Robotic Single-Site Endometriosis Resection Using Firefly Technology

STUDY OBJECTIVE: To demonstrate the feasibility of robotic single-site resection of advanced endometriosis using new technology. DESIGN: We show a video that demonstrates our technique for accomplishing single-site laparoscopic resection of advanced endometriosis. The video is a step-by-step explanation of robotic single-site resection of endometriosis nodules overlying the ureter and rectum. BACKGROUND: Laparoscopic surgery has been shown to effectively improve pain and fertility in women with endometriosis [1]. Compared with traditional multiport laparoscopy, single-incision laparoscopy is associated with similar incidence rates of blood loss, conversion to open laparotomy, and wound complications, but it has superior cosmetic outcomes and high patient satisfaction [2-5]. Furthermore, robotic single-incision laparoscopy combined with robotic Firefly technology potentially increases the removal of invisible endometriosis. Without complete resection of endometriosis, patients are less likely to achieve full pain relief postoperatively. SETTING: University hospital. PATIENT: A 36 year old G1P1 female was referred for chronic pelvic pain. She described her pain as hip pain, pain with walking, dyspareunia, dyschezia and right anterior abdominal wall pain. INTERVENTION: To improve detection of endometriosis, we injected the patient with indocyanine green (ICG), a fluorescent dye with widespread medical applications in identifying increased vascularity of tissues. We then visualized the tissues with robotic Firefly technology, a fluorescence-detection tool built into the da Vinci SI Surgical Systems (Intuitive Surgical, Inc, Sunnyvale, CA). MAIN RESULTS: Because endometriosis lesions are associated with a high degree of neovascularization, the ICG turned the endometriosis tissues dark green, thereby enabling us to detect endometriosis that would not have been seen as readily with conventional single-site laparoscopy. This video demonstrates our technique for successfully accomplishing a single-site laparoscopic resection of advanced endometriosis, including ureterolysis, adhesiolysis, peritoneal stripping, and a rectal nodule excision. CONCLUSIONS: We found that Firefly technology and ICG facilitated identification of endometriosis in single-site robotic surgery. We were able to successfully perform single-site laparoscopic resection of advanced endometriosis nodules overlying the ureter and rectum with complete resolution of pelvic pain symptoms and excellent cosmetic results.