Elliot ;

PREOPERATIVE DIAGNOSES:
Excessive menstrual bleeding.
Pelvic floor dysfunction including nocturnal 4-5 times at night and urinary urgency.
Morbid obesity.
Fibroid.

POSTOPERATIVE DIAGNOSES:
Excessive menstrual bleeding.
Pelvic floor dysfunction including nocturnal 4-5 times at night and urinary urgency.
Morbid obesity.
Fibroid.

PROCEDURE PERFORMED:
Robotic-assisted supracervical hysterectomy with bilateral salpingectomy.
Robotic-assisted excision of endometriosis.
Robotic-assisted left inferior hypogastric neurolysis.
Robotic-assisted peritoneal biopsy.
Laparoscopic transversus abdominis plane block.

ASSISTANT: Kateryna Kolesnikova, MD

ANESTHESIA: General endotracheal.

COMPLICATIONS: None.

SPECIMENS:
Uterus.
Bilateral fallopian tubes.
Left pelvic sidewall peritoneum.

ESTIMATED BLOOD LOSS: Less than 20 cc.

INTRAOPERATIVE FINDINGS: Uterus was bulky, highly consistent with adenomyosis, 12-week
size with intramural 2 x 3 cm fibroid. Both ovaries within normal limits. Left pelvic sidewall
with moderate inflammation causing retraction of peritoneum and evidence of
neovascularization. Retraction of the peritoneum over the trajectory of left inferior hypogastric
plexus. There were moderate filmy adhesions between the sigmoid colon and left pelvic
sidewall caused by chronic inflammation. The patient is status post prior tubal ligation. The
patient is morbidly obese. There was evidence of stage II uterine prolapse and stage II
cystocele. Right pelvic sidewall within normal limits and no evidence of active endometriosis
involvement. Cul-de-sac was also free. There was bilateral ureteral peristalsis during the entire
length of the surgery.
INDICATIONS FOR SURGERY:This is a 41-year-old female, gravida 3, para 3, with excessive and
continuous menstrual bleeding accompanied by an abnormal pattern. The patient has been
experiencing nonstop bleeding since February 1st, with particularly heavy bleeding during her
expected menstruation. In fact, she was saturating a tampon every half an hour. The patient
has previously consulted multiple gynecologists regarding this issue and attempted the use of a
hormonal intrauterine device (IUD) without success. As a result, she was referred to my office
to consider a definitive surgical intervention. Considering the patient's lack of desire for future
fertility, a partial hysterectomy was deemed a suitable option. It is important to note that the
patient is morbidly obese and at a high risk of developing endometrial hyperplasia. Therefore, a
permanent surgical solution would be beneficial in reducing the risk of future uterine
neoplasms. The patient has already undergone bilateral tubal ligation and has no desire for
future fertility. Additionally, the patient is experiencing significant pelvic floor dysfunction,
including nocturia 4-5 times per night, as well as urinary urgency and frequency. Upon
examination, the patient's uterus was found to be tender and bulky, indicating adenomyosis.
Furthermore, both pelvic sidewalls were tender, with the left side exhibiting a more
pronounced inflammatory effect, possibly due to suspected endometriosis affecting the
trajectory of the inferior hypogastric plexus. Consequently, the patient strongly expressed the
desire to proceed with surgery not only for a partial hysterectomy but also to evaluate the
pelvic nerve. However, the patient is aware that due to her high BMI, the surgical risks are
significantly higher, and the approach to the pelvic area is more complex, increasing the risk of
injury to the bowel, bladder, and ureter. Despite understanding these risks, the patient wished
to proceed. Consent was obtained. Prior to the procedure, the patient underwent a pelvic
ultrasound, which revealed the presence of two small fibroids and a relatively thin endometrial
lining. Additionally, the examination indicated evidence of moderate pelvic organ prolapse,
specifically stage II. Therefore, it was recommended to preserve the cervix in order to maintain
the apical support of the vagina. This decision was made considering the high risk of vaginal cuff
dehiscence and the presence of uterine prolapse. Preserving the cervix would help decrease the
risk of vaginal cuff dehiscence and maintain the integrity of the apical support of the vagina.
The patient was informed about the nature of the surgery and agreed to proceed. Consent was
obtained.

PROCEDURE: The patient was brought to the operating room where general anesthesia was
obtained and found to be adequate. The patient was then placed in dorsal lithotomy position.
The pelvic and abdominal areas were prepped and draped in the usual sterile fashion. Attention
was turned to the pelvic area. Foley catheter was inserted into the bladder and also a V-Care DX
uterine manipulator was inserted into the endometrial cavity for the means of manipulating the
uterus. Attention was turned to the patient's abdomen. On the left upper quadrant, an 8 mm
skin incision was performed. An 8 mm robotic trocar with the scope attached to it was inserted
under direct visualization into the abdominal cavity and pneumoperitoneum obtained without
difficulty. Then, on the umbilical area and right upper quadrant, two additional robotic trocars
were installed. We then proceeded with the TAP block procedure. Given the patient's history of
chronic pelvic pain the decision was made to proceed with a laparoscopic guided TAP block to
reduce postoperative pain and need for any narcotic. This was done as follows: The
laparoscopic camera was inserted again and on inspection of the abdomen, the anterior
abdominal wall was achieved. Then, 20 mL of Exparel was mixed with 40 mL of 0.25% Marcaine
and 20 mL of sterile saline. This was then injected and infiltrated into the left side of the
abdominal wall between the transversus abdominis and internal oblique muscle under direct
visualization of the laparoscope in 2 separate locations approximately 15 mL each. This was
repeated on the right side as well. The inspection of the areas of injection were noted to be
completely hemostatic. The patient was placed in steep Trendelenburg and the robot was
docked from the left-sided docking technique in the usual sterile fashion. Please note, the total
incisions of the patient's abdomen were 3. The size of each was 8 mm. There was no additional
assistant port. This included one robotic camera arm and two operative arms. Attention was
turned to the bilateral salpingectomy as follows: On the right side, the fimbria was grasped and

the mesosalpinx was coagulated aiming toward the uterus and then was amputated. This was
done bilaterally. After completion of the salpingectomy, the attention was turned to the
hysterectomy. On the right side, the right round ligament was coagulated and dissected and
then the utero-ovarian ligament was also coagulated and dissected and then the broad
ligament was sharply entered and the anterior and posterior sheath of broad ligament was
separated and dissected towards the uterocervical junction. By reaching there, the bladder was
grasped, tented up, and uterovesical peritoneal flexion of the bladder was dissected and
bladder was pushed down toward the lower aspect of the vagina and pubo-cervical fascia was
well exposed. Then the right uterine vessel complex was well skeletonized with good
visualization of the right ureter. This large uterine vessel complex was coagulated using the
robotic vessel sealer and the same exact procedure was performed on the left side as well.
Good blanching of the uterus was then noted. We then proceeded with amputationof the
uterus from the cervical stump. First, the uterine manipulator was removed. Then, with the use
of a monopolar scissors, a circumferential dissection was performed with use of monopolar
scissors resulting in amputation of the uterus and bilateral tubes and ovaries from the surgical
stump. At this point, the cervix was well coagulated and good hemostasis was noted.
Endocervical canal was then coagulated with bipolar device. Cervical canal was reapproximated
with 2-0 Vicryl in running fashion.

Then, attention was turned to the patient's pelvic area. There was noted to be evidence of
diffuse peritoneal inflammation, neovascularization, and retraction of the peritoneum on
bilateral pelvic sidewall. The decision was made to proceed with excision of the peritoneum for
both biopsy and to release the underlying hypogastric plexus nerve from this inflamed
peritoneum. Both pelvic sidewall peritoneum was dissected as follows: On the left side initially,
the retroperitoneal space was entered with a linear incision parallel and medial to the
infundibula-pelvic ligament. By entering the retroperitoneal space, the peritoneum was grasped
and tented medially, and then the peritoneum was dissected from the underlying connective
tissue and the underlying pelvic nerve was carefully dissected from the inflamed peritoneum.
This dissection was carried until the ureter was reached. The ureter was then gently lateralized
and separated from the peritoneum.
Then, we continued with the peritoneal dissection to release the inflamed hypogastric nerve
plexus that was irritated due to its involvement with this severe peritoneal inflammation. We
separated the peritoneum from the underlying connective tissue and inferior hypogastric
plexus, restoring the nerve to no longer being harmed from the severely inflamed peritoneal
tissue. Please note, the inferior hypogastric plexus was completely involved with this severe
inflammation. By releasing the inflamed peritoneum from the underlying peritoneal sidewall,
we reached to the level of left uterosacral ligament caudally, and the level of the pelvic brim
cephalad. This wide peritoneal excision of peritoneum including all the endometriotic lesion
was performed and amputated from pelvic sidewall, and then profuse irrigation was
performed, and excellent hemostasis was achieved. After separating the inflamed peritoneum
from underlying fibro-connective tissue, then attention was turned to the inferior hypogastric
plexus, there was noted to be significant fibrosis and inflammatory change surrounding the
nerve branch of the hypogastric plexus. Therefore, an extensive neurolysis was performed by
separating all the fibrosis from these small fiber unmyelinated nerves The attention was taken
making sure there was minimal damage to the nerve and the nerve was not transected during
this extensive neurolysis. This way all the fibrosis was separated with combination of blunt and
sharp dissection without use of any thermal energy and all branch of inferior hypogastric plexus
was well skeletonized all the way from their origin from the hypogastric nerve proximally
toward the smaller branch distally around the utero-sacral ligament and deep pelvic sidewall.
More specifically the nerve branch which was heading toward the bladder was well identified
and skeletonized with the similar technique.

At this point, we proceeded with extraction of the uterus and tubes from the abdominal cavity
using the minimally invasive approach as following: The robot was undocked, and laparoscopic
scope was inserted into the patient's abdomen, and we proceeded with retrieval of the
specimen as follows: Our umbilical 8 mm trocar was removed, and the large bag was inserted
under direct visualization. The uterus and tubes were placed in the bag and the bag was
withdrawn though umbilicus incision. An Alexis retractor was applied to the umbilical area, and
approximately a 2 cm incision was performed in the umbilicus and the specimen was
completely bagged and removed through the umbilical port without any difficulty. The
specimen was then cut in piece manually, with the use of scalpel in totally contained technique.
The umbilical fascial incision was reapproximated with 0-Vicryl in a running fashion and the
umbilical incision was reapproximated with 4-0 Monocryl in a subcuticular running fashion and
then dressing was applied to the umbilicus. Then the laparoscopic camera was inserted again,
and a second-look laparoscopic view was performed. Again, profuse irrigation and suctioning
were performed. Excellent hemostasis was achieved. Excellent ureteral peristalsis was noted
constantly during the entire case. At this point pneumoperitoneum was evacuated. All the
laparoscopic ports were removed. The 3 skin incisions were closed with use of #4-0 Monocryl in
subcuticular interrupted fashion. The skin was covered with Dermabond. At this point the Foley
catheter was removed and the bladder was drained. The patient received 2 grams of Ancef and
500 mg of Flagyl at the beginning of the procedure. Sponge, lap and needle counts were correct
x2. The patient tolerated the procedure well.
DESCRIPTION OF PROCEDURE: Following a 3-port robot docking was performed, robotic
supracervical hysterectomy, bilateral salpingectomy was performed. Excision of endometriosis
and left pelvic neurolysis was performed. Vistaseal was applied. Perfused irrigation and suction
was performed. Good hemostasis was achieved. Bilateral ureteral peristalsis was noted during
the entire case. Uterus was removed from the umbilicus. The patient received 2 g of Ancef and
500 mg of Flagyl.

#################

PREOPERATIVE DIAGNOSES:
Endometriosis.
Severe pelvic pain.
Right pudendal neuralgia.
Pelvic floor dysfunction including urinary urgency, urinary frequency, and unable to empty the
bladder.
Dyspareunia.
Ovarian cyst.

POSTOPERATIVE DIAGNOSES:
Endometriosis.
Severe pelvic pain.
Right pudendal neuralgia.
Pelvic floor dysfunction including urinary urgency, urinary frequency, and unable to empty the
bladder.
Dyspareunia.
Pudendal neuralgia caused by compression of engorge internal pudendal vein.
Pelvic congestive syndrome.
Ovarian cyst.

PROCEDURE PERFORMED:
Robotic-assisted supracervical hysterectomy with bilateral salpingectomy.
Robotic-assisted full transection of the right sacrospinous ligament with decompression of right
pudendal nerve.
Robotic-assisted excision of endometriosis.
Robotic-assisted pelvic neurolysis.
Robotic-assisted pelvic nerve repair with the use of allograft.
Robot-assisted bilateral ureterolysis.
Robotic-assisted right obturator internus fasciotomy.
Robotic-assisted peritoneal biopsy.
Laparoscopy TAP block.
Robotic-assisted left ovarian cystectomy.
CO-SURGEON AND ASSISTANT:
Dr. Kateryna Kolesnikova, MD.
Second assist was Antonina Avanzi, PA.

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: Less than 50 cc.

COMPLICATIONS: None.

SPECIMEN:
Left ovarian cyst.
One left pelvic sidewall peritoneum.
Right pelvic sidewall peritoneum.
Right ovarian cortex biopsy.
Uterovesical peritoneum.
Uterus with bilateral tube.

COMPLICATIONS: None.

INTRAOPERATIVE FINDINGS: The uterus had normal size, and the right ovary was within normal
limits. The left ovary with a 3 x 4 cm simple cyst. There was evidence of severe inflammation
affecting bilateral pelvic sidewall. This was more prominent on the right side causing a
significant vacuum sealing sign consistent with prolonged inflammation. This was causing the
significant retraction of peritoneum severely affecting the trajectory of the right inferior
hypogastric plexus and tissue retraction and inflammation was affecting the deeper pelvic nerve
and deep obturator space including the right obturator nerve and the right pudendal and sciatic
nerve. There was also severe retraction on the left side. However, the level of retraction was
more prominent on the right. The trajectory of left inferior hypogastric nerve was also affected
by traction of the peritoneum and chronic inflammation on its trajectory. Trajectory of both
ureters were severely affected with this retraction of peritoneum deviating the anatomy off the
bilateral ureter. There was evidence of multiple small endometrial implants on the cortex of the
right ovary, bilateral sidewall and a on the uterovesical peritoneum. The right fallopian tube
had a dense adhesion to the right inguinal area. There was evidence of inguinal hernia repair
with insertion of mesh where the ampullar portion of the fallopian tube was densely adhered to
it, retracting the fallopian tube toward the anterior abdominal wall and right lower quadrant
with dense scar. Sigmoid colon overall was free and normal from any involvement. Rectum
was also not involved with any endometriosis or inflammatory change related to it. Cul-de-sac
overall was free of endometriosis. On exploration of the obturator space, there was evidence
of chronic inflammatory change affecting the greater sciatic foramen and its surrounding
structures including the right sacrospinous ligament. There was a white color inflammatory
fibrotic change around the trajectory of sciatica nerve and also pudendal nerve , and the
pudendal nerve has dense adhesion to the dorsal aspect of the sacrospinous ligament.
Furthermore, there was a significant engorgement and varicose changed on the trajectory of
the right internal pudendal vein clearly compressing the pudendal nerve on its passage under
the sacrospinous ligament. This required a full transection of sacrospinous ligament, which
significantly reduced the congestion of the vein and therefore there was no need for full
transection of internal pudendal vein at this point, given the return to normal and
decompression of the vein after transection of the ligament. Also, given the presence of
significant tension on the nerve, additional fasciotomy on the right obturator fascia was
performed, adjacent to the sacrospinous ligament and the proximal portion of the Alcock canal
was well exposed and decompressed. Both ureters had persistent peristalsis during the entire
surgery and given the significant deviation of the anatomy, ureterolysis was performed and
there was absolutely no damage on the trajectory of both ureter during the surgery. The left
fallopian tube within normal limit. Appendix was surgically absent. There was no evidence of
active endometriosis in the abdominal cavity.

INDICATIONS FOR SURGERY: This is a 44-year-old, gravida 1, para 1, status post one C-section.
She has a known case of endometriosis and chronic pelvic pain. In 2016, she underwent
laparoscopic surgery in New York City to remove the endometriosis. Initially, the surgery
provided relief for the first year or two. The patient remained relatively pain-free during that
time. She also received a hormonal intrauterine device (IUD) to manage her dysmenorrhea and
dyspareunia. However, she could not tolerate the IUD as it caused significant pain and
discomfort, leading to its removal.

Over the past year, the patient started experiencing significant low back pain, buttock pain, and
right lower quadrant pain, which greatly affected her quality of life. The pain radiated to her
right lower extremity, both from the front and back of her thigh, and towards her knee. The
pain also extended deep into her right buttock and genital area. Despite undergoing multiple
courses of physical therapy and receiving spinal and epidural injections at L4, L5, and S5 on a
monthly basis, none of these interventions completely improved the patient's quality of life or
alleviated her pain. The patient reported that her pain worsened with prolonged sitting and
activity.

In addition to the pain, the patient also experienced pelvic floor dysfunction, including urinary
frequency and urgency, as well as difficulty emptying her bladder. These symptoms were worse
during her menstrual cycle. The pain in her lower extremity and right buttock also intensified
during this time. The patient tried a course of progesterone treatment, but it failed to improve
her symptoms and she could not tolerate it.

Considering the significant impact of the pain and pelvic floor dysfunction on her quality of life,
and the failure of other medical and conservative interventions to control her pain, the patient
strongly desires to proceed with surgical intervention. She understands the significant risks
involved, including potential injury to the bowel, bladder, ureter, and pelvic nerve due to the
complexity of the surgery and suspected inflammation in these areas. Despite understanding
these risks, the patient remains determined to proceed with the surgery.

The patient has given her informed consent and agrees to proceed with the surgical
intervention.

PROCEDURE: The patient was brought to the operating room where general anesthesia was
obtained and found to be adequate. The patient was then placed in dorsal lithotomy position.
The pelvic and abdominal areas were prepped and draped in the usual sterile fashion. Attention
was turned to the pelvic area. Foley catheter was inserted into the bladder and a V-Care DX
uterine manipulator was inserted into the endometrial cavity for the means of manipulating the
uterus. Attention was turned to the patient's abdomen. On the left upper quadrant, an 8 mm
skin incision was performed. An 8 mm robotic trocar with the scope attached to it was inserted
under direct visualization into the abdominal cavity and pneumoperitoneum obtained without
difficulty. Then, on the umbilical area and right upper quadrant, two additional robotic trocars
were installed. We then proceeded with the TAP block procedure. Given the patient's history of
chronic pelvic pain the decision was made to proceed with a laparoscopic guided TAP block to
reduce postoperative pain and need for any narcotic. This was done as follows: The
laparoscopic camera was inserted again and on inspection of the abdomen, the anterior
abdominal wall was achieved. Then, 20 mL of Exparel was mixed with 40 mL of 0.25% Marcaine
and 20 mL of sterile saline. This was then injected and infiltrated into the left side of the
abdominal wall between the transversus abdominis and internal oblique muscle under direct
visualization of the laparoscope in 2 separate locations approximately 15 mL each. This was
repeated on the right side as well. The inspection of the areas of injection were noted to be
completely hemostatic. The patient was placed in steep Trendelenburg and the robot was
docked from the left-sided docking technique in the usual sterile fashion. Please note, the total
incisions of the patient's abdomen were 3. The size of each was 8 mm. There was no additional
assistant port. This included one robotic camera arm and two operative arms.

Attention was turned to the bilateral salpingectomy as follows: On the right side, the fimbria
was grasped and the mesosalpinx was coagulated aiming toward the uterus and then was
amputated. This was done bilaterally. After completion of the salpingectomy, the attention was
turned to the hysterectomy. On the right side, the right round ligament was coagulated and
dissected and then the utero-ovarian ligament was also coagulated and dissected and then the
broad ligament was sharply entered, and the anterior and posterior sheath of broad ligament
was separated and dissected towards the uterocervical junction. By reaching there, the bladder
was grasped, tented up, and uterovesical peritoneal flexion of the bladder was dissected and
bladder was pushed down toward the lower aspect of the vagina and pubo-cervical fascia was
well exposed. Then the right uterine vessel complex was well skeletonized with good
visualization of the right ureter. This large uterine vessel complex was coagulated using the
robotic vessel sealer and the same exact procedure was performed on the left side as well.
Good blanching of the uterus was then noted. We then proceeded with amputation of the
uterus from the cervical stump. First, the uterine manipulator was removed. Then, with the use
of a monopolar scissors, a circumferential dissection was performed with use of monopolar
scissors resulting in amputation of the uterus and bilateral tubes and ovaries from the surgical
stump. At this point, the cervix was well coagulated and good hemostasis was noted.
Endocervical canal was then coagulated with bipolar device.

Then, attention was turned to the patient's pelvic area. There was noted to be evidence of
diffuse peritoneal inflammation, neovascularization, and retraction of the peritoneum on
bilateral pelvic sidewall. The decision was made to proceed with excision of the peritoneum for
both biopsy and also to release the underlying hypogastric plexus nerve from this inflamed
peritoneum. Both pelvic sidewall peritoneum was dissected as follows: On the left side initially,
the retroperitoneal space was entered with a linear incision parallel and medial to the
infundibula-pelvic ligament. By entering the retroperitoneal space, the peritoneum was grasped
and tented medially, and then the peritoneum was dissected from the underlying connective
tissue and the underlying pelvic nerve was carefully dissected from the inflamed peritoneum.
This dissection was carried until the ureter was reached. Then, in order to secure the ureter,
given the retraction and deviation of the ureter from its normal anatomy secondary to the
dense inflammatory change on the peritoneum, in order to secure the ureter from future
damage and stricture given the possible involvement of the endometriosis, decision was made
to consider a left ureterolysis. The trajectory of the ureter was identified at the pelvic brim.
Retroperitoneal space above the ureter was entered. The ureter was then lateralized and
peritoneum was delicately separated from ureter moving toward the bladder distally, carefully
without damaging the vasculature of the ureter. By reaching near the hypogastric plexus, the
level of dense fibrosis was noted requiring extensive lysis of adhesion in order to release the
ureter from surrounding fibrosis. This was also more prominent at the level of the uterine
artery, at the caudal edge of pararectal space; however, we were able to safely separate the
ureter and restore its anatomical position and release it from all fibrotic retraction. the ureter
was completely secured and separated from the inflamed peritoneum. Then, we continued
with the peritoneal dissection to release the inflamed hypogastric nerve plexus that was
irritated due to its involvement with this severe peritoneal inflammation. We separated the
peritoneum from the underlying connective tissue and inferior hypogastric plexus, restoring the
nerve to no longer being harmed from the severely inflamed peritoneal tissue. Please note, the
inferior hypogastric plexus was completely involved with this severe inflammation. By releasing
the inflamed peritoneum from the underlying peritoneal sidewall, we reached to the level of
left uterosacral ligament caudally, and the level of the pelvic brim cephalad. This wide
peritoneal excision of peritoneum including all the endometriotic lesion was performed and
amputated from pelvic sidewall, and then profuse irrigation was performed, and excellent
hemostasis was achieved. After separating the inflamed peritoneum from underlying fibro-
connective tissue, then attention was turned to the inferior hypogastric plexus, there was noted
to be significant fibrosis and inflammatory change surrounding the nerve branch of the
hypogastric plexus. Therefore an extensive neurolysis was performed by separating all the
fibrosis from these small fiber unmyelinated nerves The attention was taken making sure there
was minimal damage to the nerve and the nerve was not transected during this extensive
neurolysis. This way all the fibrosis was separated with combination of blunt and sharp
dissection without use of any thermal energy and all branch of inferior hypogastric plexus was
well skeletonized all the way from their origin from the hypogastric nerve proximally toward
the smaller branch distally around the utero-sacral ligament and deep pelvic sidewall. More
specifically the nerve branch which was heading toward the bladder was well identified and
skeletonized with the similar technique. The same exact procedure was performed on the right
side,with the exception of ureterolysis which was not performed on the right. Attention was
turned to the right paravesical space. There was a nodule on the right paravesical space medial
to the right umbilical obliterated ligament. This nodule was grasped, pulled medially and with
the use of monopolar scissors the entire nodule, which was deeply penetrating to paravesical
space was dissected with a 5 mm margin around the lesion. This measured 1 x 2 cm and the full
nodule was removed from surrounding healthier paravesical adipose tissue without damaging
the bladder. All peritoneal wide excisional biopsies were sent to pathology. After completion of
excision of peritoneal sidewall, given the high suspicion about deeper involvement of the
inflammation and endometriosis, the decision was made to explore the pelvic sidewall further
and deeper, toward the pelvic floor. The patient symptoms consistent with pudendal neuralgia
and its related pelvic floor dysfunction, and given the severe tenderness of sacrospinous
ligament, obturator internus fascia, and trajectory of the pudendal nerve inside the alcock canal
I proceeded to exploration of pelvic floor muscle and ligaments for possible decompression of
pudendal nerve and vessels. Attention was turned toward exploration and decompression of
the left pudendal nerve. On the left pelvic sidewall, the superior vesical artery was identified,
and dissection was performed on the lateral aspect of the superior vesical artery, medial to
external iliac vein,with good visualization of the ureter. This space was entered, and the blunt
and sharp dissection was continued until the obturator nerve and vessels were reached. The
obturator nerve and vessels were released from surrounding lymph nodes and were found to
be completely intact from any endometriosis or fibrosis involvement. Then, in order to reach to
the ischial spine deeper dissection on medial aspect of the obturator vein was performed. By
dissecting further, we were able to reach the obturator internus muscle, and then we were able
to identify the arcus tendineus fascia of the pelvis that was reaching to the ischial spine. Ischial
spine was identified, and there was a small amount of fat herniation at the arcus tendineus
fascia of pelvis near the ischial spine, which was removed and released. Also, dense scar and
fibrosis was noted on the left sciatica, which was all released with the use of scissors without
use of any electrocautery. Then attention was turned to transection of the sacrospinous
ligament since the entrapment of the nerve was suspected to be caused partially by the
ligament. Initially the coccygeus muscle fiber was dissected off the ligament, and the
sacrospinous ligament was well exposed. The cephalad edge of the ligament was entered
gently. the pudendal nerve then identified crossing under the sacrospinous ligament. The
dissection of the sacrospinous ligament at the level of its attachment to the ischial spine was
performed. The full thickness of the ligament was transected providing significant release on
the pudendal nerve. neurolysis was performed around the pudendal nerve and vasculators,
prior to their entry to the lesser sciatica foramen. Exploration of right obturator space was
performed with the exact same technique as described above. On the right side, only lysis of
adhesions around the trajectory the greater sciatic foramen lesser sciatic foramen was
performed. There was no need for transection of the ligament. Then, attention was turned to
the procedure of paravaginal repair, and urethropexy. The bilateral obturator spaces were
previously exposed as described above. On the right pelvic sidewall, by reaching to the levator
muscles, the fascia of the obturator internus muscle was identified and also the attachment of
the levator muscles was identified. Then on the right side, the loose foamy Space Attaching the
vagina medially to the levator muscle laterally was bluntly entered and this dissection was
continued till the deep perineal pouch and then paraurethral space was reached. The assistant
surgeon, by pushing her finger around the mid urethral area, manipulating the paraurethral
space on the right side, helped me to well identify the Paraurethral space and defects from the
inside of the deep perineal pouch. pubocervical fascia around the uretha were well
skeletonized. Then, on the lateral wall, arcus tendineus pelvic fascia was well identified from its
origin attached to the pubic bone. Then the same dissection was performed on the left side as
well in similar fashion. On bilateral para-urethral and paravaginal space, a significant defect was
noted consistent with patient's urethral hypermobility and paravaginal defect. There was
evidence avulsion of levator muscle from its attachment to the arcus tendineus fascia on
bilateral sidewall which was more prominent on the right. Then given the evidence of severe
urethral hypermobility, the decision was made to reinforce the paraurethral fascia even further
despite of the previous attachment of paraurethral fascia to the bilateral arcus tendineus fascia.
The decision was made to add additional urethropexy vertically. Therefore, additional
permanent 0 V-Loc was used and on the right side the periurethral space was identified again.
The fascia was well exposed and a suture was applied to the fascia of the right paraurethral
fascia and the suture was then attached to the right Cooper's ligament with good visualization
of the obturator foramen to be at least 2 cm lateral to area of our suture application.
Approximately 3 suspensory attachment was performed, suspending the periurethral space on
the right side to the Cooper ligament vertically. This added additional support in addition to the
lateral support was previously provided by attachment to the right arcus tendineus fascia. The
exact same procedure was performed on the left side. Then attention was turned to the pelvic
area and pelvic exam was performed after putting on a sterile glove and a previous urethral
hypermobility and a paravaginal defect was noted to be completely elevated and resolved. The
same exact procedure was performed on the left side. Then cystoscopy was performed
immediately in order to assure that there was no damage to the urethra or bladder.
Urethroscopy was performed by introducing a 70-degree scope with a 21-gauge French
cystoscopy device into the urethra with active running of sterile water. The urethra was well
exposed and perfect inspection was performed on the entire length of the urethra and there
was absolutely no evidence of damage to the urethra. After performance of the urethroscopy,
the cystoscopy device was advanced into the bladder and the bladder was fully inspected and
there was absolutely no evidence of damage to the bladder and there was no suture erosion to
the bladder either. Given the previous ureterolysis, also attention was turned to both ureteral
orifices and bilateral ureteral efflux was noted with strong force. At this point, bladder was
drained. Cystoscopy was removed and Foley catheter was replaced. Attention was turned back
to the abdominal area and robotic console. Profuse irrigation and suction was performed and
the paravaginal area was then covered with Vistaseal fibrin material. At the end, the bilateral
paravesical peritoneal incisions, lateral to the superior vesical arteries bilaterally were
reapproximated with the use of 3-0 V-Loc in a running fashion. Excellent hemostasis was
achieved. At the end, for the purpose of repairing the inflammatory damage and fibrosis of the
bilateral hypogastric plexus cause by endometriosis, we proceeded with pelvic nerve repair
with the use of allograft. A large piece of Amniox Clarix biologic allograft (6x3 cm) was dissected
in 4 small strips and passed into the laparoscopic trocar into the pelvic area. A piece of Amniox
allograft was wrapped around bilateral hypogastric nerves. This was performed in order to
reduce inflammation, after complete resection of all inflamed peritoneum off of these
hyperexcited pelvic nerves. After attachment of Amniox to bilateral pelvic sidewall, the
VistaSeal coagulating material, was sprayed on the bilateral pelvic sidewalls for both hemostatic
purposes and also to create optimal adhesion between the previously placed Amniox graft and
the pelvic sidewall. This resulted in adequate fixation of this anti-inflammatory and adhesion
barrier material to the pelvic nerve. Excellent hemostasis was achieved. At this point, we
proceeded with extraction of the uterus and tubes from the abdominal cavity using the
minimally invasive approach as following: The robot was undocked, and laparoscopic scope was
inserted into the patient's abdomen and we proceeded with retrieval of the specimen as
follows: Our umbilical 8 mm trocar was removed, and the large bag was inserted under direct
visualization. The uterus and tubes were placed in the bag and the bag was withdrawn though
umbilicus incision. An Alexis retractor was applied to the umbilical area, and approximately a 2
cm incision was performed in the umbilicus and the specimen was completely bagged and
removed through the umbilical port without any difficulty. The specimen was then cut in piece
manually, with the use of scalpel in totally contained technique. The umbilical fascial incision
was reapproximated with 0-Vicryl in a running fashion and the umbilical incision was
reapproximated with 4-0 Monocryl in a subcuticular running fashion and then dressing was
applied to the umbilicus. Then the laparoscopic camera was inserted again, and a second-look
laparoscopic view was performed. Again, profuse irrigation and suctioning were performed.
Excellent hemostasis was achieved. Excellent ureteral peristalsis was noted constantly during
the entire case. At this point pneumoperitoneum was evacuated. All the laparoscopic ports
were removed. The 3 skin incisions were closed with use of #4-0 Monocryl in subcuticular
interrupted fashion. The skin was covered with Dermabond. At this point the Foley catheter
was removed and the bladder was drained. The patient received 2 grams of Ancef and 500 mg
of Flagyl at the beginning of the procedure. Sponge, lap and needle counts were correct x2. The
patient tolerated the procedure well.

DESCRIPTION OF PROCEDURE: [_____] was performed. Supracervical hysterectomy and

bilateral salpingectomy was performed. The laparoscopy TAP block was performed. The right
pelvic sidewall and left pelvic sidewall dissection was performed and pelvic neurolysis was
performed. Bilateral urethrolysis was performed. Left ovarian cystectomy was performed in
the usual sterile fashion. Then, attention was turned to the right, where there was a small
implant of suspected endometriosis on the cortex of the ovary, it could be nodule from old
hemosiderin. However, the decision was made to remove this was approximately 5 x 5 mm
round shape, brown color. This was grasped and with the use of monopolar scissor was
dissected from the surrounding ovarian cortex and removed. Good hemostasis was achieved.
Attention was turned to the right fallopian tube. There was a dense adhesion between mid and
to lower portion of fallopian tube to the right inguinal area to the previously surgically placed
mesh. The dense adhesion between the tube and the mesh was resected and the without
damaging the installed mesh and the fallopian tube was completely relieved. Then, on the
uterovesical space, there was a piece of peritoneum, which was removed. A bilateral
ureterolysis was performed.

Then, attention was turned to the deep obturator space. The full transection of sacrospinous
ligament was performed that was noted to be significant congestion and varicose change on
the right internal pudendal vein, compressing the pudendal nerve on this trajectory under the
sacrospinous ligament. This mainly was so enlarged that had cystic appearance bulging
pressure on the ulnar side. Therefore, the decision was made to consider a full transection of
the sacrospinous ligament. After full transection of sacrospinous ligament, additional
transection of obturator fascia was performed to fully decompress the trajectory of the nerve
and also pudendal vasculature. Also around the right sciatica nerve, there was chronic
inflammation caused by attachment of inflammatory adipose tissue to the nerve, which was all
removed gently without damaging the junction of the nerve. There was also adhesion between
the dorsal aspect of the obturator internus muscle and sciatic nerve on its trajectory in the
greater sciatic foramen. This dense adhesion was released hoping to mobilize the sciatica
nerve. This resulted in significant decompression of the pudendal nerve. A piece of AmnioFix
was applied on the area and then on the left side, exploration was also performed. There was
overall mild adhesions around the greater sciatic foramen, which was released. Only 10% to
20% of cephalad edge of sacrospinous ligament was transected in order to mobilize the
pudendal nerve and also left sciatica nerve, but there was significantly less evidence of
inflammation and congestion on the left side. So, therefore the rest of the sacrospinous
ligament was left intact. At the end, AmnioFix was applied on the right pudendal nerve and also
right and left inferior hypogastric plexus. Specimen was removed through the umbilicus,
persistent, and continuous peristalsis was noted during the entire length of the surgery on both
ureter. The patient tolerated the procedure well. Received 2 g of Ancef along with 500 mg of
Flagyl.

elyses
PREOPERATIVE DIAGNOSES:
Endometriosis.
Chronic pelvic pain.
Right pudendal neuralgia.
Pelvic floor dysfunction including urinary urgency, urinary frequency, nocturia, and difficulty
emptying bladder and bowel.

POSTOPERATIVE DIAGNOSES:
Endometriosis.
Chronic pelvic pain.
Right pudendal neuralgia.
Pelvic floor dysfunction including urinary urgency, urinary frequency, nocturia, and difficulty
emptying bladder and bowel.

PROCEDURE PERFORMED:
Robotic assisted supracervical hysterectomy with bilateral salpingectomy.
Robotic assisted full transection of right sacrospinous ligament.
Robotic assisted excision of endometriosis.
Robotic assisted pelvic neurolysis.
Robotic assisted pelvic nerve repair with allograft.
Laparoscopy TAP block.
Robotic assisted right urethrolysis.

ASSISTANT: Antonina Avanzi, PA.

ANESTHESIA: General endotracheal.

COMPLICATIONS: None.

SPECIMEN: Uterus with bilateral tubes along with right pelvic sidewall peritoneum and left
pelvic sidewall peritoneum.

INTRAOPERATIVE FINDING: The uterus was normal size and anteverted. There was significant
retraction and vacuum sealing on bilateral pelvic sidewall, which was more prominent on the
right than left. This was secondary to the chronic inflammatory change caused by
endometriosis and the retraction of peritoneum on both sides was significantly affecting the
trajectory of inferior hypogastric plexus bilaterally. There was also evidence of multiple small
implants of endometriosis. On the right obturator space, there was significant inflammatory
change on the trajectory of right obturator, pudendal and sciatica nerve. There was a dense
fibrotic change affecting the greater sciatic foramen with inflammatory adipose tissue densely
adhered to the underlying nerve and with dense attachment to the fascia of the obturator
internus muscle. There was moderate congestion of internal pudendal vein secondary to
chronic inflammation causing compression on the trajectory of pudendal nerve. The tissue
around the trajectory of nerve was fibrotic consistent with prolonged inflammation. This was
also affecting the sacral spinous ligament. The trajectory of the right ureter was significantly
affected by retraction of tissue caused by this vacuum sealing of the peritoneum requiring the
ureterolysis. On the left obturator space, there was much lower amount of inflammation and
adipose tissue surrounding the nerve was much looser and without any evidence of
inflammation. There was no nodularity or formation of fibrosis on the left side. Both ovaries
were within normal limits; however, there was dense adhesion of ovary to the right pelvic
sidewall along with significant malrotation of the right fallopian tube secondary to adhesion to
the surrounding tissue including right pelvic sidewall and ovary. The left fallopian tube had
normal trajectory and there was filmy adhesion between the left pelvic sidewall and posterior
aspect of the uterus. There were multiple small implants of endometriosis on the posterior cul-
de-sac with the attachment to the rectum, which required resection of all active endometriosis.
INDICATION OF SURGERY:A 47-year-old female with a confirmed case of endometriosis,
diagnosed through surgical excision, is experiencing chronic pelvic pain. The patient previously
underwent laparoscopic excision of endometriosis, which provided moderate relief for a couple
of years. However, in the past 2 years, the pain has recurred. Additionally, the patient is
suffering from pelvic floor dysfunction, including symptoms such as urinary urgency, frequency,
and nocturia. The patient has consulted with various urologists and endometriosis specialists in
the past, but both surgical and nonsurgical interventions have failed to improve her symptoms.

The patient was initially evaluated by myself 1 year ago and was diagnosed with pudendal
neuralgia affecting both pelvic side walls, with the right side being more affected. At that time,
the patient opted for conservative management and sought the opinion of multiple urologists.
She considered undergoing Neurostim placement but the initial attempt at PNE testing did not
improve her symptoms. Multiple medical management approaches also failed to alleviate her
severe pelvic floor dysfunction. Consequently, the patient returned to our office and upon
examination, evidence of pudendal neuralgia was confirmed, with significant tenderness
observed on the ischial spine, Alcock canal, and ischial tuberosity along the full trajectory of the
right pudendal nerve. The patient also exhibited tenderness on the left pelvic sidewall, although
to a lesser extent. The patient's symptoms, including referral pain deep into the buttock and the
right corner of the genital area, as well as pain radiating to the posterior aspect of the right
lower extremity, were highly indicative of pudendal neuralgia. These symptoms, along with the
physical examination findings, strongly support the diagnosis of pudendal neuralgia.
Considering the patient's history of endometriosis, it is suspected that inflammatory changes,
causing adhesion and retraction of the nerve, are the primary cause of insult to the pudendal
and sciatic nerves. Furthermore, it is evident that the bilateral inferior hypogastric plexus is
affected, warranting surgical intervention to release the fibrotic changes surrounding the nerve.
The complexity of the surgery and the associated risks, including bowel, bladder, ureter, and
nerve injury, were explained to the patient. Despite the risks, the patient is determined to
proceed with surgery due to the significant impact of her symptoms on her quality of life.
Conservative management, including multiple medications, physical therapy, and non-
stimulation approaches, has been unsuccessful in improving her symptoms over the years. The
patient fully understands the risks involved and has provided informed consent. Given her
desire for a definitive surgical intervention and lack of future fertility plans, the removal of the
uterus is also recommended due to the suspected presence of adenomyosis.

PROCEDURE: The patient was brought to the operating room where general anesthesia was
obtained and found to be adequate. The patient was then placed in dorsal lithotomy position.
The pelvic and abdominal areas were prepped and draped in the usual sterile fashion. Attention
was turned to the pelvic area. Foley catheter was inserted into the bladder and a V-Care DX
uterine manipulator was inserted into the endometrial cavity for the means of manipulating the
uterus. Attention was turned to the patient's abdomen. On the left upper quadrant, an 8 mm
skin incision was performed. An 8 mm robotic trocar with the scope attached to it was inserted
under direct visualization into the abdominal cavity and pneumoperitoneum obtained without
difficulty. Then, on the umbilical area and right upper quadrant, two additional robotic trocars
were installed. We then proceeded with the TAP block procedure. Given the patient's history of
chronic pelvic pain the decision was made to proceed with a laparoscopic guided TAP block to
reduce postoperative pain and need for any narcotic. This was done as follows: The
laparoscopic camera was inserted again and on inspection of the abdomen, the anterior
abdominal wall was achieved. Then, 20 mL of Exparel was mixed with 40 mL of 0.25% Marcaine
and 20 mL of sterile saline. This was then injected and infiltrated into the left side of the
abdominal wall between the transversus abdominis and internal oblique muscle under direct
visualization of the laparoscope in 2 separate locations approximately 15 mL each. This was
repeated on the right side as well. The inspection of the areas of injection were noted to be
completely hemostatic. The patient was placed in steep Trendelenburg and the robot was
docked from the left-sided docking technique in the usual sterile fashion. Please note, the total
incisions of the patient's abdomen were 3. The size of each was 8 mm. There was no additional
assistant port. This included one robotic camera arm and two operative arms.

Attention was turned to the bilateral salpingectomy as follows: On the right side, the fimbria
was grasped and the mesosalpinx was coagulated aiming toward the uterus and then was
amputated. This was done bilaterally. After completion of the salpingectomy, the attention was
turned to the hysterectomy. On the right side, the right round ligament was coagulated and
dissected and then the utero-ovarian ligament was also coagulated and dissected and then the
broad ligament was sharply entered, and the anterior and posterior sheath of broad ligament
was separated and dissected towards the uterocervical junction. By reaching there, the bladder
was grasped, tented up, and uterovesical peritoneal flexion of the bladder was dissected and
bladder was pushed down toward the lower aspect of the vagina and pubo-cervical fascia was
well exposed. Then the right uterine vessel complex was well skeletonized with good
visualization of the right ureter. This large uterine vessel complex was coagulated using the
robotic vessel sealer and the same exact procedure was performed on the left side as well.
Good blanching of the uterus was then noted. We then proceeded with amputation of the
uterus from the cervical stump. First, the uterine manipulator was removed. Then, with the use
of a monopolar scissors, a circumferential dissection was performed with use of monopolar
scissors resulting in amputation of the uterus and bilateral tubes and ovaries from the surgical
stump. At this point, the cervix was well coagulated and good hemostasis was noted.
Endocervical canal was then coagulated with bipolar device.

Then, attention was turned to the patient's pelvic area. There was noted to be evidence of
diffuse peritoneal inflammation, neovascularization, and retraction of the peritoneum on
bilateral pelvic sidewall. The decision was made to proceed with excision of the peritoneum for
both biopsy and also to release the underlying hypogastric plexus nerve from this inflamed
peritoneum. Both pelvic sidewall peritoneum was dissected as follows: On the left side initially,
the retroperitoneal space was entered with a linear incision parallel and medial to the
infundibula-pelvic ligament. By entering the retroperitoneal space, the peritoneum was grasped
and tented medially, and then the peritoneum was dissected from the underlying connective
tissue and the underlying pelvic nerve was carefully dissected from the inflamed peritoneum.
This dissection was carried until the ureter was reached. Then, in order to secure the ureter,
given the retraction and deviation of the ureter from its normal anatomy secondary to the
dense inflammatory change on the peritoneum, in order to secure the ureter from future
damage and stricture given the possible involvement of the endometriosis, decision was made
to consider a left ureterolysis. The trajectory of the ureter was identified at the pelvic brim.
Retroperitoneal space above the ureter was entered. The ureter was then lateralized and
peritoneum was delicately separated from ureter moving toward the bladder distally, carefully
without damaging the vasculature of the ureter. By reaching near the hypogastric plexus, the
level of dense fibrosis was noted requiring extensive lysis of adhesion in order to release the
ureter from surrounding fibrosis. This was also more prominent at the level of the uterine
artery, at the caudal edge of pararectal space; however, we were able to safely separate the
ureter and restore its anatomical position and release it from all fibrotic retraction. the ureter
was completely secured and separated from the inflamed peritoneum. Then, we continued
with the peritoneal dissection to release the inflamed hypogastric nerve plexus that was
irritated due to its involvement with this severe peritoneal inflammation. We separated the
peritoneum from the underlying connective tissue and inferior hypogastric plexus, restoring the
nerve to no longer being harmed from the severely inflamed peritoneal tissue. Please note, the
inferior hypogastric plexus was completely involved with this severe inflammation. By releasing
the inflamed peritoneum from the underlying peritoneal sidewall, we reached to the level of
left uterosacral ligament caudally, and the level of the pelvic brim cephalad. This wide
peritoneal excision of peritoneum including all the endometriotic lesion was performed and
amputated from pelvic sidewall, and then profuse irrigation was performed, and excellent
hemostasis was achieved. After separating the inflamed peritoneum from underlying fibro-
connective tissue, then attention was turned to the inferior hypogastric plexus, there was noted
to be significant fibrosis and inflammatory change surrounding the nerve branch of the
hypogastric plexus. Therefore an extensive neurolysis was performed by separating all the
fibrosis from these small fiber unmyelinated nerves The attention was taken making sure there
was minimal damage to the nerve and the nerve was not transected during this extensive
neurolysis. This way all the fibrosis was separated with combination of blunt and sharp
dissection without use of any thermal energy and all branch of inferior hypogastric plexus was
well skeletonized all the way from their origin from the hypogastric nerve proximally toward
the smaller branch distally around the utero-sacral ligament and deep pelvic sidewall. More
specifically the nerve branch which was heading toward the bladder was well identified and
skeletonized with the similar technique. The same exact procedure was performed on the right
side,with the exception of ureterolysis which was not performed on the right. Attention was
turned to the right paravesical space. There was a nodule on the right paravesical space medial
to the right umbilical obliterated ligament. This nodule was grasped, pulled medially and with
the use of monopolar scissors the entire nodule, which was deeply penetrating to paravesical
space was dissected with a 5 mm margin around the lesion. This measured 1 x 2 cm and the full
nodule was removed from surrounding healthier paravesical adipose tissue without damaging
the bladder. All peritoneal wide excisional biopsies were sent to pathology. After completion of
excision of peritoneal sidewall, given the high suspicion about deeper involvement of the
inflammation and endometriosis, the decision was made to explore the pelvic sidewall further
and deeper, toward the pelvic floor. The patient symptoms consistent with pudendal neuralgia
and its related pelvic floor dysfunction, and given the severe tenderness of sacrospinous
ligament, obturator internus fascia, and trajectory of the pudendal nerve inside the alcock canal
I proceeded to exploration of pelvic floor muscle and ligaments for possible decompression of
pudendal nerve and vessels. Attention was turned toward exploration and decompression of
the left pudendal nerve. On the left pelvic sidewall, the superior vesical artery was identified,
and dissection was performed on the lateral aspect of the superior vesical artery, medial to
external iliac vein,with good visualization of the ureter. This space was entered, and the blunt
and sharp dissection was continued until the obturator nerve and vessels were reached. The
obturator nerve and vessels were released from surrounding lymph nodes and were found to
be completely intact from any endometriosis or fibrosis involvement. Then, in order to reach to
the ischial spine deeper dissection on medial aspect of the obturator vein was performed. By
dissecting further, we were able to reach the obturator internus muscle, and then we were able
to identify the arcus tendineus fascia of the pelvis that was reaching to the ischial spine. Ischial
spine was identified, and there was a small amount of fat herniation at the arcus tendineus
fascia of pelvis near the ischial spine, which was removed and released. Also, dense scar and
fibrosis was noted on the left sciatica, which was all released with the use of scissors without
use of any electrocautery. Then attention was turned to transection of the sacrospinous
ligament since the entrapment of the nerve was suspected to be caused partially by the
ligament. Initially the coccygeus muscle fiber was dissected off the ligament, and the
sacrospinous ligament was well exposed. The cephalad edge of the ligament was entered
gently. the pudendal nerve then identified crossing under the sacrospinous ligament. The
dissection of the sacrospinous ligament at the level of its attachment to the ischial spine was
performed. The full thickness of the ligament was transected providing significant release on
the pudendal nerve. neurolysis was performed around the pudendal nerve and vasculators,
prior to their entry to the lesser sciatica foramen. Exploration of right obturator space was
performed with the exact same technique as described above. On the right side, only lysis of
adhesions around the trajectory the greater sciatic foramen lesser sciatic foramen was
performed. There was no need for transection of the ligament. Then, attention was turned to
the procedure of paravaginal repair, and urethropexy. The bilateral obturator spaces were
previously exposed as described above. On the right pelvic sidewall, by reaching to the levator
muscles, the fascia of the obturator internus muscle was identified and also the attachment of
the levator muscles was identified. Then on the right side, the loose foamy Space Attaching the
vagina medially to the levator muscle laterally was bluntly entered and this dissection was
continued till the deep perineal pouch and then paraurethral space was reached. The assistant
surgeon, by pushing her finger around the mid urethral area, manipulating the paraurethral
space on the right side, helped me to well identify the Paraurethral space and defects from the
inside of the deep perineal pouch. pubocervical fascia around the uretha were well
skeletonized. Then, on the lateral wall, arcus tendineus pelvic fascia was well identified from its
origin attached to the pubic bone. Then the same dissection was performed on the left side as
well in similar fashion. On bilateral para-urethral and paravaginal space, a significant defect was
noted consistent with patient's urethral hypermobility and paravaginal defect. There was
evidence avulsion of levator muscle from its attachment to the arcus tendineus fascia on
bilateral sidewall which was more prominent on the right. Then given the evidence of severe
urethral hypermobility, the decision was made to reinforce the paraurethral fascia even further
despite of the previous attachment of paraurethral fascia to the bilateral arcus tendineus fascia.
The decision was made to add additional urethropexy vertically. Therefore, additional
permanent 0 V-Loc was used and on the right side the periurethral space was identified again.
The fascia was well exposed and a suture was applied to the fascia of the right paraurethral
fascia and the suture was then attached to the right Cooper's ligament with good visualization
of the obturator foramen to be at least 2 cm lateral to area of our suture application.
Approximately 3 suspensory attachment was performed, suspending the periurethral space on
the right side to the Cooper ligament vertically. This added additional support in addition to the
lateral support was previously provided by attachment to the right arcus tendineus fascia. The
exact same procedure was performed on the left side. Then attention was turned to the pelvic
area and pelvic exam was performed after putting on a sterile glove and a previous urethral
hypermobility and a paravaginal defect was noted to be completely elevated and resolved. The
same exact procedure was performed on the left side. Then cystoscopy was performed
immediately in order to assure that there was no damage to the urethra or bladder.
Urethroscopy was performed by introducing a 70-degree scope with a 21-gauge French
cystoscopy device into the urethra with active running of sterile water. The urethra was well
exposed and perfect inspection was performed on the entire length of the urethra and there
was absolutely no evidence of damage to the urethra. After performance of the urethroscopy,
the cystoscopy device was advanced into the bladder and the bladder was fully inspected and
there was absolutely no evidence of damage to the bladder and there was no suture erosion to
the bladder either. Given the previous ureterolysis, also attention was turned to both ureteral
orifices and bilateral ureteral efflux was noted with strong force. At this point, bladder was
drained. Cystoscopy was removed and Foley catheter was replaced. Attention was turned back
to the abdominal area and robotic console. Profuse irrigation and suction was performed and
the paravaginal area was then covered with Vistaseal fibrin material. At the end, the bilateral
paravesical peritoneal incisions, lateral to the superior vesical arteries bilaterally were
reapproximated with the use of 3-0 V-Loc in a running fashion. Excellent hemostasis was
achieved. At the end, for the purpose of repairing the inflammatory damage and fibrosis of the
bilateral hypogastric plexus cause by endometriosis, we proceeded with pelvic nerve repair
with the use of allograft. A large piece of Amniox Clarix biologic allograft (6x3 cm) was dissected
in 4 small strips and passed into the laparoscopic trocar into the pelvic area. A piece of Amniox
allograft was wrapped around bilateral hypogastric nerves. This was performed in order to
reduce inflammation, after complete resection of all inflamed peritoneum off of these
hyperexcited pelvic nerves. After attachment of Amniox to bilateral pelvic sidewall, the
VistaSeal coagulating material, was sprayed on the bilateral pelvic sidewalls for both hemostatic
purposes and also to create optimal adhesion between the previously placed Amniox graft and
the pelvic sidewall. This resulted in adequate fixation of this anti-inflammatory and adhesion
barrier material to the pelvic nerve. Excellent hemostasis was achieved. At this point, we
proceeded with extraction of the uterus and tubes from the abdominal cavity using the
minimally invasive approach as following: The robot was undocked, and laparoscopic scope was
inserted into the patient's abdomen and we proceeded with retrieval of the specimen as
follows: Our umbilical 8 mm trocar was removed, and the large bag was inserted under direct
visualization. The uterus and tubes were placed in the bag and the bag was withdrawn though
umbilicus incision. An Alexis retractor was applied to the umbilical area, and approximately a 2
cm incision was performed in the umbilicus and the specimen was completely bagged and
removed through the umbilical port without any difficulty. The specimen was then cut in piece
manually, with the use of scalpel in totally contained technique. The umbilical fascial incision
was reapproximated with 0-Vicryl in a running fashion and the umbilical incision was
reapproximated with 4-0 Monocryl in a subcuticular running fashion and then dressing was
applied to the umbilicus. Then the laparoscopic camera was inserted again, and a second-look
laparoscopic view was performed. Again, profuse irrigation and suctioning were performed.
Excellent hemostasis was achieved. Excellent ureteral peristalsis was noted constantly during
the entire case. At this point pneumoperitoneum was evacuated. All the laparoscopic ports
were removed. The 3 skin incisions were closed with use of #4-0 Monocryl in subcuticular
interrupted fashion. The skin was covered with Dermabond. At this point the Foley catheter
was removed and the bladder was drained. The patient received 2 grams of Ancef and 500 mg
of Flagyl at the beginning of the procedure. Sponge, lap and needle counts were correct x2. The
patient tolerated the procedure well.

DESCRIPTION OF PROCEDURE: A three port robot docking was performed. Initially, lysis of
adhesions around the tubes and ovary was performed and all filmy adhesion was released and
ovary was mobilized from its dense adhesion to the right pelvic sidewall and then on the right
side, right ureterolysis was performed, resection of pelvic sidewall was performed. On the left
side, same thing was performed; however, the urethrolysis was not performed. Hypogastric
nerve released. A cul-de-sac peritoneum was dissected and attention was turned to the deep
obturator space on the right side, deep adhesion was noted, which was all released from the
greater sciatic foramen. There was a dense inflammatory adipose tissue band of adhesion,
which was all released and this was sent to pathology. A full transection of right side was
performed, full of obturator fasciotomy was performed, AmnioFix graft was applied on the right
pudendal nerve and bilateral pelvic sidewall. The patient tolerated the procedure well.
Received 2 g of Ancef along with 500 mg of Flagyl.