Combined vNOTES and Robotic Excision of Large Endometriosis Nodule of Low Rectum, Vagina and Both Parametria (Left Side Extension to S3 Sacral Root).

Endometriosis nodules of the low rectum and vagina are a challenging localisation of deep infiltrating endometriosis. Various surgical approaches can be utilized to safely excise them. Our patient presented with a symptomatic rectovaginal endometriosis nodule with bilateral parametrial involvement and left-side extension to S3 sacral root. We performed and hereby describe the first, to the best of our knowledge, combined vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) and robotic approach for the excision of the aforementioned deep endometriosis nodule. The procedure lasted 4 hours and the blood loss was minimal. Post-operative voiding function was normal and the patient was discharged home on day 4. Recovery was uneventful. We found that this approach facilitated our dissection. We postulate that the "mirror" (vNOTES and robotic) dissection may reduce the risk of unnecessary excision of healthy vagina and extending the dissection laterally, therefore, potentially reducing the risk of post-operative voiding dysfunction. However, this needs to be balanced against the higher operative cost and need for 2 experienced surgeons operating at the same time.