Robotic management of isolated endometriosis of sciatic nerve: a reproducible approach that can guide through the labyrinth of pelvic neuroanatomy

Abstract

Objective: To present the robotic, standardized, and reproducible surgical technique we routinely use in our center to manage isolated endometriosis of the sciatic nerve.

Design: Surgical video article.

Setting: Tertiary referral center.

Patient: A 36-year-old woman suffering from left-sided sciatica pain was diagnosed with an isolated endometriotic nodule of the left sciatic nerve at preoperative assessment. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus), and other applicable sites.

Intervention(s): Complete removal of the isolated endometriotic nodule of the sciatic nerve may be performed through a stepwise robotic approach. The surgery starts laterally with the opening of the iliolumbar space between the external iliac vessels and the psoas muscle, as well as the identification of the genitofemoral and obturator nerves. The lumbosacral trunk and emergence of the sciatic nerve were then identified medially and caudally to the obturator nerve. The surgery moves medially with the anterograde dissection of both the internal iliac artery and vein, which allows a safe approach to the posterior and medial limits of the nodule. Ligation of branches of internal iliac vessels directed toward the nodule may be necessary during this step. Isolation and ligation of obturator vessels are frequently required to obtain a bloodless dissection of the lateral limit of the nodule from the lateral pelvic wall. The complete removal of the nodule was then achieved using an alternating approach to all limits of the nodule previously identified, with subsequent release of the sciatic nerve.

Main outcome measure(s): Description of the relevant pelvic neuroanatomy and the evaluation of robotic routes in the field of pelvic neurosurgery.

Result(s): The use of standardized techniques together with the advantages of a robotic route can make the radical excision of isolated endometriosis of the sciatic nerve reproducible, feasible, and safe.

Conclusion(s): Because of the complexity of neuroanatomy and the risk of severe complications, this surgery remains challenging, and patients affected by deep infiltrating endometriosis involving retroperitoneal neural structures should be referred to multidisciplinary management in expert centers.

Keywords: Endometriosis; nerve-sparing; pelvic neuroanatomy; robotic surgery; sciatic nerve.