# Two-Step Parametrial Endometriosis Nodule Excision Using Virtual Reality Technology and 3D Modelling for Surgical Planning

## TL;DR

This paper describes using VR and 3D modeling to plan and perform a complex endometriosis surgery, resulting in improved outcomes and successful pregnancy.

## Contribution

The novel use of VR and 3D modeling for preoperative planning in deep endometriosis surgery is demonstrated.

## Key findings

- VR and 3D modeling enabled precise surgical planning for a complex endometriosis case.
- The two-step excision approach prevented injury to the ureter and rectum.
- The patient experienced significant pain reduction and became pregnant post-surgery.

## Abstract

Extensive and infiltrative fibrous adhesions of the uterus and ovaries to the surrounding organs make surgical interventions in endometriosis challenging. A preoperative identification of these involvements can help the surgeon better prepare for the surgery. Traditionally, ultrasonography and magnetic resonance imaging (MRI) have been used. However, clinical use of modern VR technology for creating and visualising a three-dimensional (3D) digital model for a complex surgical case has been proposed. We describe a case of a 29-year-old who presented with dyspareunia and dysmenorrhea (VAS score of 10/10) with left parametrial endometriosis and created a 3D model from their two-dimensional (2D) DICOM images. A left parametrial endometriosis nodule was identified involving the left ureter, rectum, and vaginal fornix along with mucosa. A virtual preoperative surgery was done for precise and complete excision of the disease and to prevent injury to the left ureter and rectum. The surgery was performed as a two-step excision using a da Vinci Xi robot and included left ureterolysis, shaving of the bowel endometriosis nodule and full-thickness vaginal wall excision along with the infiltrating nodule. The infiltrating endometriosis nodule was split into two halves and was excised individually. Her postoperative VAS score for dysmenorrhea was 2/10, and she is 28 weeks pregnant at the time of submission. Advanced VR imaging can help in the evaluation and management of deep endometriosis. It can improve the surgeon's understanding of the specific anatomy, visualise the disease, and improve clinical outcomes.