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Retroperitoneal surgery
By
Dr. Khattab Omar, MD
Prof. & Head of Obstetrics and Gynaecology Department
Faculty of Medicine, Al-Azhar University, Damietta
Introduction
Retroperitoneal space of the
true pelvis differs from retroperitoneal areas elsewhere in
the abdomen by the presence
of the sub-peritoneal areolar
(cellular) connective tissue.
We can recognize about 6
retroperitoneal spaces.
Cardinal lig
The subperitoneal area of
the pelvis is partitioned
into potential spaces by the
various organs & their respective fascial coverings,
and by the selective thickenings of the endopelvic
fascia into ligaments and
septa.
Vesical fascia
Cut edge of the peritoneum
Vesicovaginal lig. & space
123456-
Indications for development of
retroperitoneal surgical approaches
Malignancy & Lymphadenectomy.
Endometriosis.
Chronic PID.
Tubo-ovarian abscess.
Large or interligamentous myoma
Complications in post-hysterect.
reserved ovaries.
7- Hypogastric artery ligation.
8-Vaginally-inaccessible urinary fistula
9- Colpopexy.
10- Laparoscopic hysterectomy.
1- The paravesical space:
It is limited
laterally by the obturator internus and levator ani Ms,
medially by the bladder pillars,
inferiorly by the endopelvic fascia,
superiorly by the lateral umbilical ligament,
and posteriorly by the uterine artery.
This space can be
developed by dissecting
between the external
iliac vessels and the
anterior division of the
internal iliac artery
(precisely, the superior
vesical artery) lateral to
the bladder.
Steps
First, expose the external iliac
vessels anteriorly near their
entrance into the femoral canal
by dividing the round ligament
near the deep inguinal ring.
Note where the circumflex iliac
vein crosses the external iliac
artery. The anterior division of
the internal iliac artery lies just
medial.
Cut round ligament
going through the deep
inguinal ring
Laparoscopically
The space can be developed
laparoscopically, but in
different steps.
Developing the space lateral to the obliterated umbilical artery.
Note direction of the pull exerted through the dissecting
forceps (arrow)
Developing the space medial to the obliterated umbilical artery.
Note direction of the pull exerted through the dissecting
forceps (arrow)
Surgical importance
On the lateral side of the paravesical space lies the obturator
fossa containing blood vessels,
nerve and lymph nodes.
Blunt dissection following the inward pelvic slope can be continued to the pelvic diaphragm.
GSI can be attributed to disruption of
muscle and fascia of the proximal
urethra  bladder neck hypermobility (midline defect). The pubocervical fascia acts as a suspending
hammock for the bladder and
urethra.
The pravaginal fascia too plays an
important role (paravaginal defect is
the most common injury occurring
>75%-80% of the time).
Impaired support of the anterior
vaginal wall is associated with stress
incontinence and prolapse of the
anterior vaginal wall.
All bladder neck surgeries carry a risk
of postoperative detrusor instability
and long-term voiding difficulties.
All such techniques rely on creation of
a "compensatory abnormality“.
Ritchardson advised repair of the
paravaginal defect that was so
anatomic that it almost never
resulted in either short- or long-term
urinary retention, and the patients
remained continent over the time.
Right paravaginal defect (the vagina's antero-lateral
sulcus is avulsed away from the white line). The
obturator foramen is 1.5-2cm above the white line.
The defect is absent in the left side.
2- The pararectal space:
Boundaries:
Laterally by the levator ani,
medially by the rectal pillars, and
posteriorly above the ischial spine by the
anterolateral aspect of the sacrum.
Anteriorly and superiorly
peripheral part of the cardinal ligament and
the uterine artery divide the paravesical &
the pararectal spaces.
Steps
To best develop the pararectal space,
dissect between the first portion of the
anterior division of the internal iliac
artery laterally and the ureter medially.
The uterosacral ligament and the ureter
are located very near to each other
between the rectovaginal and pararectal
spaces.
Remain close to the rectum to avoid the
internal iliac vein and its side wall
tributaries. Bleeding from these veins
might kill the patient.
Laparoscopically
Developing the pararectal space laparoscopically; dissecting
behind the uterine artery.
Laparoscopically
The uterine artery and the round ligament are divided and the
incision is extended along the anterior broad ligament and
bladder peritoneum.
The infundibulopelvic ligament has been divided and the ureter is
displaced laterally to extend the peritoneal incision from the broad
ligament to just below the uterosacral ligaments. The peritoneum
is separated from the uterosacral ligaments, and the peritoneal
incision is continued along the posterior cul-de-sac.
The uterosacral ligaments are coagulated and divided (inset).
3- The vesicovaginal space:
Incise the vesicouterine
peritoneal fold transversely.
Push the bladder down bluntly
or by sharp dissection. Moist
gauze packing usually controls
any encountered slow venous
bleeding.
A common error is to dissect
too close to the cervix and fail
to get into the proper plane.
Developing this space gives
access to the vesicouterine
ligament which contains the
ureter as it passes to the
bladder.
Developing this space gives
access to vesicovaginal
fistula & cervical fibriod.
4- The rectovaginal space (plane)
It extends from the Douglas pouch to the
perineal body.
It is bounded
anteriorly by the rectovaginal septum
(firmly adherent to the vagina), and
posteriorly by the anterior rectal wall.
Rectocele often results from a defect or
avulsion of the septum from the
perineal body.
How to develop?
Incise the peritoneum between the
insertion of the 2 uterosacral lig.
Bluntly dissect the vagina from the
rectum by sweeping the palm
along the posterior vaginal wall.
For adherent areas, sharp dissection
against the vagina is used.
-Rectocele often results
from a defect or avulsion
of the septum from the
perineal body.
-Enterocele -congenital
type- results from
maldevelop-ment of the
The vesicovaginal and
rectovaginal spaces may
be considerably altered.
In such instances,
developing the paravesical
and the pararectal spaces
first is very helpful.
5- The presacral space:
This space can be developed by gently
incising the overlying parietal
peritoneum.
The sigmoid colon is shifted to the left.
Inside this space, encased in fat, is the
sympathetic nerve plexus (the presacral
nerve) in addition to the middle sacral
artery and vein.
Sacral colpopexy
Frog-leg position.
The handle of a retractor is
placed into the vagina
The small intestines are
packed superiorly and the
sigmoid colon is retracted
aside using a sponge
forceps.
The apex of the vagina is
grasped in the midline
and the serosal covering
is denuded while the
vaginal retractor is
pushed up.
Then, the scissors are
used to undermine the
serosa.
The peritoneum covering
S2-3 is grasped and
incised.
The scissors are used to
undermine and incise
the peritoneum
progressively until the
vaginal apex is reached.
Denudation of the vaginal apex against handle
of the vaginal retractor. The sigmoid colon is
retracted aside using sponge forceps.
A peanut sponge is used to carefully
expose the middle sacral ligament all
the while searching for the middle
sacral artery and veins so as not to
traumatise them.
The glistening white ligament is
exposed for 2 cm.
A merselene tape is passed from the
vaginal vault retroperitoneally to
appear just medial to the sigmoid
mesocolon.
A right similar loop is taken and both
are fixed in the mid piece of the sacrum
6- The prevesical space.
Actually this is an extraperitoneal, rather than, a
retroperitoneal space.
It can be developed by gently
dissecting the areolar tissue
immediately posterior to the
symphysis pubis.
Entering the retroperitoneum
- A preoperative IVU is recommended.
- In most cases, the round ligament
may be divided and the peritoneum
lateral to the infundibulopelvic
ligament incised without difficulty.
- With large masses or when the
anatomy is severely distorted, a
paracolic or lateral psoas approach is
required.
The round ligament approach
Placing a retractor near to the round
ligament provides upward traction on it.
The ligament is then picked up & transfixed.
The broad lig. should be incised sharply in
its lateral portion overlying the psoas Ms.
The peritoneum can then be incised
cephalad lateral and parallel to the
ovarian vessels.
This is followed by sharp & blunt dissection.
The initial dissection should be bounded by
the posterior leaflet of the broad ligament
& the ureter medially (the ureter attaches
to the broad lig. peritoneum) and the iliac
vessels and the pelvic side wall laterally.
The paracolic approach
It is useful when the
pelvic anatomy is
severely distorted
and the round lig not
easily identified, or if
the pelvis is occupied
with a mass.
The paracolic peritoneum
is elevated and incised.
The incision begins over
the psoas muscle lateral
to the ureter and ovarian
vessels.
This is followed by combined
sharp and blunt dissection to
mobilize medially the coecum
or sigmoid colon, or to visualize the ureters.
Dissection is continued down
into the pelvis using the ureter
as the landmark (ureteric catheter ± inserted) around which
both the ovarian and the iliac
vessels may be identified.
Post
Lt
Rt
Anter
The incision begins over the psoas muscle
lateral to the ureter and ovarian vessels.
The retroperitoneal space
may also be entered over
or lateral to the psoas
muscle.
Begin and stay medial to
the iliac vessels.
Opening the pelvic sidewall triangles:
The uterus is deviated to one side to delineate the triangle in the opposite wall.
The base of the triangle is the round lig.,
the lateral border is the external iliac a.,
the medial border is the infundibulopelvic
lig, and the apex is where the infundibulopelvic ligament crosses the common iliac
artery.
The peritoneum in the middle of the triangle is
incised and the broad lig is opened by bluntly
separating the extraperitoneal areolar tissue.
Even tiny vessels should be coagulated.
The incision is extended to the round ligament
which is not divided at this time and then to
the apex of the triangle lateral to the
infundibulopelvic ligament.
The paravesical space is opened and the infundibulopelvic ligament is
pulled medially.
Conclusion
Retroperitoneal approaches might be the
magic key to navigate through the
darkness of frozen or severely distorted
pelvis.
Retroperitoneal navigation should be conducted very cautiously to avoid injury to
important structures, particularly veins.
Thanks
prof
morad k
hasanein