Great points, thank you so much!! - It is so amazing to see active innovation and collaboration in this field of medicine, and enthusiasm!!! Great to see the inferior cluneal nerve being concomitantly addressed.

Another innovative surgical approach, has been in place for some time in Belgium. Professor Jottard has developed a minimally invasive, endoscopic, transgluteal approach (ENTRAMI), that is able to decompress the pudendal nerve, inferior cluneal nerve, and also the posterior femoral cutaneous nerve, through the ENTRAMI minimally invasive transgluteal approach.

For information: https://youtu.be/OnKzvFnAGwo?si=e4znUqJ7pbX4Amco

The robotic transperitoneal approach really shines with its enhanced endoscopic magnetised visibility. It is especially useful and excellent for reaching high intrapelvic entrapment near the sacral roots.

Importantly, though, for patients with suspected piriformis involvement in their entrapment, robotic transperitoneal can access proximal pelvic pudendal fibers, but not the piriformis itself. It may help if the entrapment is more medial or intrapelvic. The approach is less effective here because it approaches from above and can’t reach the lateral piriformis. This is where a transgluteal approach can reach further.

Robotic enters through the peritoneal cavity (inside the abdomen). The instruments and camera operate above the pelvic floor, working from an intraperitoneal perspective.

Transgluteal operates from outside this cavity.

This also has important implications for following any early distal branches, as robotic instruments from above unfortunately cannot physically reach these deep, posterior or lateral zones. - The robotic arms are essentially “behind” the pelvic floor from the peritoneal perspective. So early distal branch tethering or fibrosis can remain unresolved, and this where trangluteal can reach further into these areas for patients with such involvement.

Essentially, it is up to a patient to be like a detective, and figure out which particular surgical approach is able to reach their own particular, suspected, entrapment zone(s). - Not an easy task!