodule without opening the intestinal \n19 Robotic Treatment of Colorectal Endometriosis\n\n152\nlumen. In cases of evident deep damage of the muscular layer, a possible reinforce-\nment suture could be applied [ 4, 7, 8]. This type of surgery could easily be per -\nformed using the two robotic arms with scissors and a bipolar grasper.\n19.3.3.2  Disc Excision\nDisc excision is performed in the case of rectal/sigmoid nodules ≤3  cm of the \nanterior wall of the bowel with muscle or full-thickness infiltration. This technique \nis a full-thickness resection of the anterior intestinal wall [2]. The first step is shav-\ning of the redundant portion of the endometriotic nodule to reduce its size, and it is \nperformed using the two robotic arms with scissors and bipolar grasper. The full-  \nthickness disc excision of the shaved nodule is performed using a 29- or 31-mm \ntransanal circular stapler placed under robotic vision and opened once it reaches \nthe bowel nodule [2, 7, 8]. A gap is then created between the anvil and the shoulder \nof the stapler, placing the targeted anterior rectal/sigmoid surface inside this gap \nwith the aid of a previous robotic intracorporeal single stitch used for pushing the \nnodule inside the jaws of the stapler. The stapler is closed and fired, resecting a \nhalf-moon shaped rectal nodule specimen. The stapler is then removed, and the \nintegrity of the suture is checked by rectal endoscopy and a “bubble-test”. This \ntechnique does not require additional laparoscopic or robotic trocars [ 2, 7, 8].\n19.3.3.3  Segmental Resection\nSegmental resection is carried out in the case of large, circumferential, obstructive \nnodules and when multiple endometriotic nodules are present in the same bowel \nsegment [ 5]. In this case, a 5-mm laparoscopic assistant trocar is placed about \n10 cm lateral to the camera port on the right and a 12-mm laparoscopic trocar is put \nin the suprapubic position for the bowel transection with the linear stapler. The first \nstep is the identification and isolation of the inferior mesenteric vessels at the sacral \npromontory which are closed between clips positioned through the 5-mm laparo -\nscopic trocar [5]. Using the robotic arms, the surgeon completes the dissection on \nthe rectum developing posteriorly the avascular plane between the Waldeyer’s fas-\ncia and the mesorectal fascia. The rectum is prepared below the endometriosis \nnodule and is transected using a linear stapler through a 12-mm laparoscopic \nsuprapubic trocar. Based on the size of the bowel resection, which is the bare mini-\nmum including the nodule, a partial mobilization of the left colon is sometimes \nrequired to obtain a floppy and tension-free anastomosis [ 5, 7, 8]. In this case, at \nthe end of the robotic phase, a partial laparoscopic lateral-to-medial mobilization \nof the left colon is performed developing the avascular plane between Gerota’s and \nToldt’s fascias. After exteriorization of the surgical specimen through a Pfannenstiel \nincision, an end-to- end colorectal anastomosis according to Knight-Griffen is per -\nformed and is checked by rectal proctoscopy and a “bubble-test”. Loop ileostomy \nis created in all cases of ultra-low rectal resection, double bowel resection, con -\ncomitant vaginal suture or ureteral reimplantation or in the case of a large bladder \nresection.\nE. Bertocchi and G. Ruffo\n\n153\n19.4  Advantages and Limitations of the Robotic Approach \nto Colorectal Endometriosis\nThe robotic approach to colorectal endometriosis, like the robotic approach for all \ncolorectal surgeries, allows the surgeon to be less reliant on a surgical assistant. A \nsitting position at a console improves the ergonomics, particularly during a long and \ncomplex surgery [ 7–9]. The robotic equipment guarantees other benefits such as \nexcellent 3D stereoscopic visualization, a stable camera platform and improved \ndexterity [7–9]. As a result, a surgeon’s possible tremor disappears and a free and \nhigh level of movement of the instruments is provided. All these aspects could be \nhelpful in increasing the precision and the accuracy of dissection with potentially \nbetter functional outcomes (sexual, bowel and urinary function) in types of surgery, \nsuch as eradication of DIE, which require a procedure close to the nerves [ 9, 10]. \nBecause of the better visualization and therefore excision, robotic procedures could \nimprove the eradication of DIE, as stated by Mosbrucker et al. These gynecologists \ndetected more endometriotic lesions using the robotic technique than with the stan-\ndard laparoscopic approach [ 10]. The early postoperative outcomes, such as post- \nand intraoperative complications and the length of the hospital stay, are similar \nwhen comparing the laparoscopic and the robotic approaches for colorectal endo -\nmetriosis [7–9]. A large number of studies have demonstrated that in this surgical \nfield the main limits of robotic surgery compared to laparoscopy include longer \noperative time and higher costs. Most of the authors who analyzed the disadvantage \nof the longer surgical duration reported that docking and trocar setup were the main \ncauses for the longer operative time [7–9]. However, a large number of papers have \ndemonstrated that the robotic learning curve is shorter than that of laparoscopic \ntechnology [7, 8].\nFurther studies, possibly controlled trials, comparing the long-term functional \noutcomes between laparoscopic and robotic surgery for the eradication of bowel \nDIE are required.\nReferences\n1. Working group of ESGE, ESHRE, and WES, Keckstein J, Becker CM, Canis M, et  al. \nRecommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. \nHum Reprod Open. 2020;2020(1):hoaa002.\n2. Ceccaroni M, Ceccarello M, Clarizia R, et al. Nerve-sparing laparoscopic disc excision of deep \nendometriosis involving the bowel: a single-center experience on 371 consecutives cases. Surg \nEndosc. 2021;35(11):5991–6000.\n3. Chapron C, Chopin N, Borghese B, et  al. Deeply infiltrating endometriosis: pathogenetic \nimplications of the anatomical distribution. Hum Reprod. 2006;21(7):1839–45.\n4. Ceccaroni M, Clarizia R, Mussi EA, et al. “The sword in the stone”: radical excision of deep \ninfiltrating endometriosis with bowel shaving – a single-Centre experience on 703 consecutive \npatients. Surg Endosc. 2022;36(5):3418–31.\n5. Ferrero S, Stabilini C, Barra F, et al. Bowel resection for intestinal endometriosis. Best Pract \nRes Clin Obstet Gynaecol. 2021;71:114–28.\n19 Robotic Treatment of Colorectal Endometriosis\n\n154\n6. American Society for Reproductive. Revised American Society for Reproductive Medicine \nclassification of endometriosis: 1996. Fertil Steril. 1997;67(5):817–21.\n7. Hur C, Falcone T.  Robotic treatment of bowel endometriosis. Best Pract Res Clin Obstet \nGynaecol. 2021;71:129–43.\n8. Morelli L, Perutelli A, Palmeri M, et al. Robot-assisted surgery for the radical treatment of \ndeep infiltrating endometriosis with colorectal involvement: short- and mid-term surgical and \nfunctional outcomes. Int J Color Dis. 2016;31(3):643–52.\n9. Le Gac M, Ferrier C, Touboul C, et al. Comparison of robotic versus conventional laparoscopy \nfor the treatment of colorectal endometriosis: pilot study of an expert center. J Gynecol Obstet \nHum Reprod. 2020;29:101885.\n10. Mosbrucker C, Somani A, Dulemba J.  Visualization of endometriosis: comparative study \nof 3-dimensional robotic and 2-dimensional laparoscopic endoscopes. J Robot Surg. \n2018;12(1):59–66.\nOpen Access This chapter is licensed under the terms of the Creative Commons Attribution-  \nNonCommercial- NoDerivatives 4.0 International License ( http://creativecommons.org/licenses/\nby- nc- nd/4.0/), which permits any noncommercial use, sharing, distribution and reproduction in \nany medium or format, as long as you give appropriate credit to the original author(s) and the \nsource, provide a link to the Creative Commons license and indicate if you modified the licensed \nmaterial. You do not have permission under this license to share adapted material derived from this \nchapter or parts of it.\nThe images or other third party material in this chapter are included in the chapter's Creative \nCommons license, unless indicated otherwise in a credit line to the material. If material is not \nincluded in the chapter's Creative Commons license and your intended use is not permitted by \nstatutory regulation or exceeds the permitted use, you will need to obtain permission directly from \nthe copyright holder.\nE. Bertocchi and G. Ruffo","source_license":"CC0","license_restricted":false}