Presented by:
Kevin Kuan
Affiliations:
University of Toronto
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What is Robotic Retroperitoneal Myomectomy in the Setting of Severe Endometriosis?
Robotic retroperitoneal myomectomy is a minimally invasive surgical approach used to remove leiomyomas, or fibroids, that develop within the retroperitoneal space rather than in their more typical location within the uterus. When severe endometriosis is also present, surgery may require extensive restoration of distorted pelvic anatomy before the fibroids can be safely identified and removed. Here’s what it involves:
- Robotic Pelvic Assessment: The pelvis is systematically inspected to identify endometriosis, ovarian cysts, adhesions, and the location of the retroperitoneal masses.
- Restoration of Anatomy: Dense adhesions and endometriosis are carefully dissected to restore normal pelvic relationships and provide access to the retroperitoneum.
- Ovarian Cystectomy: Endometriomas or other ovarian cysts may be carefully removed while attempting to preserve healthy ovarian tissue.
- Retroperitoneal Dissection: The retroperitoneum is opened and important structures, including the ureters, blood vessels, and pelvic nerves, are identified before approaching the fibroids.
- Vasopressin Injection: Dilute vasopressin may be injected around the leiomyoma to temporarily reduce blood flow and minimize bleeding during removal.
- Retroperitoneal Myomectomy: An incision is made over the mass and the leiomyoma is carefully separated from surrounding tissue and removed.
- Robotic Suturing and Reconstruction: The surgical defect is closed using robotic suturing to restore anatomy and achieve hemostasis.
- Endometriosis Excision: Additional areas of deep endometriosis may be systematically excised while protecting surrounding pelvic structures.
- Final Inspection: The operative field is inspected for bleeding and the integrity of the ureters, ovaries, bowel, bladder, and other nearby structures is reassessed.
The robotic approach provides enhanced visualization and instrument control that can assist with complex dissection, myomectomy, and reconstruction when retroperitoneal fibroids coexist with severe endometriosis.
What are the Risks of Robotic Retroperitoneal Myomectomy in the Setting of Severe Endometriosis?
The combination of a large retroperitoneal mass and advanced endometriosis can significantly distort normal pelvic anatomy, making surgery more complex than a typical myomectomy.
- Bleeding: Retroperitoneal leiomyomas can have a substantial blood supply, and significant bleeding may occur during dissection or separation of the mass.
- Ureteral Injury: Fibroids and endometriosis may displace or surround the ureters, increasing the risk of injury during retroperitoneal dissection.
- Vascular Injury: Major pelvic blood vessels lie within the retroperitoneum and may be injured while exposing or removing the fibroid.
- Bowel or Bladder Injury: Severe endometriosis and adhesions can cause pelvic organs to become densely attached to one another, increasing the risk of inadvertent injury.
- Nerve Injury: Deep retroperitoneal dissection may place pelvic nerves at risk, potentially affecting bladder, bowel, sensory, or sexual function.
- Ovarian Injury or Reduced Ovarian Reserve: Ovarian cystectomy for endometriomas can result in the loss of healthy ovarian tissue or affect ovarian blood supply.
- Vasopressin-Related Complications: Although uncommon, intravascular absorption or injection of vasopressin can cause significant cardiovascular effects, including changes in heart rate and blood pressure.
- Incomplete Excision or Recurrence: Endometriosis can recur following surgery, and additional fibroids may develop or become symptomatic in the future.
- Conversion to Open Surgery: Extensive disease, difficult anatomy, or uncontrolled bleeding may require conversion to an open surgical approach.
- General Surgical Risks: Infection, blood clots, anesthesia-related complications, postoperative adhesions, and complications related to abdominal entry are possible.
Careful retroperitoneal dissection, early identification of the ureters and major vessels, controlled use of vasopressin, and precise robotic suturing can help reduce these risks while allowing treatment of both the retroperitoneal fibroids and associated endometriosis.