Robot-assisted exploration of somatic nerves in the pelvis and transection of the sacrospinous ligament for Alcock canal syndrome

ABSTRACT Study Objective Some articles have reported the surgical management of Alcock canal syndrome (ACS) using the transperineal [1] , transgluteal [2] , or conventional laparoscopic approach [ 3 , 4 ]. In 2015, Rey and Oderda [5] reported the first robotic neurolysis of the pudendum, providing the advantages of robot-assisted surgery: magnified and 3-dimensional vision and greater precision of movements. However, to our knowledge, there have been no reports on the use of a robotic platform for the treatment of ACS in the field of gynecology. Therefore, the objective of this video is to describe the anatomic and technical highlights of robotic exploration of the somatic nerves in the pelvis and transection of the sacrospinous ligament (nerve decompression) for ACS. Design Stepwise demonstration of the technique with narrated video footage. Setting An urban general hospital. A 48-year-old woman who had no previous surgical history was referred for severe pain when sitting, cyclic pelvic pain, and gluteal and perineal pain, all of which were resistant to medication therapy. Her pain radiated to the posterior aspect of the thigh. Before coming to our hospital, she visited an orthopedic surgeon a few years earlier and was diagnosed with sciatic neuralgia. Magnetic resonance imaging revealed adenomyosis with neither deep endometriosis nor vascular entrapment. On the basis of neuropelveologic evaluation, the patient was suspected to be suffering from ACS owing to compression of the pudendal nerve and the posterior cutaneous nerve of the thigh by the sacrospinous ligament. Interventions The procedure was performed using the following 9 steps while referencing the laparoscopic neuronavigation technique [6] : step 1, opening the peritoneum along the external iliac artery; step 2, exposure of the external iliac artery; step 3, development of the lumbosacral space; step 4, identification of the lumbosacral trunk; step 5, identification of the superior gluteal nerve; step 6, identification of the sciatic nerve; step 7, identification of the inferior gluteal nerve; step 8, identification of the pudendal nerve; and step 9, transection of the sacrospinous ligament. The surgery was completed successfully without any complications, and the postoperative course was uneventful. We considered that there was no relationship between the ACS and endometriosis. The patient reported that her pain decreased gradually at postoperative month 1 and month 3, and finally the neuralgia was completely resolved at month 6. Neuropelveologic evaluation still continues every 6 months. Conclusion Robot-assisted transection of the sacrospinous ligament is a feasible, safe technique for selected patients with ACS. Exploration of the pelvic nerves should be performed for further diagnosis and therapy before prematurely labeling the patient as refractory to the treatment [7] .