Robotic Excision of Deep Endometriosis Involving the Superior Gluteal Nerve

STUDY OBJECTIVE: To present how robotic excision of deep endometriosis involving the superior gluteal nerve may be safely and efficiently performed using robotic assistance. DESIGN: Video article presenting a surgical technique. SETTING: Tertiary referral center. PATIENTS: A 45-year-old patient presenting with deep endometriosis responsible for recent left sciatica and palsy of the left gluteus minimus, gluteus medius, and tensor fasciae latae muscles. INTERVENTIONS: The magnetic resonance imaging revealed a small endometriosis nodule in contact with the left sciatic notch and atrophy of the 3 muscles innervated by the left superior gluteal nerve. Inspection of the pelvis found a small peritoneal dimple on the posterior leaf of the left broad ligament, the depth of the dimple indicating the tip of the endometriosis nodule. To excise this nodule, we followed the 10 steps to remove deep endometriosis nodules involving the sciatic nerve [1]. The lumbosacral trunk was dissected following this approach, and the nodule was identified on its lateral border. The nodule is removed in small fragments, until the nerves are completely released, the piriformis muscle is visible below the nerves, and the ilium bone is clean. During this step, the stability of the view, the miniaturized tips of the robotic instruments, and the 6 degrees of freedom of instruments with an additional seventh degree at the instrument tip may make the difference and reduce the surgical trauma of nerves compared with straight instruments used in conventional laparoscopy [2,3]. Despite the lack of evidence, we used antiadhesion barriers to reduce the risk of adhesions of surrounding tissues to nerves. Histological examination of the specimen confirmed the endometriosis. One month after the surgery, there was a significant improvement in hip abduction and contraction of the gluteus minimus, gluteus medius, and tensor fasciae latae muscles. CONCLUSION: Deep endometriosis nodules may involve somatic nerves of the pelvis leading to palsy of muscles specifically innervated by these nerves. Nodule excision is feasible using robotic surgery, owing to the specific advantages related to this technology, with good functional outcomes. VIDEO ABSTRACT.