{"paper_id":"ab79ee92-0974-4c9e-9f8b-31a2806b0665","body_text":"Nanotechnology and Advanced Material Science  \nVolume 2 Issue 3\nNanotechnol Adv Mater Sci, Volume 2(3): 1–2, 2019\nResearch Open\nResearch Article      \nBowel endometriosis treatment with robotic assisted \nlaparoscopic resection – Is it a feasible alternative to \nlaparoscopic approach? \nRosa Maria Neme1,2* and Vladimir Schraibman3 \n*1Hospital das Clinicas Faculdade de Medicina Universidade de São Paulo\n2Centro de Endometriose São Paulo; São Paulo, Brazil\n3Universidade Federal de São Paulo; São Paulo, Brazil \n*Corresponding Author: Dr. Rosa Maria Neme, M.D., PhD, Centro de Endometriose São Paulo, Rua Joaquim Floriano 533 cj 1407-1414, São Paulo, Brazil; E-mail: \nrosaneme@uol.com.br \nReceived: September 29, 2019; Accepted: October 07, 2019; Published: October 11, 2019\nIntroduction\nEndometriosis is a gynecolog ic disorder defined by the presence \nof the endometrial gland and stroma outside the uterus. Deep \ninfiltrating pelvic endometriosis with bowel involvement is one of the \nmost aggressive forms and can cause infertility, chronic pelvic pain, \npain at defecation, and altered quality of life.\nBowel endometriosis involvement is estimated to occur in 5.3% \nto 12% of women with endometriosis. In specialized centers, its \nprevalence can reach 35% among women with deep infiltrating \nendometriosis. The rectum and sigmoid together account for 70% to \n93% of all intestinal endometriotic sites. \nRectovaginal and recto-sigmoid endometriosis are generally \nassociated with severe progressively debilitating abdominal and pelvic \npain, which markedly affects the quality of life in most the patients. \nCurrently available medical approaches are equally effective in the \ntreatment of endometriosis-associated pain, producing temporary \nrelief of symptoms, but none has yet been shown to achieve a long-\nterm cure. For these reasons, surgery needs to be considered the first \ntreatment of choice [1]. \nSince the first case of laparoscopic sigmoid resection for \nendometriosis published by Redwine and Sharpe, few studies have \nconfirmed the feasibility of laparoscopic colorectal resection for \nendometriosis.\nThe management of intestinal endometriosis depends on the \ndepth of the bowel wall invasion [superficial, partial, or full-thickness \ninvasion], leading to different surgical options [from disc excision \nto segmental resection]. It has been reported that the best results in \nterms of recurrence rates and improvement of symptoms are achieved \nby intestinal resection when the muscularis is compromised. \nOn the other hand, robotic technology and telemanipulation \nsystems represent the latest developments in minimally-invasive \nsurgery. They offer improved ergonomic position of the surgeon, three-\ndimensional visualization of the operating field, fine instrumentation \nand increased maneuverability of the instruments. These key features \nallow complex minimally invasive procedures to be performed more \neasily than with conventional laparoscopic surgery. The feasibility \nof a variety of robotic-assisted surgical procedures in gastrosurgery \nsuch as cholecystectomy, colorectal resection, cardiomyotomy, and \neven esophagectomy has been demonstrated in many papers in the \nlast decade. Several limitations of conventional endoscopic tools, such \nas limited instrument mobility or decreased ergonomics, have been \npartially overcome with the use of robotics.\nResults\nFrom September 2009 to January 2019, we have selected 134 \npatients with colorectal endometriosis referred to our private clinic \n[Centro de Endometriose  São Paulo, São Paulo, Brazil ] for the \nrobotic approach. All patients had clinical and imaging diagnosis \nof deep infiltrating colorectal endometriosis evolving at least the \nmuscularis of rectum or sigmoid. All these women were submitted \nto a robotic assisted retosigmoidectomy with a mean operative time \nof 120 minutes. Regarding complications blood loss was insignificant \n[near zero] in all cases and there weren’t any intra-operative or post-\noperative complications [as pneumonia, anastomotic or rectovaginal \nfistula, abdominal collections, long term ileus, intestinal adhesions]. \nNone of the patients had ileostomy or colostomy and mean hospital \nstay was 3 days.\nSixty one patients had infertility before surgery, with a mean \ninfertility time of 2 years. After 12 months of follow-up period, \n28 [46%] women conceived naturally, and in 120 [90%] women \nsymptoms as dysmenorrhea, dyspareunia and dyschezia, intestinal \ncramping, diarrhea or constipation completely disappeared. \nDiscussion\nDeep infiltrating endometriosis is a challenge for laparoscopic \npelvic surgeons. This series demonstrates that deep infiltrating \nendometriosis is a condition that requires interdisciplinary approach \nin order to obtain optimal clinical and medical results.\nDeep infiltrating endometriosis cases are difficult to manage and \nrequire specific skills in laparoscopic, robotic and colorectal surgery. \n\nRosa Maria Neme (2019) Bowel endometriosis treatment with robotic assisted laparoscopic resection – Is it a feasible alternative to laparoscopic \napproach?\nNanotechnol Adv Mater Sci, Volume 2(3): 2–2, 2019\nThese proced ures are relatively safe and in the context of close \ncollaboration between gynaecologists and surgeons, it presents low \nmorbidity and mortality.\nImportant issue is that these procedures require adequate training \nand also short and long term results after the treatment of deeply \ninfiltrating lesions are strictly operator-dependent. A multidisciplinary \napproach to manage deep pelvic endometriosis is mandatory in order \nto offer patients the best possible treatment using the combined skills \nof the colorectal and gynecologic surgical teams. [2]\nAs we know, the risk of complications depends on clinical \nconditions, vascular preservation, nerve preservation, the extension \nof endometriosis infiltration, and the surgeon’s experience. \nThe use of robotic assistance provided a very precise dissection of \nthe pelvic area, allowing good visualization of the pelvic plexus nerves, \nthus providing resection without nerve injury. The stable camera \nand the freedom of movement allow a very delicate and accurate \ndissection, as well as identification and preservation of the superior \nhemorrhoidal artery, providing good irrigation to the rectal stump \nand diminishing the incidence of rectal fistula. We did not have any \ncomplications in this series, such as fistula, local pain, nerve injury, \nor fecal or urinary incontinence, due to our previous large series in \nlaparoscopic treatment for endometriosis and the association of the \nrobotic technology in these cases. [3]\nThe main concern about robotic surgery is the cost, including the \ncapital and ongoing maintenance charges.  Robotic rectal surgery is \nconstantly increasing over the years. Previous reviews have already \ndemonstrated its safety and feasibility [4-6], although there are not \npublished studies demonstrating its superiority over the laparoscopic \napproach mainly due to the lack of randomized control trials. This \nlack of evidence about the effectiveness of robotic rectal surgery is \nin contrast with the overall opinion of surgeons that report an easier \nsurgical approach especially to narrow and difficult anatomic spaces \nsuch as the pelvis [7]. \nConclusions\nIn conclusion, results from the present study demonstrate that \nrobotic surgery is as feasible and safe as conventional laparoscopy \nin the treatment of colorectal endometriosis. The magnified view, \nthe improved ergonomics and dexterity might improve the diffusion \nof minimally invasive approach in the treatment of deep infiltrating \nendometriosis, mainly evolving recto sigmoid area. \nFurther randomized studies should address the role of robotics for \nthe treatment of deep infiltrating endometriosis.\nReferences \n1. Pierre Collinet , Pierre Leguevaque,  Rosa Maria Neme,  Vito Cela,  Peter Barton-\nSmith, et al. (2014) Robot-assisted laparoscopy for deep infiltrating endometriosis: \ninternational multicentric retrospective study. Surg Endosc 28: 2474–9.\n2. Sparić R , Hudelist G, Keckstein J (2011) Diagnosis and treatment of deep \ninfiltrating endometriosis with bowel involvement: a case report. Srp Arh Celok \nLek 139: 531–5.\n3. Neme RM, Schraibman V , Okazaki S, Maccapani G, Chen WJ, et al. (2013) \nDeep infiltrating colorectal endometriosis treated with robotic-assisted \nrectosigmoidectomy. JSLS 17: 227–34.\n4. Mirnezami AH, Mirnezami R, Venkatasubramaniam AK, Chandra  kumaran K, \nCecil TD, et al. (2010) Robotic colorectal surgery: hype or new hope? A systematic \nreview of robotics in colorectal surgery. Colorectal Dis 12: 1084 –1093 \n5. Scarpinata R, Aly EH (2013) Does robotic rectal cancer surgery offer im  proved \nearly postoperative outcomes? Dis Colon Rectum  56: 253 –262 \n6. Mak TW, Lee JF, Futaba K, Hon SS, Ngo DK, Ng SS (2014) Robotic surgery for \nrectal cancer: A systematic review of current practice. World J Gastrointest Oncol \n6: 184 –193\n7. Fabio Staderini, Caterina Foppa, Alessio Minuzzo, Benedetta Badii, Etleva Qirici, \net al. (2016) Robotic rectal surgery: State of the art. World J Gastrointest Oncol 8: \n757–771.\nCitation: \nRosa Maria Neme, Vladimir Schraibman (2019) Bowel endometriosis \ntreatment with robotic assisted laparoscopic resection – Is it a feasible \nalternative to laparoscopic approach?. Nanotechnol Adv Mater Sci  V olume \n2(3): 1–2.","source_license":"CC0","license_restricted":false}