Robotic Surgery a Step Forward in Standardization of Hysterectomy in Patients with Deep Infiltrating Endometriosis

Introduction: Hysterectomy in cases with deep infiltrating endometriosis (DIE) poses a particular challenge represented by the lack of standardization, causing technical difficulties or incomplete resection of the deep endometriosis lesions.

This article attempts to use the concept of lateral and antero-posterior virtual compartments in the standardization of robotic hysterectomy (RH) in cases of deep parametrial lesions according to ENZIAN classification.

We collected data from 81 patients who underwent total hysterectomy and en bloc excision of the endometriotic lesions by robotic surgery. Results: Excision was realized by the technique of retroperitoneal hysterectomy, its standardization depending on the ENZIAN classification being described step by step. Tailored robotic hysterectomy always included the en-block removal of uterus, adnexa, and posterior and anterior parametria, which included endometriotic lesions and the upper one-third of the vagina with all endometriotic lesions of posterior and lateral vaginal mucosa. Discussion: The hysterectomy and parametrial dissection must be done according to the size and location of the endometriotic nodule. The goal of hysterectomy for DIE is to release the uterus and the endometriotic tissue without risks of complication.

"En-bloc" hysterectomy together with endometriotic nodules, where the parametrial resection is tailored according to the lesions, is an optimum method, because the blood loss, operative time, and intraoperative complications are reduced comparing with other methods.