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Retroperitoneal surgery
2
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 pararectal space
Boundaries:
Laterally by the levator ani,
medially by the rectum & rectal pillars,
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).
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.
Post
Lt
Rt
Anter
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.
The retroperitoneal space
may also be entered over
or lateral to the psoas
muscle.
Begin and stay medial to
the iliac vessels.
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