Laparoconversion for Hemostasis During Robotic Surgery for Complex Deep Endometriosis of Sacral Plexus and Sciatic Nerve Does Not Avoid Coming Back to Gasless Robotic Procedure

STUDY OBJECTIVE: To show that the laparoconversion in an emergency because of intraoperative complications does not require irreversibly abandoning the robotic procedure. SETTING: Tertiary referral center. PARTICIPANTS: A young patient with deep endometriosis involving the lower rectum, both ureters with right hydronephrosis, the right sacral plexus, and the sciatic nerve, who underwent a previous excision attempt 4 years earlier. INTERVENTION: The film summarizes a 10-hour complex surgical procedure of robotic excision of deep endometriosis. During the excision of the parametrial nodule [1], we injured a right sacral vein, leading to severe hemorrhage. Hemostasis attempts [2] were unsuccessful with the loss of 900 mL of blood during 10 minutes. The laparoconversion by median sub umbilical incision was carried out in an emergency and the hemorrhage was stopped by vein ligation. However, the dissection of the sacral plexus and sciatic nerve by open surgery appeared to be challenging because of the low visibility of anatomical structures behind the deep nodule of the parametrium. We decided to go back to gasless robotic surgery, thanks to the strengths of the 4 robotic arms, which could efficiently suspend the abdominal wall. The surgery ended by rectal resection with coloanal anastomosis [3] and reimplantation of the ureter. Nine months after the surgery, the patient is pain-free and completely satisfied by the outcomes, with complete bladder voiding, no deep dyspareunia, and satisfactory bowel movements. CONCLUSION: The laparoconversion in an emergency, because of severe hemorrhage or other intraoperative complication, does not require irreversibly abandoning the robotic procedure, particularly in cases where the open approach does not offer comparable visibility, precision, or technical accuracy. Despite the opening of the abdomen and complete loss of the pneumoperitoneum, the robotic procedure may be successfully carried out in a gasless manner, thanks to the suspension of the abdominal wall by the strong robotic arms. VIDEO ABSTRACT.