O-115 The value of robotic surgery in the management of endometriosis

Abstract Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity, predomi nantly, but not exclusively, in the pelvic compartment. It is an oestrogen-dependent chronic inflammatory condition that affects women in their reproductive period and is associated with pelvic pain and infertility. Endometriosis occurs in 6–10% of women of reproductive age, with a prevalence of 38% (range, 20–50%) in infertile women and in 71–87% of women with chronic pelvic pain . This disease can be asymptomatic or associated with several symptoms such as dysmenorrhea, chronic pelvic pain, dyspareunia, infertility, as well as cyclic urinary and intestinal symptoms according to the location of the disease. For many years, diagnostic laparoscopy with pathological confirmation has been considered to be the gold standard for the diagnosis of endometriosis. However, in symptomatic women, noninvasive diagnosis with methods such as transvaginal ultrasound with or without bowel preparation and magnetic resonance imaging have been gaining a greater role in the diagnosis of endometriosis outside of surgery. Endometriosis is classifed as superfcial (or peritoneal), ovarian (endometrioma), and deep (defned as infltrating lesions greater than 5 mm in depth). Deep infltrating endometriosis (DIE) are nodules that extend deep into the peritoneal surface (>5mm) and often occur in the uterosacral ligaments, pouch of Douglas, vagina, bowel, bladder, and ureter. Treatment recommendations are generally based according to symptoms, response to medical treatment, and fertility status. Many studies agree that surgical resection of DIE improves pain and quality of life. There are no specific guidelines from any society regarding the indication and surgical approach for bladder and bowel DIE. In women who desire future fertility, conservative surgical treatment sparing the uterus and adnexa should be ofered. Limited data are available on reproductive outcomes after treatment of DIE . During the last decades, laparoscopic surgery (LPS) has been accepted as the technique of choice for the treatment of endometriosis, because it provides long-term outcomes comparable to those achieved by laparotomy (LPT), with the established advantages of a minimally invasive technique (MIS), including better visualization, shorter hospital stays, faster recovery and better cosmetic results. More recently, robotic-assisted laparoscopic surgery (RAS) has become available. Robotic surgery, has progressively gained relevance in the treatment of endometriosis, especially in complex forms involving multiple pelvic organs. This minimally invasive approach offers significant technical advantages over traditional laparoscopy, enabling greater surgical precision and dexterity. Technical Aspects • 3D Visualization and Magnification: • The robotic system provides high-definition, three-dimensional visualization of the surgical field, with magnification capabilities, allowing for improved identification and dissection of endometriotic lesions, even in confined anatomical spaces. • Articulated Instruments: • EndoWrist robotic instruments, with seven degrees of freedom, mimic human wrist movements, enabling greater precision in tissue dissection, suturing, and coagulation. • Ergonomics: • The surgeon’s console offers optimal ergonomics, reducing fatigue during prolonged and complex procedures, such as those required in the treatment of deep endometriosis. • Specific Applications: • Robotic surgery is particularly indicated for: • Resection of rectovaginal septum endometriosis. • Resection of endometriotic lesions infiltrating the bowel, bladder, and ureters. • Presacral neurectomy for the treatment of chronic pelvic pain. • Robotic surgery allows complex procedures, such as rectal disc resection with primary anastomosis and sigmoid segmental resection, to be performed with increased accuracy and control. • Considerations • Despite the technical advantages, robotic surgery requires a specific learning curve and an experienced surgical team. • The higher costs of the robotic system must be balanced against the potential clinical benefits for the patient. Conclusion Robotic surgery represents a significant evolution in the surgical treatment of endometriosis, offering technical advantages that can improve clinical outcomes and the quality of life for patients with complex forms of the disease.