Design: Case report with video illustration.

Setting: Patient was placed in a semi-gynecological position under general anesthesia, with arms alongside the body and legs abducted 80 degrees in adjustable stirrups. Three robotic portals were positioned: one in the umbilical scar for the optics, one on the right and one on the left flank. In addition, a conventional laparoscopic portal was positioned in the upper right flank.

Patients or Participants: 38-year-old patient presenting significant pelvic pain, incapacitating dysmenorrhea, and diarrhea during periods. Despite partial symptom improvement with the use of oral contraceptives and anti-inflammatories, patient referred impact of the pain in her daily activities. MRI showed uterine volume of 522.9 cm³, lobulated uterus due to multiple leiomyomas and presence of two endometriomas on the left (0.5 and 1.7 cm). There were also thickened areas suggesting endometriosis in the following locations: retrocervical, retrovaginal, uterosacral ligament , round ligament, ovaries, rectum, and sigmoid, with a bowel loop bending due to fibro endometriotic process.

Interventions: Patient underwent robot-assisted myomectomy and deep endometriosis’ treatment. Procedure started with retroperitoneal development and proper ureterolysis, allowing correct identification and safe excision of endometriosis lesions. Subsequently, myomectomy was performed. Rectosigmoidectomy with primary anastomosis and appendectomy were performed by the gastrointestinal surgery team.

Measurements and Main Results: Surgical duration was four hours, with minimal blood loss and no complications. Patient had a satisfactory postoperative clinical evolution and was discharged on the fifth postoperative day. Pathology report confirmed endometriosis nodules and leiomyomas.

Conclusion:

Endometriosis and uterine fibroids are two benign gynecological conditions that can bring extremely challenging management when fertility preservation is desired. Our video demonstrates a multidisciplinary and efficient approach of an advanced case, with patient's reproductive status preservation due to an adequate and meticulously planned robotic surgical treatment.