Laparoconversion for hemostasis during robotic surgery for complex deep endometriosis of sacral plexus and sciatic nerve does not avoid coming back to gasless robotic procedure.

Objective: To show that the laparoconversion in emergency due to intraoperative complications does not require to irreversibly abandon the robotic procedure.

Setting: Tertiary referral center PARTICIPANTS: A young patient with deep endometriosis involving the low rectum, both ureters with right hydronephrosis, the right sacral plexus and sciatic nerve, who underwent previous excision attempt 4 years earlier.

Intervention: The film summarizes a 10h complex surgical procedure of robotic excision of deep endometriosis. During the excision of the parametrial nodule (1) we injured a right sacral vein leading to severe hemorhage. Hemostasis attempts (2) were unsuccessful with the loss of 900 ml of blood during 10 minutes. The laparoconversion by median sub umbilical incision was carried out in emergency and the hemorrhage was stopped by vein ligation. However, the dissection of sacral plexus and sciatic nerve by open surgery appeared to be challenging, due to the low visibility of anatomical structures behind the deep nodule of the parametrium. We decided to go back to gasless robotic surgery, thanks to the strengths of the 4 robotic arms which could efficiently suspend the abdominal wall. The surgery ended by rectal resection with coloanal anastomosis (3) and reimplantaton of the ureter. Nine months after the surgery, the patient is pain free and completely satisfied by outcomes, with complete bladder voiding, no deep dyspareunia and satisfactory bowel movements.

Conclusion: The laparoconversion in emergency, due to severe hemorrhage or other intraoperative complication, does not require to irreversibly abandon the robotic procedure, particularly in cases where the open approach does not offer comparable visibility, precision or technical accuracy. Despite the opening of the abdomen and complete loss of the pneumoperitoneum, the robotic procedure may be successfully carried out in a gasless manner, thanks to the suspension of the abdominal wall by the strong robotic arms.