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Robotic Perforating Cutaneous Nerve Decompression

Robotic Perforating
Cutaneous Nerve
Decompression

Beyond Unexplained Buttock Pain—Identifying a Hidden Nerve Source

Chronic lower buttock pain is often attributed to musculoskeletal conditions or generalized sciatic nerve irritation. However, in many patients, the true source of pain originates from the perforating cutaneous nerve—a small but clinically significant sensory nerve that is frequently overlooked.

At our center, we specialize in robotic-assisted intrapelvic evaluation and decompression of the perforating cutaneous nerve, allowing precise identification and treatment of pathology at its origin and along its deep pelvic course.

Understanding the Nerve

What Is the Perforating Cutaneous Nerve?

The perforating cutaneous nerve arises from the sacral plexus (S2–S3) and travels through or around the sacrotuberous ligament, exiting into the lower gluteal region.

It provides sensation to:

The inferior gluteal (lower buttock) region
The skin overlying the lower aspect of the buttock

Due to its deep origin and small size, this nerve is rarely evaluated in standard clinical assessments.

Symptoms Why This Happens Why Standard Treatments Often Fail Our Surgical Approach

Symptoms

Patients with perforating cutaneous nerve involvement may experience:

Localized pain in the lower buttock region
Burning, sharp, or aching discomfort
Pain worsened by sitting
Focal tenderness near the inferior gluteal fold
Overlap with sciatic or posterior femoral cutaneous nerve symptoms

Because of symptom overlap, this condition is often misdiagnosed or untreated.

Why This Happens

Common causes include:

Pelvic neuroinflammation
Compression at the level of the sacrotuberous ligament
Fibrosis or adhesions in the greater sciatic region
Inflammatory adipose tissue encasing the nerve
Extension of endometriosis into the deep pelvic sidewall

In many cases, this nerve is involved as part of a broader lumbosacral plexus or deep gluteal syndrome.

Why Standard Treatments Often Fail

These treatments frequently fail because they:

Do not identify the specific nerve involved
Cannot access the nerve at its deep pelvic origin
Focus on symptoms rather than underlying pathology

External surgical approaches are limited and may not provide adequate visualization of the nerve’s origin or surrounding disease.

Our Surgical Approach

We utilize a robotic intrapelvic approach, allowing access to the perforating cutaneous nerve at its origin within the sacral plexus and greater sciatic region. This technique provides:

Safe entry into the retroperitoneal space
Identification of the sacral plexus branches
Visualization of the nerve as it courses toward the sacrotuberous ligament
Precise decompression under high-definition magnification

Seeing the Full Picture

Comprehensive Access to the
Greater Sciatic Region

A key advantage of this approach is the ability to achieve direct access and excellent visualization of the entire greater sciatic region, where the perforating cutaneous nerve originates and travels. This allows the surgeon to:

Identify the exact origin and course of the nerve
Detect fibrosis, adhesions, or inflammatory nodules
Perform targeted neurolysis with minimal disruption to surrounding structures

Importantly, this approach enables simultaneous evaluation and treatment of adjacent neural structures, including:

Posterior femoral cutaneous nerve
Sciatic nerve
Pudendal nerve
Inferior gluteal nerve
Superior gluteal nerve

In addition, the approach provides visibility to:

The broader lumbosacral plexus
Deep pelvic sidewall pathology
Endometriosis or inflammatory disease affecting the region

Conditions & Challenges

A Truly Comprehensive Neuroanatomical Approach

Unlike traditional approaches that focus on a single nerve or symptom, this technique allows:

Global assessment of pelvic and gluteal nerve networks

Identification of overlapping pain generators

Simultaneous treatment of multiple nerve pathways

Removal of underlying inflammatory or endometriotic pathology

The Surgical Journey

What to Expect

Minimally invasive robotic procedure

High precision with minimal blood loss

Typically outpatient or short hospital stay

Procedure duration varies based on complexity

The Healing Process

Recovery & Nerve Healing

Recovery is gradual:

Early symptom improvement may begin within weeks
Continued recovery over several months
Adjunct therapies may support nerve healing

Due to the minimally invasive nature of the approach, patients typically experience:

Less postoperative pain
Faster recovery compared to traditional approaches

Who is a candidate?

You may be a candidate if you have:

Persistent lower buttock pain
Pain worsened by sitting
Focal tenderness in the inferior gluteal region
Symptoms not explained by spine imaging
Failure of conservative treatment

Finding the Overlooked

The Key Difference

This nerve is often overlooked in traditional evaluation.
Our approach allows us to identify and treat even the smallest contributors to complex pelvic and gluteal pain.

FAQ

Everything You Need

to Know

Can I drive after surgery?

For patients undergoing minimally invasive, robotic-assisted procedures, it is recommended to wait 1 week before driving on your own.

Do I have to come back to the office after surgery?

Yes. Patients are required to return to the office 2 weeks after surgery for their first post-op visit and then return for their 2nd post op visit about 4 weeks later, unless otherwise directed by Dr. Shakiba.

Do I need antibiotics after surgery?

Patients will receive antibiotics during surgery and most patient do not require any antibiotics after procedure unless there is a specific condition, in you will be notified by Dr. Shakiba

Do I need to prep my bowel prior to surgery?

Usually bowel prep prior to any bowel surgery or endometriosis surgery is unnecessary. the patient will be notified for any exceptions.

How long will I be out of work for surgery?

Depending on the complexity of the surgery, patients can expect to be out of work somewhere between 2-4 weeks. In most cases, patients undergoing a laparoscopic procedure can expect to be out of work 2 weeks while others undergoing a robotic-assisted procedure are more likely to require 4 weeks out of work.

How will my bowel function be after surgery?

It is common for patients to encounter constipation after surgery, so we advise that the patient have a bowel movement one day prior to surgery and begin taking stool softeners, such as Colace, on day 1 after surgery. Patients are advised to continue taking stool softeners within 2-4 weeks unless bowel movements are loose enough that they are no longer needed.

For a rectocele repair or other pelvic reconstruction surgery, constipation is to be expected on day 3 after procedure and is sometimes painful. If patient continues to have difficulty with bowel movements after day 3, patient advised to take Milk of Magnesia.

I cannot tolerate narcotic pain medications. Will this be an issue during my recovery?

Although we routinely send Percocet during preoperative visits for pain management after the surgery, if you cannot tolerate narcotics this will not be an issue. Fortunately due to the minimal invasive approach Dr. Shakiba takes in most of his surgeries, the severity of post-operative pain as well as the amount of blood lost during surgery is minimalized.

Most of his patients find relief through OTC NSAIDS (i.e. Ibuprofen, Motrin) for the first few days after surgery and then no longer require any type of pain medication.

If I have a sling surgery, do I need a urinary catheter after the procedure at home?

Typically, after pelvic reconstructive surgery and urinary incontinence surgery with or without the use of mesh, a test will be done following the procedure to see if your bladder is ready to resume normal function. It is common that the bladder may not be ready to function and will require an additional day of rest. In this case, you will be sent home with a catheter for 1-2 days after procedure. This is temporary and we will instruct you how to remove the catheter at home by yourself. If you are still unable to void 4-5 hours after removal of the catheter, contact our office.

If I schedule an appointment, how long can I expect to be scheduled for surgery?

Our surgical coordinator does her absolute best to schedule surgeries on dates that are convenient to the patient. However, it is ultimately dependent upon the volume of surgeries Dr. Shakiba is facing at that time and the availability of the OR.

It is highly recommended that if you are expecting time off from work in the upcoming months, or have a specific time frame of which would be more convenient for you to undergo surgery to allow yourself to have necessary recovery time, to schedule your initial visit with Dr. Shakiba 2-3 months prior to the desired time frame.

This is because depending on the procedure, Dr. Shakiba may require you to undergo additional testing prior to surgery and you will also need medical clearance from your primary care physician. It does not always take 2-3 months to schedule a surgery, but there are times of the year where patients are more inclined to want to schedule surgery (i.e. the end of the year, summer, holiday season) so by getting in early, you would be optimizing your chances to get your desired date. Regarding surgery since we use the belly button for specimen removal, we ask the patient to please make sure you adequately wash belly button and make sure there is no debris.

Should I be concerned if I notice some spotting or bleeding after surgery?

Noticing small amount of blood after surgery is normal and should diminish over time. The bleeding can be managed with the use of pads or panty-liners avoiding the use of tampons unless otherwise noted from Dr. Shakiba. However, if you are experiencing a large amount of blood or notice passage of clots with the bleeding, you should call the office immediately for reevaluation.

What is the benefit of having my procedure performed robotically?

There are many benefits to robotic-assisted procedures. Some of the few include:

Shorter recovery time
Less blood loss
Less scarring
Short hospital stays
Less post-operative pain

Will I have a big scar after surgery?

Dr. Shakiba prefers to utilize a minimally invasive approach when performing surgery on his patients, which means no big scars going up and down or across your abdomen! For patients who are eligible to undergo the minimally invasive, robotic-assisted procedures, you can expect to have 3-5 small incisions on the abdomen, one of which is often placed inside the umbilicus making it unnoticeable. Each remaining incision measures no more than an inch and are virtually unnoticeable by 10 weeks post-operative time.

Robotic Perforating Cutaneous Nerve Decompression