Robotic‐assisted transumbilical single‐site and transvaginal <scp>NOTES</scp> resection of abdominal wall cesarean scar endometriosis: Two case reports

Abdominal wall endometriosis (AWE), particularly in cesarean scars, is an uncommon yet increasingly recognized form of extra-pelvic endometriosis caused by iatrogenic implantation of endometrial tissue during uterine incision closure.1-3 The incidence of cesarean scar endometriosis (CSE) ranges from 0.03% to 1%,1-3 presenting as a cyclic, painful, palpable mass near the surgical scar. Ultrasound is typically the first-line imaging modality, while magnetic resonance imaging (MRI) more accurately defines lesion depth and extent, essential for surgical planning.3-5 Histopathology demonstrating endometrial glands and stroma remains diagnostic.2 Surgical excision with wide margins is the treatment of choice, as hormonal therapy alone carries high recurrence rates. Traditional approaches include open excision or laparoscopic resection, often requiring mesh reinforcement for large fascial defects. Despite the expanding role of robotic-assisted surgery in complex endometriosis, robotic excision of CSE has rarely been described.6 Here, we present two cases of robotic-assisted CSE resection: one using a single-site umbilical Xi approach and the other utilizing transvaginal natural orifice transluminal endoscopic surgery (vNOTES) with the SP platform (Intuitive, Sunnyvale, USA). Case 1: A 43-year-old woman (G3P1112) with a prior cesarean presented with cyclic pain and a palpable right lower quadrant mass near her Pfannenstiel incision. MRI showed a 2.2 × 3.6 × 2.4 cm spiculated mass involving the right rectus abdominis. The patient underwent robotic SP-assisted vNOTES hysterectomy, bilateral salpingectomy, excision of pelvic endometriosis, and resection of the abdominal wall nodule with mesh repair. Pathology confirmed CSE. The SP port was anchored transvaginally using “4-P” methods.7 A robotic-assisted vNOTES hysterectomy with salpingectomy was performed utilizing the da Vinci SP surgical system, which was subsequently reoriented to the anterior abdominal wall. The endometriotic nodule was sharply excised en bloc with clear margins. General surgery reinforced the fascial defect with dual-sided composite mesh secured to healthy fascia. The patient tolerated the procedure without complications (Figure 1a–f). Case 2: A 44-year-old woman (G3P2012) with a history of two prior cesarean sections presented with progressive scar pain. MRI demonstrated a 3.1 × 1.6 × 2.1 cm enhancing nodule in the anterior abdominal wall with rectus involvement. She underwent robotic Xi single-site transumbilical resection of endometriosis, enterolysis, uterine myomectomy, and nodule excision with mesh repair. Pathology confirmed CSE. A 15 mm umbilical incision and an additional 8 mm incision in the left lower quadrant were made for Xi port placement. After peritoneal lesion excision, a needle was inserted externally to localize the abdominal wall nodule. The nodule was excised using monopolar scissors, resulting in a 3 × 3 cm abdominal wall defect. General surgery repaired the resulting fascial defect with dual-sided composite mesh (Figure 1g–k). The total operative times were 385 min (Case 1, from colpotomy to cuff closure) and 265 min (Case 2, from skin incision to closure). Estimated blood loss was 50 and 15 mL, respectively. Both patients were discharged the same day without complications. At 6 weeks, both reported symptom resolution and satisfactory recovery. Postoperative visual analog scale (VAS) pain, was 6, 6, and 4 at weeks 1–3 in Case 1, and 9, 8, and 8 in Case 2. We describe the first reported cases of robotic SP vNOTES and Xi umbilical single-site excision of CSE with mesh reinforcement. Although open resection remains the standard for AWE, minimally invasive approaches provide reduced morbidity, superior cosmesis, and faster recovery. Based on the analysis of prior studies, several key clinical recommendations emerge to guide AWE management (Tables S1 and S2). Preoperative imaging, particularly MRI, is critical for defining lesion boundaries and guiding surgical planning. Achieving wide margins is essential to prevent recurrence. For lesions exceeding 3 cm, mesh reinforcement is recommended to avoid postoperative herniation, as performed in both cases. Minimally invasive techniques, including robotic-assisted surgery and transumbilical single-site laparoscopy (TU-LESS),6 are effective and cosmetically favorable, especially for deeply located or multifocal lesions. Robotic surgery provides key advantages such as avoiding direct incision over the lesion, reducing pain and infection risk, improving cosmesis, and enabling precise dissection with wristed instrumentation. The same incision can also facilitate mesh placement by general surgeons, streamlining collaboration. Our findings, consistent with emerging reports like vNOTES umbilical hernia repair,8 underscore the expanding role of robotics in abdominal wall surgery. However, these techniques may not be ideal for large or infiltrative lesions requiring extensive en bloc excision. In such cases, or when surgery is contraindicated, hormonal therapy may serve as an adjunct or alternative treatment. Robotic-assisted approaches for CSE, including Xi single-site umbilical and SP vNOTES platforms, are feasible, safe, and cosmetically advantageous. These cases highlight the role of advanced robotic techniques in managing abdominal wall endometriosis, particularly when combined with appropriate imaging, multidisciplinary care, and mesh repair for larger defects. Prospective studies comparing robotic and open approaches with long-term follow-up on recurrence, mesh durability, and alternatives such as high-intensity focused ultrasound are warranted to establish efficacy and broaden minimally invasive treatment strategies for this challenging condition. Xiaoming Guan: Data curation, conceptualization, methodology, supervision, project administration, surgeon, writing—original draft, writing—review and editing, and validation. Qiannan Yang: Data curation, visualization, writing—original draft, writing—review and editing, and validation. Victoria Zhang: Writing—review and editing, and validation. Chunhua Zhang: Writing—review and editing, and validation. All authors have read and agreed to the published version of the manuscript. This research received no external funding. The authors declare no conflicts of interest. The data that support the findings of this study are available on reasonable request to the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Table S1. Summary of existing literature abdominal wall endometrioma or cesarean scar endometriosis. Table S2. Summary of key clinical considerations in the management of abdominal wall endometrioma and cesarean scar endometriosis based on published literature. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.