Intraoperative Nerve Monitoring in Robotic-Assisted Resection Of Presacral Ganglioneuroma: Operative Technique

Background Robotic-assisted techniques have been implemented in the surgical treatment of tumors in the pelvis, abdomen, and thorax. In pelvic tumors, robotic-assisted techniques evade the need for sizable surgical exposure, but make stimulation of the nerves of the sacral plexus very difficult. Objective To describe how laparoscopic robotic-assisted surgery can couple with tools such as the nerve stimulator to aid in the resection of presacral masses emanating from the neural elements and potentially improve neurological outcome by preventing inadvertent injury to involved nerves. Methods A patient with a large presacral ganglioneuroma underwent resection using the DaVinci system (Intuitive Surgical, Sunnyvale, California) for robotic assistance. A nerve stimulator was coupled to the bipolar cautery instrument of the DaVinci robot to define the presence of functional nerves in the surroundings of the tumor. Results By coupling a nerve stimulator to the bipolar cautery instrument of the DaVinci robot (Intuitive Surgical), it was possible to identify important neural structures in close proximity to the tumor. After identifying functional nerves, the surgeon was able to preserve them and preserve neurological function avoiding motor dysfunction. Conclusion The use of a nerve stimulator coupled to the bipolar cautery instrument of the DaVinci robot (Intuitive Surgical) during laparoscopic, robotic-assisted surgery for resection of presacral masses is safe and feasible. In addition to the preoperative evaluation, intraoperative monitoring and stimulation of nerves in close proximity to the tumor and also exiting through neural foramina involved by the tumor allowed the surgeon to understand the anatomy and preserve neurological function while obtaining optimal surgical resection.