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Retroperitoneal surgery
3
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
Indications for development of
retroperitoneal surgical approaches
12345-
Malignancy & Lymphadenectomy.
Endometriosis.
Chronic PID.
Tubo-ovarian abscess.
Complications in post-hysterect.
reserved ovaries.
6- Hypogastric artery ligation.
7- Large, cervical, ligamentous myoma
8-Vaginally-inaccessible urinary fistula
9- Colpopexy.
10- Laparoscopic hysterectomy.
The vesicovaginal & the
rectovaginal spaces
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
Surgical
importance
- 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 fibroid.
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.
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.
Surgical
importance
-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.
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 lateral psoas 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