{"paper_id":"ac99566b-c547-464b-ad3d-6707e8805d3f","body_text":"Submit Manuscript | http://medcraveonline.com\nAbbreviations: LESS, laparoendoscopic single-site surgery; \nMRA, magnetic resonance angiography; SILS, single-incision \nlaparoscopic surgery; CPP, chronic pelvic pain; PCS, pelvic congestion \nsyndrome; RASI, robotic assisted single incision laparoscopic; AUB, \nabnormal uterine bleeding; IP, infundibulopelvic; ICG, indocyanine \ngreen; NSAIDs, non-steroidal anti-inflammatory drugs; GnRH, \ngonadotropin releasing hormone; CBT, cognitive behavioral therapy; \nMIGS, minimally invasive gynecological surgery\nBackground\nPelvic congestion syndrome (PCS) is a condition which although \nnot clearly understood is associated with chronic pelvic pain \n(CPP).1−3 Pelvic congestion syndrome (PCS) is most commonly \nseen in multiparous premenopausal women but may also be \nasymptomatic.4 This syndrome occurs when the veins of the pelvis \nbecome dilated leading to blood pooling in the pelvis and even causing \nreverse flow. Two anatomical findings are characteristic of pelvic \ncongestion syndrome; ovarian vein reflux and pelvic varicosities.5,2\nWomen affected by PCS most commonly present with pain, which \nmay vary from being acute to chronic, unilateral to bilateral, or sharp \nto dull.4,5 The pain associated with PCS occurs when the intima of \npelvic vessels are stretched releasing inflammatory mediators such as \nsubstance P.4Patients often describe PCS as a postcoital ache rather \nthan pain which is exacerbated by standing, and relieved when lying \ndown.6 PCS may also be associated with non-pain symptoms such as \nbladder or bowel irritability, and leg fullness or varicosities.6\nUnfortunately, most underlying causes of pelvic pain syndrome \ngo undiagnosed and make up a large proportion of gynecological \nvisits.4 Differential diagnosis for chronic pelvic pain (CPP) includes \nendometriosis, pelvic inflammatory syndrome, fibroids and \nadenomyosis.7\nThe etiology of PCS remains unclear but is thought to be \nmultivariable including physical and hormonal factors. 5,8 These \nfactors cause pelvic veins to become incompetent leading to \ncongestion and retrograde flow. 7 Congenital or acquired valvular \ninsufficiency, and venous obstruction are the mechanical causes of \nPCS.9 Hormones, specifically those which result in venodilation or \ndecrease in vasomotor tone, play a role in PCS. This correlates with \nthe increased incidence seen in multiparous women and the decrease \nin incidence after menopause.6\nInvestigations for PCS include pelvic ultrasound, venography \nand laparoscopy. 4 These investigations will reveal pelvic venous \ncongestion or atypical flow.4 Treatment of PCS can be medical, surgical \nor endovascular.4 When medical management fails, surgical treatment \nhas been shown to be effective in the majority of patients.10 We present \na case of robotic assisted single-incision (RASI) hysterectomy, with \nleft ovarian vein ligation for a patient with PCS.11\nObstet Gynecol Int J. 2018;9(3):167‒169. 167\n©2018 Rezai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestrited use, distribution, and build upon your work non-commercially.\nSingle site robotic-assisted laparoscopic \ntransperitoneal ligation of ovarian veins for \ntreatment of pelvic congestion syndrome; a case \nreport and review of literature\nVolume 9 Issue 3 - 2018\nShadi Rezai,1,5  Alexander C Hughes,2 Ninad \nM Patil,4 Elise Bardawi,1,5 Cassandra E \nHenderson,3 Xiaoming Guan5 \n1Department of Obstetrics and Gynecology, Southern California \nKaiser Permanente, USA\n2St Georges University, School of Medicine, Grenada\n3Maternal and Fetal Medicine, Department of Obstetrics and \nGynecology, Lincoln Medical and Mental Health Center, USA\n4Department of Pathology & Immunology, Baylor College of \nMedicine, USA\n5Division of Minimally Invasive Gynecologic Surgery, \nDepartment of Obstetrics and Gynecology, Baylor College of \nMedicine, USA\nCorrespondence: Xiaoming Guan MD PhD, Section Chief and \nFellowship Director, Division of Minimally Invasive Gynecologic \nSurgery, Department of Obstetrics and Gynecology, Baylor \nCollege of Medicine, 6651 Main Street, 10th Floor, Houston, \nT exas, 77030, USA, T el (832) 826-7464, Fax (832) 825-9349, \nEmail \nReceived: April 22, 2018 | Published: May 24, 2018\nAbstract\nBackground: Pelvic congestion syndrome (PCS) is a condition which is not clearly \nunderstood but is associated with chronic pelvic pain. Pelvic congestion syndrome is most \ncommonly seen in multiparous premenopausal women but may also be asymptomatic. PCS \noccurs when the veins of the pelvis are dilated leading to blood pooling in the pelvis and \neven causing reverse flow. Two anatomical findings are characteristic of PCS ovarian vein \nreflux and pelvic varicosities.\nCase: The patient was a 32 year old female gravida 8, para 1-2-5-3, with pelvic congestion \nsyndrome who was managed by single site robotic-assisted laparoscopic transperitoneal \nligation of the left ovarian veins. The patient underwent robotic assisted single-incision \n(RASI) hysterectomy, with left ovarian vein ligation for pelvic congestion syndrome.\nConclusion: While robotics continue to have the benefits of excellent 3D visualization, \nthe robotic-single site instruments have decreased range of motion and do not yet have \nthe ability to articulate which requires minor changes to surgical technique. Despite minor \ntechnology limitation, single-site robotic technology is a useful tool to perform very fine \ndissections.\nKeywords: endovascular embolization treatment, endovascular therapy, endovascular \ntreatment, laparoendoscopic single-site surgery (LESS), magnetic resonance angiography \n(MRA), ovarian vein, ovarian vein embolization, ovarian vein ligation, ovarian vein \nsyndrome, pelvic congestion syndrome, pelvic vein ligation, robotic-assisted laparoscopic \ntransperitoneal ligation of ovarian veins, single-incision laparoscopic surgery (SILS), \ntransperitoneal\nObstetrics & Gynecology International Journal\nCase Report\n Open Access\n\n\nSingle site robotic-assisted laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic \ncongestion syndrome; a case report and review of literature\n168\nCopyright:\n©2018 Rezai et al.\nCitation: Rezai S, Hughes AC, Patil NM, et al. Single site robotic-assisted laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic \ncongestion syndrome; a case report and review of literature. Obstet Gynecol Int J. 2018;9(3):167‒169. DOI: 10.15406/ogij.2018.09.00329\nPresentation of the case\nThe patient was a 32 year old female gravida 8, para 1-2-5-3, \nwith a past medical history of anxiety, depression, and post-partum \ndepression, as well as 3 cesarean deliveries and 5 spontaneous \nabortions. She had undergone elective bilateral tubal ligation as well as \nhysteroscopy and endometrial ablation for abnormal uterine bleeding \none year prior and had tried oral contraceptive pills and an intrauterine \ndevice without relief. The patient presented to our clinic with constant \nbloating, pelvic discomfort, pelvic pressure, dyspareunia and vaginal \nsoreness for the previous 2-3 weeks. She also reported hot flashes, \nnight sweats and difficulty sleeping that started about 2 months prior.\nLaboratory work up for prolactin, testosterone, vitamin D, vitamin \nB12, vitamin B6, hemoglobin A1C and Lyme disease as well as sleep \nstudies were all unremarkable. Vaginal exam and bimanual exam \nwere normal.\nPelvic ultrasound was unremarkable but Magnetic resonance \nangiography (MRA) pelvis revealed engorged bilateral paravaginal \nvessels and enlarged bilateral pelvic varices ( Figure 1 ) ( Figure 2 ). \nPost-contrast images with Valsalva demonstrated reflux into the left \ngonadal vein with left pelvic varices. The left pelvic varix measured \n0.9cm and the right pelvic varix measured 0.7cm. The left gonadal \nvein measured 0.5cm in the short axis. There was antegrade filling \nof the right paravaginal vessels with Valsalva. These findings were \ncompatible with PCS with reflux into the left gonadal vein.\nFigure 1 Post Magnetic Resonance Angiography (MRA) Pelvis.\nFigure 2 Sagittal Posts MRA of Pelvis. Vessels: Engorged bilateral paravaginal \nvessels and enlarged bilateral pelvic varices noted. Post contrast images with \nValsalva demonstrate reflux into the left gonadal vein with left pelvic varices. \nThe left pelvic varix measures 0.9cm. A right pelvic varix measures 0.7cm. The \nleft gonadal vein measures 0.5cm in short axis. There is antegrade filling of the \nright paravaginal vessels with Valsalva. The findings are compatible with pelvic \ncongestion syndrome with reflux into the left gonadal vein.\nThe patient underwent RASI laparoscopic surgery, consisting of \ntotal hysterectomy with bilateral salpingectomy, left ovarian vein \nligation and cystoscopy (Figure 3A). Intraoperative findings included: \nnormal uterus, fallopian tubes and ovaries. Omental and bowel \nadhesions to the left infundibulopelvic (IP) ligament were visualized \nand lysed ( Figure 3B ). An enlarged left ovarian vein as well as \nsignificant amount of bladder adhesions were also noted (Figure 3C).\nAfter the left infundibulopelvic (IP) ligament was dissected out \nto identify the ovarian vessels, the left ovarian artery was identified \nwith the assistance of Indocyanine green (ICG) administration (Figure \n3D). The left ovarian vein was then ligated with Ethibond suture 0. \nPathologic examination demonstrated congestion of large vessels and \ncapillaries, including ectatic capillaries compatible with increased \npressure (Figure 4).\nFigure 3 Intraoperative laparoscopic images:\n3A (top left):  Single-Site Wristed Needle Driver was used. Survey after \novarian vein ligation showing hemostasis and tied sutures in place.\n3B (top right): Adhesions of left ovary and the bowel.\n3C (bottom Left):  Indocyanine Green (ICG) was used to identify the left \novarian artery.\n3D (bottom Right): left ovary with enlarged, engorged ovarian vessels.\nFigure 4 Pathology Slide:  Congested ectatic capillaries (arrows) in the \nmyometrium. (H&E stain).\nThe patient had an uncomplicated recovery course. On \npostoperative follow up visit, she reported that the symptoms had \nresolved.\nDiscussion\nPCS can be a complicated and debilitating syndrome affecting \nmany women. Medical management of PCS 12 includes non-steroidal \nanti-inflammatory drugs (NSAIDs), 13 medroxyprogesterone acetate \nand gonadotropin releasing hormone (GnRH), which are effective, \nbut only for a short period of time. 7 As in the case described above \nour patient attempted medical management which failed and she \n\n\nSingle site robotic-assisted laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic \ncongestion syndrome; a case report and review of literature\n169\nCopyright:\n©2018 Rezai et al.\nCitation: Rezai S, Hughes AC, Patil NM, et al. Single site robotic-assisted laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic \ncongestion syndrome; a case report and review of literature. Obstet Gynecol Int J. 2018;9(3):167‒169. DOI: 10.15406/ogij.2018.09.00329\nopted for surgical treatment. Because she had already undergone a \nsterilization procedure, fertility was no longer an issue; therefore a \ntotal hysterectomy and salpingectomy were performed. In patients \ndesiring to preserve fertility, pelvic vein ligation alone has been \nshown to be effective.14\nLeft ovarian artery and left ovarian vein ligation was done in this \ncase. Left sided congestion is more common (for anatomical reasons) \nas it is with male varices.7,15,16\nOccasionally, bilateral ovarian embolization can be done for \nmanagement of PCS. Hysterectomy and oophorectomy have been \nshown to be effective in most patients.6\nOur goal for surgical management was to reduce blood flow to \nthe pelvis and thereby reduce congestion and pain. This can be \naccomplished by ligating large vessels (ovarian) with or without \nremoval of the uterus and fallopian tubes. Ligation of the ovarian \nvein effectively cuts off circulation to the pelvis and can be done \nlaparoscopically or by interventional radiology. 7 In our case because \nsurgery was performed endoscopically, we sutured to achieve ligation. \nICG was used to assist in identification of the pelvic vasculature \n(Figure 3).\nRobotic assisted single-incision (RASI) was used in this \ncase, and has some limitations compared to multi-port robotic \nsurgery.11 However, the use of robotics, by an experienced surgeon, \nhas shown improved outcomes with reduced surgical time, reducing \nhospital stays and improving pain management.17,18 The single incision \nendoscopic approach has the potential to produce a ‘no scar’ surgical \nsite as the incision can be hidden in the navel.19\nPCS has been associated with a host of psychiatric conditions \nsuch as anxiety, depression and postpartum depression. 20,21 Previous \nmiscarriage or childhood trauma have also been shown to be \nassociated with PCS. 22 The connection between PCS and a \ncomplicated obstetrical/ gynecological or psychiatric history adds \nto the complexity of this syndrome, as seen in the case presented. \nAlthough not applied to our patient, studies have shown some benefit \nfrom cognitive behavioral therapy (CBT) in the treatment of PCS.4\nConclusion\nTwo minimally invasive gynecological surgery (MIGS) techniques \nwere used in combination for this case. While robotics continue to \nhave the benefits of excellent 3D visualization, the robotic-single \nsite instruments have decreased range of motion and do not yet have \nthe ability to articulate which requires minor changes to surgical \ntechnique. Despite minor technology limitation, single-site robotic \ntechnology is a useful tool to preform very fine dissections. 11 The \nuse of RA-SILS for dissection and ligation of pelvic vessels proved \nbeneficial with complete resolution of the patientsin this case after \nsymptoms.\nAcknowledgements\nNone.\nConflicts of interest\nDr. Xiaoming Guan is a speaker for Applied Medical, Rancho \nSanta Margarita, California. Other authors did not report any potential \nconflicts of interests.\nReferences\n1. Atashroo DT, Castellanos M, Desai N, et al. Selective Pelvic Vein \nLigation for Pelvic Congestion Syndrome. J Minim Invasive Gynecol . \n2012;19(6):S93.\n2. Ki KD, Huh CY , Choi YJ, et al. The Long Term Outcome of Selective \nOvarian Vein Embolization for Chronic Pelvic Pain with Pelvic \nCongestion Syndrome. J Minim Invasive Gynecol . 2012;19(6S):S161–\nS162.\n3. Rastogi N, Kabutey NK, Kim D. Incapacitating pelvic congestion \nsyndrome in a patient with a history of May-Thurner syndrome and left \novarian vein embolization. Ann Vasc Surg. 2012;26(5):732.e7−11.\n4. Osman MW, Nikolopoulos I, Jayaprakasan K, et al. Pelvic congestion \nsyndrome. The Obstetrician & Gynaecologist. 2013;15:151–7.\n5. Mahmoud O, Vikatmaa P, Aho P, et al. Efficacy of endovascular \ntreatment for pelvic congestion syndrome. J Vasc Surg Venous Lymphat \nDisord. 2016;4(3):355−70.\n6. Rane N, Leyon JJ, Littlehales T, et al. Pelvic congestion syndrome. Curr \nProbl Diagn Radiol. 2013;42(4):135−40.\n7. Phillips D, Deipolyi AR, Hesketh RL, et al. Pelvic congestion syndrome: \netiology of pain, diagnosis, and clinical management. J Vasc Interv \nRadiol. 2014;25(5):725−33.\n8. Mathias SD, Kuppermann M, Liberman RF, et al. Chronic pelvic pain: \nprevalence, health-related quality of life, and economic correlates. Obstet \nGynecol. 1996;87(3):321−7.\n9. Durham JD, Machan L. Pelvic congestion syndrome. Semin Intervent \nRadiol. 2013;30(4):372−80.\n10. Vilasagar S, Carrillo JF. Laparoscopic Ovarian Vein Ligation for \nTreatment of Pelvic Congestion Syndrome. J Minim Invasive Gynecol . \n2016;23(7):S16.\n11. Guan X, Walsh TM, Hernandez A, et al. Robotic Single-Incision Ovarian \nVein Ligation for Pelvic Congestion Syndrome. J Minim Invasive \nGynecol. 2015;22(6S):S154.\n12. Gavrilov SG, Karalkin A V , Turischeva OO. Compression treatment of \npelvic congestion syndrome. Phlebology. 2017:268355517717424.\n13. Pieri S, Agresti P, Morucci M, et al. Percutaneous treatment of pelvic \ncongestion syndrome. Radiol Med. 2003;105(1-2):76−82.\n14. Hibner M, Castellanos M, Cookingham L, et al. Pelvic Vein Ligation for \nthe Treatment of Pelvic Congestion Syndrome in Women Who Desire \nPreservation of Fertility. J Minim Invasive Gynecol. 2011;18(6):S8.\n15. Machan L. Pelvic Congestion Syndrome. Vascular Embolotherapy . \nBerlin, Heidelberg: Springer; 2006:199−212.\n16. Gargiulo T, Mais V , Brokaj L, et al. Bilateral laparoscopic transperitoneal \nligation of ovarian veins for treatment of pelvic congestion syndrome. \nJ Am Assoc Gynecol Laparosc. 2003;10(4):501−4.\n17. Scheib SA, Fader AN. Gynecologic robotic laparoendoscopic single-site \nsurgery: prospective analysis of feasibility, safety, and technique. Am J \nObstet Gynecol. 2015;212(2):179.e1−8.\n18. Fader AN, Rojas-Espaillat L, Ibeanu O, et al. Laparoendoscopic single-\nsite surgery (LESS) in gynecology: a multi-institutional evaluation. Am \nJ Obstet Gynecol. 2010;203(5):501.e1−6.\n19. Fader AN, Levinson KL, Gunderson CC, et al. Laparoendoscopic \nsingle-site surgery in gynecology: A new frontier in minimally invasive \nsurgery. J Minim Access Surg. 2011;7(1):71−7.\n20. Latthe P, Mignini L, Gray R, et al. Factors predisposing women to \nchronic pelvic pain: systematic review. BMJ. 2006;332(7544):749−55.\n21. Ahangari A. Prevalence of chronic pelvic pain among women: an \nupdated review. Pain Physician. 2014;17(2):E141−7.\n22. Walker E, Katon W, Harrop-Griffiths J, et al. Relationship of chronic \npelvic pain to psychiatric diagnoses and childhood sexual abuse. Am J \nPsychiatry. 1988;145(1):75−80.","source_license":"CC0","license_restricted":false}