To demonstrate use of intra-operative robotic ultrasound to precisely localize and guide the excision of a sacral plexus deep infiltrating endometriosis nodule.

Design:

Case report.

Setting:

The surgery was performed at a tertiary medical center using a robotic surgery platform.

Patients or Participants:

The patient is a 26 year-old nulligravid with known endometriosis. She previously underwent laparoscopic excision of endometriosis including removal of a recto-vaginal deep infiltrating endometriosis nodule invading through the vagina. Approximately 1 year after index surgery, she developed worsening pelvic pain and sciatica.

Interventions:

Pre-operative imaging including magnetic resonance imaging (MRI) of the pelvis and lumbar and sacral plexuses. Robotic-assisted, fertility-sparing, complete excision of sacral plexus endometriosis.

Measurements and Main Results:

A preoperative MRI showed a retroperitoneal mass compatible with deep infiltrating endometriosis with the involvement of the sacral roots and edema of homolateral sciatic nerve. With a robotic-assisted laparoscopic approach, the retroperitoneum was dissected starting with the opening of pre-sacral space, development of avascular spaces, and identification and preservation of hypogastric nerves. Given extensive retroperitoneal fibrosis and altered anatomy given the patient’s surgical history, the borders of the nodule were intra-operatively visualized with a drop-in robotic ultrasound integrated probe. The live images showed that the mass was above the S2-S3 sacral roots without involvement of the lumbosacral trunk. With the guidance of this useful tool, we limited the dissection at the level of the sacral roots and completely removed the nodule.

Conclusion:

Minimally invasive excision of sacral plexus endometriosis requires advanced surgical retroperitoneal dissection. Intraoperative robotic ultrasound may represent a novel tool in the surgeon’s hands to tailor the surgical steps without compromising the radicality of the excision.