Robotic assisted rectal disk excision: the 3-cm diameter cut off may be abandoned

OBJECTIVE: To describe the robotic full-thickness rectal excision using a transanal circular stapler in rectovaginal endometriosis nodule infiltrating the rectum >3 cm. DESIGN: Surgical video article. The local institutional review board was consulted, and the requirement for institutional review board approval was waived because the video describes a technique and the patient cannot be identified whatsoever. Written informed consent was obtained from the patient for the use of personal data. SETTING: A tertiary referral center. PATIENTS: Patients undergoing excision of rectal endometriosis. INTERVENTION(S): Standardized technique of full-thickness disk excision of large rectovaginal endometriosis nodules employing a combined robotic and trans anal approach. MAIN OUTCOME MEASURE(S): Feasibility of the technique. RESULT(S): The technique is designed for deep rectovaginal nodules infiltrating middle and low-rectum up to 3 to 5 cm in length. The procedure was performed with robotic assistance. The 7-degree freedom mobility of the robotic scissors allows for a deep rectal shaving, with the goal of progressive reduction of the thickness of rectal wall. The scissors follow the rectal wall tangentially and leave behind a thin rectal wall which can be bent and pushed into the trans anal stapler's jaws. We employed end-to-end, 33 mm-diameter, circular trans anal staplers to increase the area of rectal wall to be caught into the stapler. A stitch was placed on the superior and the inferior limits of the shaved area, then the shaved area was bent and pushed into the stapler by tying a suture. The general surgeon closed and fired the stapler, then the stapler was removed together with a rectal patch of 4- to 6-cm diameter. The procedure ended in the bubble test which checked the integrity of the stapled line. Supplementary stitches may be placed to reinforce the suture, if required. CONCLUSION(S): The preliminary rectal shaving represents the real keystone of this procedure, and our experience suggests that the robotic assistance improves its feasibility in large nodule responsible for intrarectal protrusion.