Multidisciplinary Approach to Robotic Diaphragmatic Endometriosis Resection

INTRODUCTION: This is a video demonstration of a multidisciplinary approach to diaphragmatic and liver endometriosis resection involving multiple organ systems and surgical teams. Endometriosis affects many reproductive-aged women who require surgical resection. When patients present with severe symptoms including dyspnea, upper abdominal pain, and shoulder pain, diaphragmatic endometriosis (DE) should be on the differential diagnosis. When DE is suspected, a multidisciplinary surgical approach should be planned for resection and optimal debulking. OBJECTIVE: To provide robotic surgeons with best surgical practices in approaching multi-organ endometriosis pathology. METHODS: Setting: Academic Medical Center Patients or Participants: The case example is that of a 41-year-old female with a history of chronic kidney disease and surgically diagnosed stage IV endometriosis, now presenting with worsening right shoulder pain and MRI concerning for significant endometriosis involving the diaphragm, liver, and pelvic anatomy. Interventions: Robotic-assisted laparoscopic left ovarian cystectomy and uterine myomectomy, followed by partial hepatectomy and diaphragmatic resection, in order to optimally surgically debulk all endometriosis disease burden. RESULTS: In the case example provided, the patient underwent successful and optimal endometriosis debulking surgery without complications. The surgery had a total estimated blood loss of 50 ml, and the patient was discharged on postoperative day 3 without complications. Surgical pathology showed extensive evidence of endometriosis involving the patient’s left ovary, diaphragm, and liver. CONCLUSIONS: There is an important role for a multidisciplinary approach to severe endometriosis surgery involving multiple organ systems. All necessary teams must work together to ensure good outcomes that address all of the patient’s concerns. Good practices in endometriosis surgery include re-establishing normal anatomy, finding safe dissection planes despite extensive adhesive disease, and maintaining adequate visualization with all available robotic instruments, ports, and patient positioning.