Robotic interposition of the mesorectum during low anterior resection of the rectum for endometriosis using tissue perfusion assessment with indocyanine green

INTRODUCTION: Rectal endometriosis is a serious disease, and its surgical treatment belongs among demanding procedures, often requiring a multidisciplinary approach. It is associated with a significant risk of peri- and postoperative complications, the most serious being the development of rectovaginal fistula, which may occur in up to 10% of resections for rectal endometriosis. Preventive measures include the choice of surgical technique, such as a two-stage procedure (resection with terminal stoma followed by stoma closure and bowel anastomosis), which is not optimal for the patient due to the necessity of having two surgeries. Another option is the interposition of the patient's vital tissues into the site of anastomosis or intestinal wall suture. For this purpose, an omental flap is often used, or part of the mesorectum may be utilized. The ability to verify the vitality of such a flap should be considered crucial in preventing anastomotic leakage. METHODS: A patient underwent robotic-assisted laparoscopic segmental resection of severe rectal endometriosis involving the rectovaginal septum and vagina, classified as #ENZIAN A3 and C3, with interposition of the mesorectum and intraoperative tissue perfusion assessment using indocyanine green. CONCLUSION: The use of tissue perfusion assessment when performing interposition of patient-derived flaps may, in the future, improve surgical precision, enhance success rates, and contribute to the prevention of rectovaginal fistula formation.