FCV-158 Robotic-assisted Excision of Sciatic Nerve Endometriosis Encapsulating the Iliac Vessels and Invading the Obturator Internus

Aims: Demonstrate the excision of endometriosis with significant lateral and posterior infiltration, affecting the right lumbosacral plexus, ureter and anterior division of the internal iliac vessels.

Background: Nerve endometriosis is rare (0.1%) but can have a significant effect on quality of life.  Symptoms and signs include cyclical/non-cyclical pain with associated sensory symptom with dermatomal distribution and/or motor weakness. Surgical management involves neurolysis of one or more nerves. This requires careful dissection and skeletonization of these structures with the intention to normalise the anatomy.

Patient/Interventions: The patient was a 37-year-old P2 with cyclical gluteal pain and sciatica.

MRI had revealed significant lateral infiltration up to the right obturator internus with the disease enveloping the anterior division of the internal iliac vessels and lumbosacral plexus.

At robotic-assisted laparoscopy, following hysterectomy, extended colpotomy for vaginal endometriosis and shave of rectal endometriosis, a medial and lateral approach was taken to delineate the nodule. The nodule had enveloped the entirety of the anterior division of the internal iliac, which had to be ligated to remove the disease. Careful and cautious dissection is demonstrated to circumnavigate the nodule and finally excise it entirely from the lumbosacral plexus. The video also highlights the management of a vascular injury. 

Conclusion/Discussion: Endometriosis has an innate capacity to infiltrate surrounding structures; displayed to a severe extent in this case. Careful planning and discussion is paramount. Multidisplinary surgery offers procedural flexibility and facilitates appropriate decision making in cases such as this.