Robotic Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Resection of Parametrial and Bowel Deeply Infiltrated Endometriosis

Study objective: To demonstrate stepwise techniques for the successful utilization of the Robotic-assisted transvaginal Natural Orifice Transluminal Endoscopy Surgery (NOTES) technique for safely surgically managing deeply infiltrated endometriosis (DIE).

Design: Stepwise demonstration with narrated video footage.

Setting: An academic tertiary care hospital.

Interventions: A 38-year-old woman-G3P3, who had 1 normal spontaneous vaginal delivery and 1 cesarean delivery for twin pregnancy-with worsening chronic pelvic pain. History of laparoscopic ablation of endometriosis 10 years ago. Magnetic resonance imaging demonstrated adenomyosis, deeply infiltrated endometriosis, and intrapelvic adhesions. Robotic transvaginal NOTES hysterectomy has been demonstrated to be feasible and safe in the surgical management of benign gynecology disease compared with traditional NOTES hysterectomy; however, it can be technically challenging to perform, particularly in managing of additional deep infiltrated endometriosis removal surgery after hysterectomy. The researchers demonstrated that robotic vaginal NOTES surgeries are feasible in complex benign gynecologic procedures such as endometriosis and sacrocolpopexy [1-3]. The robotic wristed instruments with 3D visualization, resulting in delicate tissue dissection and easier suturing and knot tying, are beneficial to surgeons for overcoming the cumbersome surgical techniques in transvaginal NOTES complete endometriosis removal [4,5]. Integration of robotic transvaginal single site surgery and resection of DIE is a novel alternative minimally invasive route that is more cosmetic and less painful. The procedure was successfully performed in approximately 200 minutes, with unevenly postoperative recovery. The patient was discharged home the same day. Her pain level was 7 out of 10 in the first week, 5 out of 10 in the second week, and 2 out of 10 in the third week. Pathology confirmed uterine adenomyosis, endometriosis in the right ureteral, right uterine artery pedicle, and rectum with muscular propria involvement.

Conclusion: Robotic transvaginal NOTES for deeply invasive endometriosis is challenging but feasible in patients with parametrial and rectal involvement. The advantages of articulating instrumentation and 3D visualization are especially pivotal in complex transvaginal NOTES surgery.