Combined decompression of pudendal and inferior cluneal nerves for entrapment neuralgias using transperitoneal robotic laparoscopy: feasibility and our 4 steps technique.

OBJECTIVE: To demonstrate the feasibility of a combined decompression of pudendal and inferior cluneal nerves for entrapment syndrome using a transperitoneal robotic laparoscopy.

DESIGN: Demonstration of our 4 steps technique with narrated video footage.

SETTING: Pudendal and inferior cluneal neuralgias caused by an entrapment syndrome are both responsible for perineal pain (1). Although more precise data are lacking, these two neuralgias are frequently associated. Failure of surgical pudendal nerve decompression in the early 2000 has driven to discover the entity of a potential entrapment syndrome of the posterior cutaneous nerve of the tight and its inferior cluneal branches between the ischium bone and the sacrotuberous ligament (2). The corresponding neuralgia is responsible for a neuropathic pain to a more posterior part of the perineum and the thigh, without any neuro-vegetative symptom. In case of failure of medical treatment, surgery can be proposed using an invasive open trans-gluteal approach as a standard treatment (3-5).

INTERVENTIONS: Transperitoneal robotic laparoscopy for a mini-invasive releasing of both pudendal and inferior cluneal nerves, following a 4 steps technique: 1. Opening of the peritoneum between external iliac vessels and umbilical ligament 2. Dissection of the internal iliac and pudendal arteries up to the pudendal nerve 3. Section of sacrospinous ligament and release of pudendal nerve 4. Section of sacrotuberous ligament and release of inferior cluneal nerve.

CONCLUSION: Previously, pudendal and inferior cluneal neuralgias have been managed with an invasive open trans-gluteal surgery. Here, we demonstrate the feasibility of a mini-invasive transperitoneal robotic laparoscopy, with a standardized 4 steps surgical technique.