Instruments and Techniques
Robotic Shaving Technique in 25 Patients Affected by Deep Infiltrating Endometriosis of the Rectovaginal Space Antonio Pellegrino, MD, Gianluca Raffaello Damiani, MD*, Claudia Trio, MD, Paolo Faccioli, MD, Paolo Croce, MD, Fulvio Tagliabue, MD, and Emanuele Dainese, MD From the Departments of Obstetrics and Gynecology (Drs. Pellegrino, Damiani, and Trio), Radiology (Dr. Faccioli), General Surgery (Dr. Tagliabue), Pathology (Dr. Dainese), Ospedale di Lecco Alessandro Manzoni, Lecco, Italy, and Department of Obstetrics and Gynecology, Azienda Ospedaliera di Lodi, Lodi, Italy (Drs. Damiani and Croce).
ABSTRACT Minimally invasive surgery represents the gold standard for the management of deep infiltrating endometriosis (DIE) involving the rectovaginal septum (RVS). This analysis aimed to evaluate the feasibility of robotic-assisted laparoscopy (RAL) and clinical outcomes in terms of long-term complications, pain relief, and recurrence rate for the treatment of DIE of the RVS. A prospective cohort study of robotic procedures was performed between October 2010 and July 2014, including removal of endometriotic nodules from the RVS with rectal shaving alone or in combination with accessory procedures. In all cases, the revised American Society for Reproductive Medicine (rASRM) score for endometriosis was .40 points (stage IV). Twenty-five consecutive patients underwent RAL, with a successful complete nodule debulking by the wall shaving technique. Pathology confirmed the adequacy of the surgical specimen and the median largest endometriotic nodule was of 21 mm (range, 10–60 mm), with free margins in all cases. The median operative time from skin opening to closure was 174 minutes (range, 75–300 minutes), and blood loss was close to 0 mL. The median revised Enzian score for location A (RVS) was 2 (range, 1-3). The most frequent Enzian class was A2B0C0 (48%), followed by A3B0C0 (12%). In 3 cases (12%), partial vaginal resection was required to remove endometriotic nodules of the RVS (1 each in classes A3B0C1FI, A3B0C0FO, and A3B0C0). No intraoperative complications occurred. This series has a median long-term follow up of 22 months (range, 6–50 months) currently available with an optimal operative time, demonstrating good long-term outcomes. Our data support robotics as a safe and attractive alternative for comprehensive surgical treatment of DIE. Journal of Minimally Invasive Gynecology (2015) -, -–- Ó 2015 AAGL. All rights reserved. Keywords:
DISCUSS
Deep infiltrating endometriosis; Endometriotic nodules; Rectovaginal septum; Robotic; Shaving
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Robotic-assisted laparoscopy (RAL) has progressed significantly over the past few years. Recent advances in the field of minimally invasive surgery have focused on the incorporation of robotic technology for the treatment of gynecologic malignancies [1,2]. RAL is also a wellDisclosures: None declared. Corresponding author: Gianluca Raffaello Damiani, MD, Department of Obstetrics and Gynecology, Ospedale di Lecco Alessandro Manzoni, Via Dell’Eremo 11, 23900 Lecco, Italy. E-mail: [email protected] Submitted April 28, 2015. Accepted for publication June 3, 2015. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2015 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2015.06.002
described procedure for the staging and treatment of gynecologic and urologic malignancies, overcoming anatomic barriers to the process of staging for endometrial cancer without increasing patient morbidity. Owing to its increased range of indications, RAL appears to be feasible in treating deep infiltrating endometriosis (DIE) as well. DIE, a complex disorder that affects 6% to 12% all women of childbearing age [3,4], is histologically defined as endometriotic lesions extending more than 5 mm beneath the peritoneal surface. RVS and sigmoid endometriosis, the most common types of DIE, are often associated with severe, progressively debilitating abdominal and pelvic pain, negatively affecting the
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patient’s quality of life. No medical treatment has yet been shown to achieve a long-term cure, with symptom recurrence rates as high as 76%. Surgical excision, effective in relieving pain [5–8], is considered the treatment of choice. In addition, the adhesions related to initial endometriosis or induced by the surgery negatively affect the subsequent pregnancy rate [9]. The American Fertility Society [10] system classifies DIE as 1, superficial endometriosis involving the peritoneum; 2, ovarian endometriomas; or 3, DIE resulting in fibrosis, adhesions, and significant nodules that invade deeper than 5 mm into the retroperitoneum of the pelvic sidewalls or the RVS, or involves at least the muscularis of the bowel, bladder, or ureters [11–13]. RAL overcomes many of the difficulties associated with standard laparoscopy through improved high-definition 3D visualization of the operating field, improved range of motion with increased maneuverability of the instruments with 6 of freedom, surgical dexterity, and ergonomics. The advantages offered by RAL may be highly valuable in the management of infertility with the assimilation of microsurgery principles into fertility-promoting procedures. Owing to the numerous drawbacks of laparoscopic surgery in DIE and the very limited data available to date [14], consideration should be given to the potential role of robotics for this indication. Here we present our results and evaluate the feasibility and long-term outcomes of RAL for treating DIE of the RVS, including complications, pain relief, and recurrence rate. Materials and Methods This was a prospective analysis of patients who underwent robotic surgery for the treatment of DIE of the RVS in our institution between October 2010 and July 2014. All of the robotic procedures were performed by the same surgeon (A.P.), who has extensive experience and expertise in laparoscopic and abdominal gynecologic surgery for oncologic conditions. Institutional Review Board approval was obtained. The diagnosis of DIE was established based on medical history, clinical symptoms, and instrumental findings. Baseline characteristics included age, body mass index (BMI), previous surgery, parity, and previous cesarean delivery (Table 1). Examined factors included total operative time, robot docking time, estimated blood loss (EBL), histological findings, nodule diameter, length of stay, and both early and long-term complications. EBL was calculated by measuring the blood collected in the suction canister and subtracting the amount of irrigation used during the surgery. Preoperative and postoperative complete blood cell counts were compared for accuracy. Neither high BMI nor previous abdominal surgery was considered a contraindication for RAL. All clinical data were collected by our team, and all patients were interviewed preoperatively about endometriosis-related symptoms. The preoperative workup included clinical examination with bimanual palpation and with rectal exploration, along with transvaginal and abdominal ultrasound. Magnetic resonance imaging was performed to assess the extent of the disease and to plan surgery and ureteral involvement. Patients with bowel symptoms associated
Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2015
Table 1 Patient demographic data and characteristics of previous surgery Characteristic
Value
Age, yr, mean 6 SD BMI, kg/m2, mean 6 SD Pregnancy, n (%) Spontaneous delivery Cesarean section, n (%) Nulliparous, n (%) Previous abdominal surgery, n (%) No surgery, n (%) Surgery for endometriosis, n (%) Previous laparoscopic surgery, n (%) Previous obstetric/gynecologic surgery, n (%) Diagnostic LPS, n (%) LPS miomectomy1 DT of EL, n (%) LPS escission of EL of the RVS, cystotomy, n (%) LPS Miomectomy 1 enucleation of ovarian cyst, n (%) LPS escission of EL of the bladder, n (%) LPS escission of the utero sacral endometriotic nodule, n (%) CA-125 serum level, UI/L/dL, median (range)*
33.9 6 6.1 21.2 6 2.9 4 (16) 2 (0–1) 2 (8) 23 (92) 0 (0) 18 (72) 7 (28) 7 (28) 7 (28) 2 (8) 1 (4) 1 (4) 1 (4) 1 (4) 1 (4) 35 (4–368)
BMI 5 body mass index; LPS 5 laparoscopy; DT 5 diatermocoagulation; RVS 5 rectovaginal septum; EL 5 endometriotic lesion. * Preoperative value.
with nodules of the RVS underwent a double-contrast barium enema and/or rectocolonoscopy. Data were analyzed using SPSS 17.0 (SPSS Inc, Chicago, IL). The Student t test for paired samples was used to compare the outcomes regarding evaluation symptoms. A p value , .05 was considered statistically significant. Inclusion criteria were the presence of more than 1 lesion of the RVS partially involving the muscle layer (no involvement of the deep muscle layer or mucosal layer), and no change in symptoms with hormone treatment (for .6 months) or previous surgery. Before surgery, all patients were informed about potential risks and benefits of this kind of intervention. On the day before surgery, all patients received a clear fluid diet and bowel preparation with 2 L of polyethlene glycol. Low-molecular weight heparin was given 12 hours after surgery. Prophylactic antibiotic therapy (cefazoline 2 g and metronidazole 500 mg intravenously) was administered at the beginning of the procedure. Surgery was performed with the Da Vinci S system (Intuitive Surgical, Sunnvale, CA), docked in a standard fashion at the foot of the bed, between the patient’s legs. All patients underwent surgery under general anesthesia. The patient was positioned supine with both arms tucked comfortably, and her legs placed in Allen stirrups, abducted and with hip extension to accommodate the second assistant surgeon. A Foley catheter was placed to empty the bladder and control urine output, and a uterine manipulator was introduced through the cervix. After induction of pneumoperitoneum established to 20 mmHg with a closed Verres needle and insertion of the robotic videolaparoscope, through a 12-mm port just above the umbilicus, the entire abdominal cavity was explored to evaluate the extension of the endometriotic lesions.
Pellegrino et al.
Shaving Technique for Deep Infiltrating Endometriosis
A 12-mm umbilical trocar was placed using the open Hasson technique. Two 8-mm ancillary robotic trocars were placed bilaterally, approximately 1 handbreadth away from the camera port to prevent collision of the robotic arms. An ancillary 10-mm trocar was placed in the left subcostal area to be used by the assistant surgeon. A 0-degree camera was used for the entire procedure. Once robotic docking was completed, the primary surgeon controlled the robot remotely from the console. Instruments included monopolar scissors, bipolar forceps, a monopolar hook, a suction/irrigator probe, and a large needle holder. The dissection was carried out through the rectovaginal septum, and the rectum was mobilized below the nodule until a soft area distal to palpable abnormalities was encountered. During dissection, care was taken to avoid injury to the left ureter, which often runs more medially in cases of DIE. Lesions extending through the vagina were treated with en bloc resection of the posterior vaginal wall. Reconstruction of the muscular wall portion of the rectal wall was performed in all cases involving rectal shaving, using 3/0 absorbable monofilament sutures. The principal surgical procedures performed are described in Table 3. Shaving, the least invasive procedure, involving layer-by-layer excision of the lesion without full-thickness resection, was performed in all cases where the lesion was superficial or had partially involved the muscular layer but without full-thickness bowel wall infiltration. All patients were interviewed and ranked endometriosis-related symptoms, including dysmenorrhea, chronic pelvic pain, dyspareunia, and specific gastrointestinal symptoms, on a 10-point visual analog scale (VAS), from 0 (absent to 10 (unbearable). Preoperative and postoperative dysmenorrhea, gastrointestinal symptoms, and dyspareunia scores are reported in Table 2. Any hormonal therapy was stopped 1 month before surgery. Fever was defined as body temperature of .38 C on 2 consecutive measurements at least 6 hours apart, excluding the first day after surgery. Patients were allowed to return home when fully mobile, apyretic, and passing urine satisfactorily. We followed up all patients at 1 month, 3 months, and 6 months postoperatively and yearly thereafter with pelvic examination, a clinical interview regarding symptoms, and eventually a pelvic ultrasound scan. Follow-up evaluation consisted of pelvic physical and ultrasound examination. Relapse was defined as the presence of de novo symptomatic or asymptomatic endometrioma and/or RVS or bowel nodules. During the follow-up interviews, patients were also asked about postoperative conception and any further surgery. Postoperative hormonal therapy, consisting of continuous low-dose monophasic oral contraceptives for 6 months, was prescribed for all patients except those seeking pregnancy. Table 3 categorizes the cases according to the new revised Enzian classification scheme for DIE [15,16]. We adopted the new
Table 2 Preoperative and postoperative symptoms at 3-month follow-up Symptom
Preoperative
Postoperative
p value
Dysmenorrhea Dyspareunia Gastrointestinal symptoms Chronic pelvic pain
8 (4–10) 8 (2–10) 7 (0–10) 8 (0–5)
2 (0–4) 1 (0–3) 1 (0–4) 0 (0–4)
,.05 ,.05 ,.05 ,.05
Data are median (range).
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Table 3 Spectrum of robotic procedures Procedure
n (%)
Nodule ecission of RVS Concomitant surgery Hysterectomy Excision of uterosacral nodules Excision of right uterosacral nodule Excision of left uterosacral nodule Ovariectomy Opening of vaginal wall Intraoperative complication: opening of rectal wall Conversion to laparoscopy
25 (100) 7 (28) 2 (8) 4 (16) 3 (12) 1 (4) 1 (4) 3 (12) 1 (4) 1 (4)
RVS 5 rectovaginal septum.
Enzian classification because the revised American Society for Reproductive Medicine (rASRM) score does not take DIE into account, and it enables clinicians to classify DIE. It provides an excellent complement for morphological description of DIE, including the size of the lesions. Nonetheless, international studies are required before the Enzian classification will become established and accepted by the medical community.
Results The mean patient age was 33.9 6 6.1 years, and mean BMI was 21.2 6 2.9. A total of 25 RAL procedures for endometriosis of the RVS were performed. Concomitant surgery for synchronous lesions (28%) consisted of 2 hysterectomies (class A3B0C0FB and A1B1C0FA), 1 ovarietomy (class A3B0C0FO), and 4 excisions of uterosacral nodules (16%; class A2B3C1, A2B2C0FA, A1B1C0FA, and A1B1C0FA), involving the right uterosacral in 3 cases (Table 4). Of 25 patients, 7 (28%) had undergone previous surgery for endometriosis. Fifteen (60%) were affected by infertility, and 23 (92%) were nulliparous. In 3 cases (classes A3B0C1FI, A3B0C0FO, and A3B0C0), vaginal opening was required to remove endometriotic nodules of the RVS, and partial vaginal resection was performed. No intraoperative complications occurred. All 25 patients underwent medical therapy before surgery. The median operating time from skin opening to closure was 174 minutes (range, 75–300 minutes). Median docking time was 20 minutes (range, 5–25 minutes). The median EBL was 0 mL (range, 0–100 mL). The median length of stay was 3 nights (day of surgery was counted as night 1; range, 2–4 nights). The anatomic specimens had a median large axis of endometriotic excised nodule of 21 mm (range, 10–60 mm), with free margin in all cases. The median revised Enzian score for location A (RVS) was 2 (range, 1–3). The most frequent Enzian class was A2B0C0 (48%), followed by A3B0C0 (12%). No patient was readmitted to the
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Table 4 Cases of DIE (stage IV, rASRM score .40) according to the revised Enzian classification after surgery Enzian class
n (%)
A1B1C0FA A2B2C0FA A2B1C0 A3B0C0FO A3B0C1FI A3B0C0FB A2B3C1 A2B0C0 A3B0C0 A1B1C0
2 (8) 1 (4) 1 (4) 1 (4) 1 (4) 1 (4) 1 (4) 12 (48) 3 (12) 2 (8)
DIE 5 deep infiltrating endometriosis. A: rectovaginal septum and/or vagina. B: sacrouterine ligament and/or pelvic wall. C: rectum and/or sigmoid colon. Grading: 1, ,1 cm; 2, 1–3 cm; 3, .3. FA: adenomyosis. FO: other locations such as abdominal wall. FB: involvement of the bladder. FI: cranial bowel disease.
hospital after discharge or experienced any adverse event, bowel obstruction or injury, or incisional hernia. An intraoperative drainage catheter was not needed in any case. Postoperative pain was well controlled with intravenous paracetamol. Ketoprofen was added to control pain in some cases. Rapid return of voiding, with removal of the urinary catheter on the day after surgery, bowel function, and mobilization were observed in all cases. All patients received clear fluids at 12 hours after the procedure and started eating by 24 hours. The median duration of follow-up was 22 months (range, 6–50 months). Three cases of recurrent endometriosis of the RVS (classes A2B0C0, A3B0C0, and A2B2C0FA, at 13, 24, and 25 months of follow-up, respectively) were diagnosed by vaginal exploration and ultrasound. Second-step surgery was not necessary in any of the 3 recurrences. In 1 case, estroprogestinic therapy was administered for dysmenorrhea, and in the other 2 cases, dienogest 2 mg/day was administered for 6 and 12 months, respectively, producing a reduction of lesions and symptoms. The fertility outcome in patients with a history of infertility was 27%, compared with an estimated range in the literature of 10% to 31% [3,17]. Complete or significant pain relief was reported in all cases at the third month of follow-up. Discussion DIE is a very symptomatic form of endometriosis that often affects very young women who are sexually active
and desiring pregnancy. Surgery is not always a definitive treatment because of the natural trend toward relapse. Radical ablation of DIE often requires rectosigmoid resection to improve symptoms and restore a good quality of life, but not always fertility. Considering that this kind of surgery is affected by a certain rate of specific morbidity and is usually indicated for young women, proper patient selection appears to be the crucial step in correct management. Treatment of DIE remains a great challenge, and it must be tailored for each individual patient’s desires and expectations. We used the shaving technique because the lesions did not involve the bowel lumen. Furthermore, shaving carries a significantly lower overall complication rate (6%) compared with disc excision (23%; p , .007) and segmental resection (38%; p , .001) [18]. In addition, a higher pregnancy rate has been associated with minimally invasive procedures such as shaving and discoid excision compared with segmental resection [18–21]. More extensive surgery and endometriosis may independently contribute to significant adhesion formation. Thus, partial treatment, as a first-step choice, may be an alternative for patients who desire to achieve pregnancy. Based on our experience, it could be used in cases of recurrence without any widespread lesions and infiltration of bowel lumen in young patients desiring pregnancy. In this application, it is important to emphasize the advantages of robotic surgery, which allows for minimally invasive surgery with high precision, accomplished by ablating the endometriosis and lysing existing adhesions without entering the bowel lumen and thus decreasing the possibility of pelvic infection and adhesion formation, a crucial pivotal point to take future fertility into account. In many cases, achieving complete resolution of symptoms may require hysterectomy or bilateral salpingooophorectomy as accessory procedures reported in our study. These procedures should be performed in patients who have no desire for future pregnancy. Very limited data are available and no recommendations exist regarding the potential benefits of RAL in DIE. The robot-assisted technique might help complete resections in poorly accessible areas, particularly in the cul-de-sac, with greater dexterity (owing to the jointed robotic arms). Advantages are 3D magnification of the operating field, smaller instruments, and tremor filtration. Adequate application of microsurgery rules should reduce postoperative adhesions and conserve ovarian reserve in the case of ovarian cyst excision. Partial treatment may be an alternative for patients desiring pregnancy and with asymptomatic bowel endometriosis. Ablation/shaving carries a significantly lower procedure-specific major complication rate compared with resection (0% vs 12.5%), and it is a relatively safe procedure for the first stage of a planned 2-stage procedure [18]. These patients must be followed closely and may need surgical intervention after they have finished child-bearing. Pregnancy might have a treatment effect in patients with endometriosis.
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Shaving Technique for Deep Infiltrating Endometriosis
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RAL appears to be feasible in DIE. In a reported series of 78 cases, RAL (n 5 40) and standard laparoscopy (n 5 38) demonstrated similar rates of complications and blood loss, but RAL had a longer operative duration (191 minutes vs 159 minutes) [22]. Other authors consider RAL a revolutionary approach to treating DIE with colorectal involvement. A 14-month study of 22 patients with this disease showed significant symptom improvement postoperatively, and no cases of laparoscopic conversion [23]. In our study, the median duration of the procedure was optimal compared with literature data [3], with a long term follow-up period. Another strength of this study is the extensive experience of the primary surgeon and the operating room staff. This experience may resolve the commonly observed longer operative time and increased blood loss observed during the surgeon’s and operating room team’s learning curve. Our finding that use of the surgical robot increases overall operative time is consistent with the literature, however [24]. Several factors in addition to the time needed to dock and undock likely contribute to the increased operative time. In cases of large endometriomas, trocar placement and specimen removal might have increased the operative time. In some cases an extra trocar was needed and it was difficult to manipulate the robotic arms, particularly in very thin and/or short patients. In addition, there was substantial delay in removing cyst wall pieces or endometriosis specimens, because these all must be passed to the assistant’s instrument, then removed, and the assistant’s instrument then must be replaced and reoriented. Larger specimens were removed through the larger robotic camera port; however, again this was associated with delays for repositioning of the bulky camera. Not using the CO2 laser with the da Vinci robot also may have contributed to the increased operative time. We agree with Berkes and Nezhat [25–27] that the CO2 laser can readily remove DIE lesions with minimal bleeding, because of the physics of the CO2 laser compared with radiofrequency energy. This technologic advantage offers numerous advantages over conventional laparoscopy, well described in literature [14]. RAL provides for precise dissection of the pelvic area, allowing good visualization of the pelvic plexus nerves, thereby allowing resection without nerve injury. The stable camera and freedom of movement allow for very delicate and accurate dissection, as well as identification and preservation of the superior hemorrhoidal artery, providing good irrigation to the rectal stump and diminishing the incidence of rectal fistula [28]. Current robotic systems do not provide tactile or haptic feedback to the operating surgeon, however. Under certain circumstances, particularly with manipulation of delicate tissues and suture materials, this may prove a significant impediment. In our study, this drawback could be the reason why 12% of patients required vaginal resection. In fact,
the fibrotic tissue in the RVS, a consequence of DIE, can be readily felt with maneuvers during conventional laparoscopy. However, the main reason for the limited use of robotic surgery is the cost of the device and related expenditures for annual maintenance contracts and instruments that cost $2000 each. Our patients did not experience any complications, such as fistula, local pain, nerve injury, or fecal or urinary incontinence. RAL allows excision of an adequate diameter of endometriotic nodules with free margins. Surprisingly, in 8% of the reported cases, the margins of resection were not free of disease [3]. Furthermore, despite the appropriate follow-up of our series, the small number of patients is an important drawback. We believe that RAL allows appropriate surgical radicality, with less surgical morbidity in this type of disease, avoiding considerable surgical trauma. The surgeon must take this into account, especially in cases of infertility treatment, with an extremely wide access to a virtual region. The use of this enabling technology could allow less experienced surgeons to perform this type of complex procedures instead to adhering to the old-fashioned exploratory laparotomy and provides another tool among different techniques. Conclusion The robotic shaving technique could be performed with the understanding that later reoperation may be required for more extensive resection, being a relatively safe procedure designed to give the patient a window of opportunity in which to bear children. We believe that if surgery is specifically planned to improve spontaneous or assisted fecundity and minimize the impact of pathology, robotic microsurgery with ablation/shaving technique should be the mainstay of treatment owing to the lower rate of procedure-specific major complications. The concept of RAL has appeal and is well suited for DIE, with successful complete nodule debulking by the wall-shaving technique, incorporating the minimally invasive benefits of classic laparoscopy with the additional benefits of increased visualization and dexterity. In the hands of an experienced surgeon, use of the present robotic platform is apparently safe and effective for treating advanced endometriosis. References 1. Boggess JF, Gehrig PA, Cantrell L, et al. A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy. Am J Obstet Gynecol. 2008; 199:360.e1–360.e9. 2. Damiani GR, Turoli D, Cormio G, et al. Robotic approach using simple and radical hysterectomy for endometrial cancer with long-term followup evaluation. Int J Med Robot. 2015; http://dx.doi.org/10.1002/ rcs.1647 [Epub ahead of print]. 3. De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P. Bowel resection for deep endometriosis: a systematic review. Br J Obstet Gynaecol. 2011;118:285–291.
6 4. Wills HJ, Reid GD, Cooper MJ, Morgan M. Fertility and pain outcomes following laparoscopic segmental bowel resection for colorectal endometriosis: a review. Aust N Z J Obstet Gynaecol. 2008;48:292–295. 5. Fedele L, Bianchi S, Zanconato G, Berlanda N, Borruto F, Frontino G. Tailoring radicality in demolitive surgery for deeply infiltrating endometriosis. Am J Obstet Gynecol. 2005;193:114–117. 6. Sahw RW. Treatment of endometriosis. Lancet. 1992;340:1267–1271. 7. Garry R, Clayton R, Hawe J. The effect of endometriosis and its radical laparoscopic excision on quality of life indicators. Br J Obstet Gynaecol. 2000;107:44–54. 8. Abbott JA, Hawe J, Clayton RD, Garry R. The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2–5 year follow-up. Hum Reprod. 2003;18:1922–1927. 9. Canis M, Mage G, Wattiez A, Chapron C, Pouly JL, Bassil S. Secondlook laparoscopy after laparoscopic cystectomy of large ovarian endometriomas. Fertil Steril. 1992;58:617–619. 10. Revised American Fertility Society classification of endometriosis: 1985. Fertil Steril. 1985;43:351–352. 11. Chapron C, Chopin N, Borghese B, et al. Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution. Hum Reprod. 2006;21:1839–1845. 12. Chapron C, Pietin-Vialle C, Borghese B, Davy C, Foulot H, Chopin N. Associated ovarian endometrioma is a marker for greater severity of deeply infiltrating endometriosis. Fertil Steril. 2009;92:453–457. 13. Chapron C, Bourret A, Chopin N, et al. Surgery for bladder endometriosis: long-term results and concomitant management of associated posterior deep lesions. Hum Reprod. 2010;25:884–889. 14. Carbonnel M, Goetgheluck J, Frati A, Even M, Ayoubi JM. Robot-assisted laparoscopy for infertility treatment: current views. Fertil Steril. 2014;101:621–626. 15. Haas D, Oppelt P, Shebl O, Shamiyeh A, Schimetta W, Mayer R. Enzian classification: does it correlate with clinical symptoms and the rASRM score? Acta Obstet Gynecol Scand. 2013;92:562–566. 16. Haas D, Shebl O, Shamiyeh A, Oppelt P. The rASRM score and the Enzian classification for endometriosis: their strengths and weaknesses. Acta Obstet Gynecol Scand. 2013;92:3–7.
Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2015 17. Ferrero S, Anserini P, Abbamonte LH, Ragni N, Camerini G, Remorgida V. Fertility after bowel resection for endometriosis. Fertil Steril. 2009;92:41–46. 18. Mohr C, Nezhat FR, Nezhat CH, Seidman DS, Nezhat CR. Fertility consideration in laparoscopic treatment of infiltrative bowel endometriosis. J Soc Laparosc Surg. 2005;9:16–24. 19. Woods RJ, Heriot AG, Chen FC. Anterior rectal wall excision for endometriosis using the circular stapler. Aust N Z J Surg. 2003;73:647–648. 20. Pereira RM, Zanatta A, Reich H, et al. Use of circular stapler for laparoscopic excision of recto-sigmoid anterior wall endometriosis. Surg Technol Int. 2008;17:181–186. 21. Nezhat C, Hajhosseini B, King LP. Laparoscopic management of bowel endometriosis: predictors of severe disease and recurrence. JSLS. 2011; 15:431–438. 22. Nezhat C, Lewis M, Kotikela S, et al. Robotic versus standard laparoscopy for the treatment of endometriosis. Fertil Steril. 2010;94: 2758–2760. 23. Ercoli A, D’asta M, Fagotti A, et al. Robotic treatment of colorectal endometriosis: technique, feasibility and short-term results. Hum Reprod. 2012;27:722–726. 24. Garguillo AR, Sroiji SS, Missmer SA, Correia KF, Vellinga TT, Einarsson JI. Robot-assisted laparoscopic myomectomy compared with conventional laparoscopic myomectomy. Obstet Gynecol. 2012; 120:284–291. 25. Berkes E, Bokor A, Rigo J Jr. Current treatment of endometriosis with laparoscopic surgery. Orv Hetil. 2010;151:1137–1144. 26. Nezhat CR, Stevens A, Balassiano E, Soliemannjad R. Robotic-assisted laparoscopy vs conventional laparoscopy for the treatment of advanced stage endometriosis. J Minim Invasive Gynecol. 2015;22:40–44. 27. Nezhat C, Nezhat F, Pennington E. Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser. Br J Obstet Gynaecol. 1992;99:664–667. 28. Neme RM, Schraibman V, Okazaki S, et al. Deep infiltrating colorectal endometriosis treated with robotic-assisted rectosigmoidectomy. JSLS. 2013;17:227–234.
Robotic Shaving Technique in 25 Patients Affected by Deep Infiltrating Endometriosis of the Rectovaginal Space Antonio Pellegrino, MD, Gianluca Raffaello Damiani, MD*, Claudia Trio, MD, Paolo Faccioli, MD, Paolo Croce, MD, Fulvio Tagliabue, MD, and Emanuele Dainese, MD From the Departments of Obstetrics and Gynecology (Drs. Pellegrino, Damiani, and Trio), Radiology (Dr. Faccioli), General Surgery (Dr. Tagliabue), Pathology (Dr. Dainese), Ospedale di Lecco Alessandro Manzoni, Lecco, Italy, and Department of Obstetrics and Gynecology, Azienda Ospedaliera di Lodi, Lodi, Italy (Drs. Damiani and Croce).
ABSTRACT Minimally invasive surgery represents the gold standard for the management of deep infiltrating endometriosis (DIE) involving the rectovaginal septum (RVS). This analysis aimed to evaluate the feasibility of robotic-assisted laparoscopy (RAL) and clinical outcomes in terms of long-term complications, pain relief, and recurrence rate for the treatment of DIE of the RVS. A prospective cohort study of robotic procedures was performed between October 2010 and July 2014, including removal of endometriotic nodules from the RVS with rectal shaving alone or in combination with accessory procedures. In all cases, the revised American Society for Reproductive Medicine (rASRM) score for endometriosis was .40 points (stage IV). Twenty-five consecutive patients underwent RAL, with a successful complete nodule debulking by the wall shaving technique. Pathology confirmed the adequacy of the surgical specimen and the median largest endometriotic nodule was of 21 mm (range, 10–60 mm), with free margins in all cases. The median operative time from skin opening to closure was 174 minutes (range, 75–300 minutes), and blood loss was close to 0 mL. The median revised Enzian score for location A (RVS) was 2 (range, 1-3). The most frequent Enzian class was A2B0C0 (48%), followed by A3B0C0 (12%). In 3 cases (12%), partial vaginal resection was required to remove endometriotic nodules of the RVS (1 each in classes A3B0C1FI, A3B0C0FO, and A3B0C0). No intraoperative complications occurred. This series has a median long-term follow up of 22 months (range, 6–50 months) currently available with an optimal operative time, demonstrating good long-term outcomes. Our data support robotics as a safe and attractive alternative for comprehensive surgical treatment of DIE. Journal of Minimally Invasive Gynecology (2015) -, -–- Ó 2015 AAGL. All rights reserved. Keywords:
DISCUSS
Deep infiltrating endometriosis; Endometriotic nodules; Rectovaginal septum; Robotic; Shaving
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Robotic-assisted laparoscopy (RAL) has progressed significantly over the past few years. Recent advances in the field of minimally invasive surgery have focused on the incorporation of robotic technology for the treatment of gynecologic malignancies [1,2]. RAL is also a wellDisclosures: None declared. Corresponding author: Gianluca Raffaello Damiani, MD, Department of Obstetrics and Gynecology, Ospedale di Lecco Alessandro Manzoni, Via Dell’Eremo 11, 23900 Lecco, Italy. E-mail: [email protected] Submitted April 28, 2015. Accepted for publication June 3, 2015. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2015 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2015.06.002
described procedure for the staging and treatment of gynecologic and urologic malignancies, overcoming anatomic barriers to the process of staging for endometrial cancer without increasing patient morbidity. Owing to its increased range of indications, RAL appears to be feasible in treating deep infiltrating endometriosis (DIE) as well. DIE, a complex disorder that affects 6% to 12% all women of childbearing age [3,4], is histologically defined as endometriotic lesions extending more than 5 mm beneath the peritoneal surface. RVS and sigmoid endometriosis, the most common types of DIE, are often associated with severe, progressively debilitating abdominal and pelvic pain, negatively affecting the
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patient’s quality of life. No medical treatment has yet been shown to achieve a long-term cure, with symptom recurrence rates as high as 76%. Surgical excision, effective in relieving pain [5–8], is considered the treatment of choice. In addition, the adhesions related to initial endometriosis or induced by the surgery negatively affect the subsequent pregnancy rate [9]. The American Fertility Society [10] system classifies DIE as 1, superficial endometriosis involving the peritoneum; 2, ovarian endometriomas; or 3, DIE resulting in fibrosis, adhesions, and significant nodules that invade deeper than 5 mm into the retroperitoneum of the pelvic sidewalls or the RVS, or involves at least the muscularis of the bowel, bladder, or ureters [11–13]. RAL overcomes many of the difficulties associated with standard laparoscopy through improved high-definition 3D visualization of the operating field, improved range of motion with increased maneuverability of the instruments with 6 of freedom, surgical dexterity, and ergonomics. The advantages offered by RAL may be highly valuable in the management of infertility with the assimilation of microsurgery principles into fertility-promoting procedures. Owing to the numerous drawbacks of laparoscopic surgery in DIE and the very limited data available to date [14], consideration should be given to the potential role of robotics for this indication. Here we present our results and evaluate the feasibility and long-term outcomes of RAL for treating DIE of the RVS, including complications, pain relief, and recurrence rate. Materials and Methods This was a prospective analysis of patients who underwent robotic surgery for the treatment of DIE of the RVS in our institution between October 2010 and July 2014. All of the robotic procedures were performed by the same surgeon (A.P.), who has extensive experience and expertise in laparoscopic and abdominal gynecologic surgery for oncologic conditions. Institutional Review Board approval was obtained. The diagnosis of DIE was established based on medical history, clinical symptoms, and instrumental findings. Baseline characteristics included age, body mass index (BMI), previous surgery, parity, and previous cesarean delivery (Table 1). Examined factors included total operative time, robot docking time, estimated blood loss (EBL), histological findings, nodule diameter, length of stay, and both early and long-term complications. EBL was calculated by measuring the blood collected in the suction canister and subtracting the amount of irrigation used during the surgery. Preoperative and postoperative complete blood cell counts were compared for accuracy. Neither high BMI nor previous abdominal surgery was considered a contraindication for RAL. All clinical data were collected by our team, and all patients were interviewed preoperatively about endometriosis-related symptoms. The preoperative workup included clinical examination with bimanual palpation and with rectal exploration, along with transvaginal and abdominal ultrasound. Magnetic resonance imaging was performed to assess the extent of the disease and to plan surgery and ureteral involvement. Patients with bowel symptoms associated
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Table 1 Patient demographic data and characteristics of previous surgery Characteristic
Value
Age, yr, mean 6 SD BMI, kg/m2, mean 6 SD Pregnancy, n (%) Spontaneous delivery Cesarean section, n (%) Nulliparous, n (%) Previous abdominal surgery, n (%) No surgery, n (%) Surgery for endometriosis, n (%) Previous laparoscopic surgery, n (%) Previous obstetric/gynecologic surgery, n (%) Diagnostic LPS, n (%) LPS miomectomy1 DT of EL, n (%) LPS escission of EL of the RVS, cystotomy, n (%) LPS Miomectomy 1 enucleation of ovarian cyst, n (%) LPS escission of EL of the bladder, n (%) LPS escission of the utero sacral endometriotic nodule, n (%) CA-125 serum level, UI/L/dL, median (range)*
33.9 6 6.1 21.2 6 2.9 4 (16) 2 (0–1) 2 (8) 23 (92) 0 (0) 18 (72) 7 (28) 7 (28) 7 (28) 2 (8) 1 (4) 1 (4) 1 (4) 1 (4) 1 (4) 35 (4–368)
BMI 5 body mass index; LPS 5 laparoscopy; DT 5 diatermocoagulation; RVS 5 rectovaginal septum; EL 5 endometriotic lesion. * Preoperative value.
with nodules of the RVS underwent a double-contrast barium enema and/or rectocolonoscopy. Data were analyzed using SPSS 17.0 (SPSS Inc, Chicago, IL). The Student t test for paired samples was used to compare the outcomes regarding evaluation symptoms. A p value , .05 was considered statistically significant. Inclusion criteria were the presence of more than 1 lesion of the RVS partially involving the muscle layer (no involvement of the deep muscle layer or mucosal layer), and no change in symptoms with hormone treatment (for .6 months) or previous surgery. Before surgery, all patients were informed about potential risks and benefits of this kind of intervention. On the day before surgery, all patients received a clear fluid diet and bowel preparation with 2 L of polyethlene glycol. Low-molecular weight heparin was given 12 hours after surgery. Prophylactic antibiotic therapy (cefazoline 2 g and metronidazole 500 mg intravenously) was administered at the beginning of the procedure. Surgery was performed with the Da Vinci S system (Intuitive Surgical, Sunnvale, CA), docked in a standard fashion at the foot of the bed, between the patient’s legs. All patients underwent surgery under general anesthesia. The patient was positioned supine with both arms tucked comfortably, and her legs placed in Allen stirrups, abducted and with hip extension to accommodate the second assistant surgeon. A Foley catheter was placed to empty the bladder and control urine output, and a uterine manipulator was introduced through the cervix. After induction of pneumoperitoneum established to 20 mmHg with a closed Verres needle and insertion of the robotic videolaparoscope, through a 12-mm port just above the umbilicus, the entire abdominal cavity was explored to evaluate the extension of the endometriotic lesions.
Pellegrino et al.
Shaving Technique for Deep Infiltrating Endometriosis
A 12-mm umbilical trocar was placed using the open Hasson technique. Two 8-mm ancillary robotic trocars were placed bilaterally, approximately 1 handbreadth away from the camera port to prevent collision of the robotic arms. An ancillary 10-mm trocar was placed in the left subcostal area to be used by the assistant surgeon. A 0-degree camera was used for the entire procedure. Once robotic docking was completed, the primary surgeon controlled the robot remotely from the console. Instruments included monopolar scissors, bipolar forceps, a monopolar hook, a suction/irrigator probe, and a large needle holder. The dissection was carried out through the rectovaginal septum, and the rectum was mobilized below the nodule until a soft area distal to palpable abnormalities was encountered. During dissection, care was taken to avoid injury to the left ureter, which often runs more medially in cases of DIE. Lesions extending through the vagina were treated with en bloc resection of the posterior vaginal wall. Reconstruction of the muscular wall portion of the rectal wall was performed in all cases involving rectal shaving, using 3/0 absorbable monofilament sutures. The principal surgical procedures performed are described in Table 3. Shaving, the least invasive procedure, involving layer-by-layer excision of the lesion without full-thickness resection, was performed in all cases where the lesion was superficial or had partially involved the muscular layer but without full-thickness bowel wall infiltration. All patients were interviewed and ranked endometriosis-related symptoms, including dysmenorrhea, chronic pelvic pain, dyspareunia, and specific gastrointestinal symptoms, on a 10-point visual analog scale (VAS), from 0 (absent to 10 (unbearable). Preoperative and postoperative dysmenorrhea, gastrointestinal symptoms, and dyspareunia scores are reported in Table 2. Any hormonal therapy was stopped 1 month before surgery. Fever was defined as body temperature of .38 C on 2 consecutive measurements at least 6 hours apart, excluding the first day after surgery. Patients were allowed to return home when fully mobile, apyretic, and passing urine satisfactorily. We followed up all patients at 1 month, 3 months, and 6 months postoperatively and yearly thereafter with pelvic examination, a clinical interview regarding symptoms, and eventually a pelvic ultrasound scan. Follow-up evaluation consisted of pelvic physical and ultrasound examination. Relapse was defined as the presence of de novo symptomatic or asymptomatic endometrioma and/or RVS or bowel nodules. During the follow-up interviews, patients were also asked about postoperative conception and any further surgery. Postoperative hormonal therapy, consisting of continuous low-dose monophasic oral contraceptives for 6 months, was prescribed for all patients except those seeking pregnancy. Table 3 categorizes the cases according to the new revised Enzian classification scheme for DIE [15,16]. We adopted the new
Table 2 Preoperative and postoperative symptoms at 3-month follow-up Symptom
Preoperative
Postoperative
p value
Dysmenorrhea Dyspareunia Gastrointestinal symptoms Chronic pelvic pain
8 (4–10) 8 (2–10) 7 (0–10) 8 (0–5)
2 (0–4) 1 (0–3) 1 (0–4) 0 (0–4)
,.05 ,.05 ,.05 ,.05
Data are median (range).
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Table 3 Spectrum of robotic procedures Procedure
n (%)
Nodule ecission of RVS Concomitant surgery Hysterectomy Excision of uterosacral nodules Excision of right uterosacral nodule Excision of left uterosacral nodule Ovariectomy Opening of vaginal wall Intraoperative complication: opening of rectal wall Conversion to laparoscopy
25 (100) 7 (28) 2 (8) 4 (16) 3 (12) 1 (4) 1 (4) 3 (12) 1 (4) 1 (4)
RVS 5 rectovaginal septum.
Enzian classification because the revised American Society for Reproductive Medicine (rASRM) score does not take DIE into account, and it enables clinicians to classify DIE. It provides an excellent complement for morphological description of DIE, including the size of the lesions. Nonetheless, international studies are required before the Enzian classification will become established and accepted by the medical community.
Results The mean patient age was 33.9 6 6.1 years, and mean BMI was 21.2 6 2.9. A total of 25 RAL procedures for endometriosis of the RVS were performed. Concomitant surgery for synchronous lesions (28%) consisted of 2 hysterectomies (class A3B0C0FB and A1B1C0FA), 1 ovarietomy (class A3B0C0FO), and 4 excisions of uterosacral nodules (16%; class A2B3C1, A2B2C0FA, A1B1C0FA, and A1B1C0FA), involving the right uterosacral in 3 cases (Table 4). Of 25 patients, 7 (28%) had undergone previous surgery for endometriosis. Fifteen (60%) were affected by infertility, and 23 (92%) were nulliparous. In 3 cases (classes A3B0C1FI, A3B0C0FO, and A3B0C0), vaginal opening was required to remove endometriotic nodules of the RVS, and partial vaginal resection was performed. No intraoperative complications occurred. All 25 patients underwent medical therapy before surgery. The median operating time from skin opening to closure was 174 minutes (range, 75–300 minutes). Median docking time was 20 minutes (range, 5–25 minutes). The median EBL was 0 mL (range, 0–100 mL). The median length of stay was 3 nights (day of surgery was counted as night 1; range, 2–4 nights). The anatomic specimens had a median large axis of endometriotic excised nodule of 21 mm (range, 10–60 mm), with free margin in all cases. The median revised Enzian score for location A (RVS) was 2 (range, 1–3). The most frequent Enzian class was A2B0C0 (48%), followed by A3B0C0 (12%). No patient was readmitted to the
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Table 4 Cases of DIE (stage IV, rASRM score .40) according to the revised Enzian classification after surgery Enzian class
n (%)
A1B1C0FA A2B2C0FA A2B1C0 A3B0C0FO A3B0C1FI A3B0C0FB A2B3C1 A2B0C0 A3B0C0 A1B1C0
2 (8) 1 (4) 1 (4) 1 (4) 1 (4) 1 (4) 1 (4) 12 (48) 3 (12) 2 (8)
DIE 5 deep infiltrating endometriosis. A: rectovaginal septum and/or vagina. B: sacrouterine ligament and/or pelvic wall. C: rectum and/or sigmoid colon. Grading: 1, ,1 cm; 2, 1–3 cm; 3, .3. FA: adenomyosis. FO: other locations such as abdominal wall. FB: involvement of the bladder. FI: cranial bowel disease.
hospital after discharge or experienced any adverse event, bowel obstruction or injury, or incisional hernia. An intraoperative drainage catheter was not needed in any case. Postoperative pain was well controlled with intravenous paracetamol. Ketoprofen was added to control pain in some cases. Rapid return of voiding, with removal of the urinary catheter on the day after surgery, bowel function, and mobilization were observed in all cases. All patients received clear fluids at 12 hours after the procedure and started eating by 24 hours. The median duration of follow-up was 22 months (range, 6–50 months). Three cases of recurrent endometriosis of the RVS (classes A2B0C0, A3B0C0, and A2B2C0FA, at 13, 24, and 25 months of follow-up, respectively) were diagnosed by vaginal exploration and ultrasound. Second-step surgery was not necessary in any of the 3 recurrences. In 1 case, estroprogestinic therapy was administered for dysmenorrhea, and in the other 2 cases, dienogest 2 mg/day was administered for 6 and 12 months, respectively, producing a reduction of lesions and symptoms. The fertility outcome in patients with a history of infertility was 27%, compared with an estimated range in the literature of 10% to 31% [3,17]. Complete or significant pain relief was reported in all cases at the third month of follow-up. Discussion DIE is a very symptomatic form of endometriosis that often affects very young women who are sexually active
and desiring pregnancy. Surgery is not always a definitive treatment because of the natural trend toward relapse. Radical ablation of DIE often requires rectosigmoid resection to improve symptoms and restore a good quality of life, but not always fertility. Considering that this kind of surgery is affected by a certain rate of specific morbidity and is usually indicated for young women, proper patient selection appears to be the crucial step in correct management. Treatment of DIE remains a great challenge, and it must be tailored for each individual patient’s desires and expectations. We used the shaving technique because the lesions did not involve the bowel lumen. Furthermore, shaving carries a significantly lower overall complication rate (6%) compared with disc excision (23%; p , .007) and segmental resection (38%; p , .001) [18]. In addition, a higher pregnancy rate has been associated with minimally invasive procedures such as shaving and discoid excision compared with segmental resection [18–21]. More extensive surgery and endometriosis may independently contribute to significant adhesion formation. Thus, partial treatment, as a first-step choice, may be an alternative for patients who desire to achieve pregnancy. Based on our experience, it could be used in cases of recurrence without any widespread lesions and infiltration of bowel lumen in young patients desiring pregnancy. In this application, it is important to emphasize the advantages of robotic surgery, which allows for minimally invasive surgery with high precision, accomplished by ablating the endometriosis and lysing existing adhesions without entering the bowel lumen and thus decreasing the possibility of pelvic infection and adhesion formation, a crucial pivotal point to take future fertility into account. In many cases, achieving complete resolution of symptoms may require hysterectomy or bilateral salpingooophorectomy as accessory procedures reported in our study. These procedures should be performed in patients who have no desire for future pregnancy. Very limited data are available and no recommendations exist regarding the potential benefits of RAL in DIE. The robot-assisted technique might help complete resections in poorly accessible areas, particularly in the cul-de-sac, with greater dexterity (owing to the jointed robotic arms). Advantages are 3D magnification of the operating field, smaller instruments, and tremor filtration. Adequate application of microsurgery rules should reduce postoperative adhesions and conserve ovarian reserve in the case of ovarian cyst excision. Partial treatment may be an alternative for patients desiring pregnancy and with asymptomatic bowel endometriosis. Ablation/shaving carries a significantly lower procedure-specific major complication rate compared with resection (0% vs 12.5%), and it is a relatively safe procedure for the first stage of a planned 2-stage procedure [18]. These patients must be followed closely and may need surgical intervention after they have finished child-bearing. Pregnancy might have a treatment effect in patients with endometriosis.
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RAL appears to be feasible in DIE. In a reported series of 78 cases, RAL (n 5 40) and standard laparoscopy (n 5 38) demonstrated similar rates of complications and blood loss, but RAL had a longer operative duration (191 minutes vs 159 minutes) [22]. Other authors consider RAL a revolutionary approach to treating DIE with colorectal involvement. A 14-month study of 22 patients with this disease showed significant symptom improvement postoperatively, and no cases of laparoscopic conversion [23]. In our study, the median duration of the procedure was optimal compared with literature data [3], with a long term follow-up period. Another strength of this study is the extensive experience of the primary surgeon and the operating room staff. This experience may resolve the commonly observed longer operative time and increased blood loss observed during the surgeon’s and operating room team’s learning curve. Our finding that use of the surgical robot increases overall operative time is consistent with the literature, however [24]. Several factors in addition to the time needed to dock and undock likely contribute to the increased operative time. In cases of large endometriomas, trocar placement and specimen removal might have increased the operative time. In some cases an extra trocar was needed and it was difficult to manipulate the robotic arms, particularly in very thin and/or short patients. In addition, there was substantial delay in removing cyst wall pieces or endometriosis specimens, because these all must be passed to the assistant’s instrument, then removed, and the assistant’s instrument then must be replaced and reoriented. Larger specimens were removed through the larger robotic camera port; however, again this was associated with delays for repositioning of the bulky camera. Not using the CO2 laser with the da Vinci robot also may have contributed to the increased operative time. We agree with Berkes and Nezhat [25–27] that the CO2 laser can readily remove DIE lesions with minimal bleeding, because of the physics of the CO2 laser compared with radiofrequency energy. This technologic advantage offers numerous advantages over conventional laparoscopy, well described in literature [14]. RAL provides for precise dissection of the pelvic area, allowing good visualization of the pelvic plexus nerves, thereby allowing resection without nerve injury. The stable camera and freedom of movement allow for very delicate and accurate dissection, as well as identification and preservation of the superior hemorrhoidal artery, providing good irrigation to the rectal stump and diminishing the incidence of rectal fistula [28]. Current robotic systems do not provide tactile or haptic feedback to the operating surgeon, however. Under certain circumstances, particularly with manipulation of delicate tissues and suture materials, this may prove a significant impediment. In our study, this drawback could be the reason why 12% of patients required vaginal resection. In fact,
the fibrotic tissue in the RVS, a consequence of DIE, can be readily felt with maneuvers during conventional laparoscopy. However, the main reason for the limited use of robotic surgery is the cost of the device and related expenditures for annual maintenance contracts and instruments that cost $2000 each. Our patients did not experience any complications, such as fistula, local pain, nerve injury, or fecal or urinary incontinence. RAL allows excision of an adequate diameter of endometriotic nodules with free margins. Surprisingly, in 8% of the reported cases, the margins of resection were not free of disease [3]. Furthermore, despite the appropriate follow-up of our series, the small number of patients is an important drawback. We believe that RAL allows appropriate surgical radicality, with less surgical morbidity in this type of disease, avoiding considerable surgical trauma. The surgeon must take this into account, especially in cases of infertility treatment, with an extremely wide access to a virtual region. The use of this enabling technology could allow less experienced surgeons to perform this type of complex procedures instead to adhering to the old-fashioned exploratory laparotomy and provides another tool among different techniques. Conclusion The robotic shaving technique could be performed with the understanding that later reoperation may be required for more extensive resection, being a relatively safe procedure designed to give the patient a window of opportunity in which to bear children. We believe that if surgery is specifically planned to improve spontaneous or assisted fecundity and minimize the impact of pathology, robotic microsurgery with ablation/shaving technique should be the mainstay of treatment owing to the lower rate of procedure-specific major complications. The concept of RAL has appeal and is well suited for DIE, with successful complete nodule debulking by the wall-shaving technique, incorporating the minimally invasive benefits of classic laparoscopy with the additional benefits of increased visualization and dexterity. In the hands of an experienced surgeon, use of the present robotic platform is apparently safe and effective for treating advanced endometriosis. References 1. Boggess JF, Gehrig PA, Cantrell L, et al. A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy. Am J Obstet Gynecol. 2008; 199:360.e1–360.e9. 2. Damiani GR, Turoli D, Cormio G, et al. Robotic approach using simple and radical hysterectomy for endometrial cancer with long-term followup evaluation. Int J Med Robot. 2015; http://dx.doi.org/10.1002/ rcs.1647 [Epub ahead of print]. 3. De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P. Bowel resection for deep endometriosis: a systematic review. Br J Obstet Gynaecol. 2011;118:285–291.
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