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Retroperitoneal surgery1
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.
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.
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 psoas muscle approach:
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.
Thanks
prof
morad k
hasanein