Robot-Assisted Vaginal Natural Orifice Transluminal Endoscopic Surgery for Frozen Pelvis

Study Objective: To show feasibility and techniques used to perform a total hysterectomy, bilateral salpingectomy, endometriosis resection, and ovarian reconstruction in a patient with a frozen pelvis secondary to a history of ruptured tubo-ovarian abscess. Design: Narrated step-by-step video demonstration. Setting: Single academic institution. Interventions: In patients with a history of multiple abdominal surgeries, abdominal mesh, or in the case of this patient, a history of a ruptured tubo-ovarian abscess, a vaginal approach may be safer. Immediate access to the uterine pedicles through the vagina bypasses the need for extensive enterolysis and adhesiolysis when compared to an abdominal approach. With the use of indocyanine green injected into bilateral ureters, we highlight the benefits of immediate identification of the ureters allowing for safer and more efficient dissection. We show rotational uterine maneuvers to aid in rectosigmoid-toposterior-uterus dissection in a limited space due to dense pelvic adhesions. Lastly, we demonstrate ovarian reconstruction and oophoropexy for the purpose of easier ovarian identification in future surgeries to possibly reduce the risks of ovarian remnant syndrome. Conclusion: This video highlights the feasibility and strategies used to perform robot-assisted vaginal natural orifice transluminal endoscopic surgery on a patient with a frozen pelvis.