Retroperitoneal surgeryRetroperitoneal surgeryBy By

Dr. Khattab Omar, MDDr. Khattab Omar, MD

Prof. & Head of Obstetrics and Gynaecology Prof. & Head of Obstetrics and Gynaecology Department Department

Faculty of Medicine, Al-Azhar University, Faculty of Medicine, Al-Azhar University, DamiettaDamietta

IntroductionRetroperitoneal space of the true pelvis differs from retro-peritoneal areas elsewhere in the abdomen by the presence of the sub-peritoneal areolar (cellular) connective tissue.

We can recognize about 6 We can recognize about 6 retroperitoneal spaces. retroperitoneal spaces.

Cardinal lig

The subperitoneal area of the pelvis is partitioned

into potential spaces by the various organs & their re-

spective fascial coverings, and by the selective thick-

enings of the endopelvic fascia into ligaments and

septa.

Vesical fascia

Cut edge of the peritoneum

Vesicovaginal lig. & space

1- Malignancy & Lymphadenectomy. 1- Malignancy & Lymphadenectomy. 2- Endometriosis. 2- Endometriosis. 3- Chronic PID. 3- Chronic PID. 4- Tubo-ovarian abscess. 4- Tubo-ovarian abscess. 5- Large or interligamentous myoma 5- Large or interligamentous myoma 6- Complications in post-hysterect. 6- Complications in post-hysterect.

reserved ovaries. reserved ovaries. 7- Hypogastric artery ligation. 7- Hypogastric artery ligation.

8-Vaginally-inaccessible urinary fistula 8-Vaginally-inaccessible urinary fistula 9- Colpopexy.9- Colpopexy.10- Laparoscopic hysterectomy. 10- Laparoscopic hysterectomy.

Indications for development of retroperitoneal surgical approaches

1- The paravesical space: 1- The paravesical space:

It is limitedIt is limited

laterallylaterally by the obturator internus and levator ani Ms, by the obturator internus and levator ani Ms,

mediallymedially by the bladder pillars, by the bladder pillars,

inferiorlyinferiorly by the endopelvic fascia, by the endopelvic fascia,

superiorlysuperiorly by the lateral umbilical ligament, by the lateral umbilical ligament,

and and posteriorlyposteriorly by the uterine artery. by the uterine artery.

This space can be developed This space can be developed by dissecting between by dissecting between thethe external iliacexternal iliac vessels and the vessels and the anterior division of the anterior division of the internal iliacinternal iliac artery (precisely, artery (precisely, the superior vesical artery) the superior vesical artery) lateral to the bladder. lateral to the bladder.

StepsSteps

First, exposeFirst, expose the external iliac the external iliac vessels vessels anteriorly near their anteriorly near their entrance into the femoral canal entrance into the femoral canal by dividing the by dividing the round ligamentround ligament near the deep inguinal ring. near the deep inguinal ring.

Note where the Note where the circumflex iliac circumflex iliac vein crosses the external iliac vein crosses the external iliac arteryartery. The anterior division of . The anterior division of the internal iliac arterythe internal iliac artery lies just lies just medial. medial.

Cut round ligament

going through the deep inguinal ring

LaparoscopicallyLaparoscopically

The space can be developed The space can be developed laparoscopically, but in laparoscopically, but in different steps. different steps.

Developing the space Developing the space laterallateral to the obliterated to the obliterated umbilicalumbilical artery. artery. Note direction of the pull exerted through the dissecting Note direction of the pull exerted through the dissecting forceps (arrow)forceps (arrow)

Developing the space Developing the space medialmedial to the obliterated to the obliterated umbilicalumbilical artery. artery. Note direction of the pull exerted through the dissecting Note direction of the pull exerted through the dissecting forceps (arrow)forceps (arrow)

Surgical importance Surgical importance

On the lateral side of the para-On the lateral side of the para-vesical space lies the obturator vesical space lies the obturator fossa containing blood vessels, fossa containing blood vessels, nerve and lymph nodes. nerve and lymph nodes.

Blunt dissection following the in-Blunt dissection following the in-ward pelvic slope can be continu-ward pelvic slope can be continu-ed to the pelvic diaphragm. ed to the pelvic diaphragm.

GSI can be attributed to disruption of muscle and fascia of the proximal urethra bladder neck hyper-mobility (midline defect). The pubo-cervical 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: 2- The pararectal space: Boundaries: Boundaries:

LaterallyLaterally by the levator ani, by the levator ani,

mediallymedially by the rectal pillars, and by the rectal pillars, and

posteriorlyposteriorly above the ischial spine by the above the ischial spine by the anterolateral aspect of the sacrum.anterolateral aspect of the sacrum.

Anteriorly and superiorlyAnteriorly and superiorly

peripheral part of the cardinal ligament and the peripheral part of the cardinal ligament and the uterine artery divide the paravesical & the uterine artery divide the paravesical & the

pararectal spaces.pararectal spaces.

StepsSteps To best develop the pararectal space, To best develop the pararectal space,

dissect between the first portion of the dissect between the first portion of the anterior division of the internal iliac artery anterior division of the internal iliac artery laterally and the ureter medially. laterally and the ureter medially.

The uterosacral ligament and the ureter are The uterosacral ligament and the ureter are located very near to each other between located very near to each other between the rectovaginal and pararectal spaces. the rectovaginal and pararectal spaces.

Remain close to the rectum to avoid the Remain close to the rectum to avoid the internal iliac vein and its side wall internal iliac vein and its side wall tributaries. Bleeding from these veins tributaries. Bleeding from these veins might kill the patient. might kill the patient.

Laparoscopically Laparoscopically

Developing the pararectal space laparoscopically; dissecting Developing the pararectal space laparoscopically; dissecting behind the uterine artery. behind the uterine artery.

Laparoscopically Laparoscopically

The uterine artery and the round ligament are divided and the The uterine artery and the round ligament are divided and the incision is extended along the anterior broad ligament and incision is extended along the anterior broad ligament and bladder peritoneum.bladder peritoneum.

The infundibulopelvic ligament has been divided and the ureter is The infundibulopelvic ligament has been divided and the ureter is displaced laterally to extend the peritoneal incision from the broad displaced laterally to extend the peritoneal incision from the broad ligament to just below the uterosacral ligaments. The peritoneum ligament to just below the uterosacral ligaments. The peritoneum is separated from the uterosacral ligaments, and the peritoneal is separated from the uterosacral ligaments, and the peritoneal incision is continued along the posterior cul-de-sac.incision is continued along the posterior cul-de-sac.

The uterosacral ligaments are coagulated and divided (inset). The uterosacral ligaments are coagulated and divided (inset).

3- The vesicovaginal space:3- The vesicovaginal space: Incise the vesicouterine Incise the vesicouterine peritoneal fold transversely. peritoneal fold transversely. Push the bladder down bluntly Push the bladder down bluntly or by sharp dissection. Moist or by sharp dissection. Moist gauze packing usually gauze packing usually controls any encountered slow controls any encountered slow venous bleeding. venous bleeding.

A common error is to dissect A common error is to dissect too close to the cervix and fail too close to the cervix and fail to get into the proper plane. to get into the proper plane.

Developing this space gives Developing this space gives access to the vesicouterine access to the vesicouterine ligament which contains ligament which contains the ureter as it passes to the ureter as it passes to the bladder. the bladder.

Developing this space gives Developing this space gives access to vesicovaginal access to vesicovaginal fistula & cervical fibriod. fistula & cervical fibriod.

4- The rectovaginal space (plane) 4- The rectovaginal space (plane) It extends from the Douglas pouch to the It extends from the Douglas pouch to the

perineal body. perineal body.

It is bounded It is bounded

anteriorlyanteriorly by the rectovaginal septum by the rectovaginal septum (firmly adherent to the vagina), and (firmly adherent to the vagina), and

posteriorlyposteriorly by the anterior rectal wall. by the anterior rectal wall.

Rectocele often results from a defect or Rectocele often results from a defect or avulsion of the septum from the avulsion of the septum from the perineal body.perineal body.

How to develop?How to develop?

Incise the peritoneum between the Incise the peritoneum between the insertion of the 2 uterosacral lig. insertion of the 2 uterosacral lig.

Bluntly dissect the vagina from the Bluntly dissect the vagina from the rectum by sweeping the palm rectum by sweeping the palm along the posterior vaginal wall. along the posterior vaginal wall.

For adherent areas, sharp dissection For adherent areas, sharp dissection against the vagina is used. against the vagina is used.

-Rectocele often results from -Rectocele often results from a defect or avulsion of the a defect or avulsion of the septum from the perineal septum from the perineal body.body.

-Enterocele -congenital type- -Enterocele -congenital type- results from maldevelop-results from maldevelop-ment of the rectovaginal ment of the rectovaginal septum. septum.

The vesicovaginal and The vesicovaginal and rectovaginal spaces may rectovaginal spaces may be considerably altered. be considerably altered.

In such instances, In such instances, developing the paravesical developing the paravesical and the pararectal spaces and the pararectal spaces first is very helpful. first is very helpful.

5- The presacral space:5- The presacral space:

This space can be developed by gently This space can be developed by gently incisingincising the overlying parietal the overlying parietal peritoneumperitoneum. .

The sigmoid colon is shifted to the left. The sigmoid colon is shifted to the left.

Inside this space, encased in fat, is the Inside this space, encased in fat, is the sympathetic nerve plexus (the presacral sympathetic nerve plexus (the presacral nerve) in addition to the middle sacral nerve) in addition to the middle sacral artery and vein. artery and vein.

Frog-legFrog-leg position position . .

The handle of a retractor is The handle of a retractor is placed into the vaginaplaced into the vagina

The small intestines are The small intestines are packed superiorly and the packed superiorly and the sigmoid colon is retracted sigmoid colon is retracted aside using a aside using a spongesponge forceps forceps . .

Sacral colpopexy

The The apexapex of the vagina is of the vagina is graspedgrasped in the midline in the midline and the and the serosaserosal covering l covering is is denudeddenuded while the while the vaginal vaginal retractorretractor is is pushedpushed up up . .

Then, the scissors are Then, the scissors are used to used to undermineundermine the the serosaserosa . .

The The peritoneumperitoneum covering covering S2-3S2-3 is is graspedgrasped and and incisedincised . .

The scissors are used to The scissors are used to undermineundermine and and inciseincise the the peritoneum progressively until peritoneum progressively until the vaginal apex is reachedthe vaginal apex is reached . .

Denudation of the vaginal apex against handle of the vaginal retractor. Denudation of the vaginal apex against handle of the vaginal retractor. The sigmoid colon is retracted aside using sponge forcepsThe sigmoid colon is retracted aside using sponge forceps..

  

A peanut sponge is used to carefully A peanut sponge is used to carefully expose expose the middle sacral ligamentthe middle sacral ligament all all the while searching for the middle the while searching for the middle sacral artery and veins so as not to sacral artery and veins so as not to traumatise themtraumatise them . .

The glistening white ligament is The glistening white ligament is exposedexposed for 2 cm for 2 cm . .

A merselene tape is passed from the A merselene tape is passed from the vaginal vault retroperitoneally to vaginal vault retroperitoneally to appear just medial to the sigmoid appear just medial to the sigmoid mesocolonmesocolon . .

A right similar loop is taken and both A right similar loop is taken and both are fixed in the mid pieceare fixed in the mid piece of the of the sacrumsacrum

6- The prevesical space.6- The prevesical space.Actually this is an Actually this is an extra-extra-peritonealperitoneal, rather than, a , rather than, a retroperitoneal space. retroperitoneal space.

It can be developed by gently It can be developed by gently dissectingdissecting the areolar tissue the areolar tissue immediately posterior to the immediately posterior to the symphysis pubis.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 approachThe round ligament approach

Placing a retractor near to the round Placing a retractor near to the round ligament provides upward traction on it. ligament provides upward traction on it.

The ligament is then picked up & transfixed.The ligament is then picked up & transfixed.

The broad lig. should be incised sharply in its The broad lig. should be incised sharply in its lateral portion overlying the psoas Ms.lateral portion overlying the psoas Ms.

The peritoneum can then be incised cephalad The peritoneum can then be incised cephalad lateral and parallel to the ovarian vessels. lateral and parallel to the ovarian vessels.

This is followed by sharp & blunt dissection. This is followed by sharp & blunt dissection.

The initial dissection should be bounded by The initial dissection should be bounded by the posterior leaflet of the broad ligament the posterior leaflet of the broad ligament & the ureter medially (the ureter attaches & the ureter medially (the ureter attaches to the broad lig. peritoneum) and the iliac to the broad lig. peritoneum) and the iliac vessels and the pelvic side wall laterally. vessels and the pelvic side wall laterally.

The paracolic approachThe paracolic approach

It is useful when the It is useful when the pelvic anatomy is pelvic anatomy is severely distorted severely distorted and the round lig not and the round lig not easily identified, or if easily identified, or if the pelvis is occupied the pelvis is occupied with a mass.with a mass.

The paracolic peritoneum The paracolic peritoneum is elevated and incised. is elevated and incised.

The incision begins over The incision begins over the psoas muscle lateral the psoas muscle lateral to the ureter and ovarian to the ureter and ovarian vessels. vessels.

This is followed by combined sharp This is followed by combined sharp and blunt dissection to mobilize and blunt dissection to mobilize medially the coecum or sigmoid medially the coecum or sigmoid colon, or to visual-ize the ureters. colon, or to visual-ize the ureters.

Dissection is continued down into Dissection is continued down into the pelvis using the ureter as the the pelvis using the ureter as the landmark (ureteric cath-eter ± landmark (ureteric cath-eter ± inserted) around which both the inserted) around which both the ovarian and the iliac vessels may ovarian and the iliac vessels may be identified. be identified.

The incision begins over the psoas muscle lateral to the ureter and ovarian vessels. The incision begins over the psoas muscle lateral to the ureter and ovarian vessels.

Post

Anter

RtLt

The retroperitoneal space The retroperitoneal space may also be entered over may also be entered over or lateral to the psoas or lateral to the psoas muscle. muscle.

Begin and stay Begin and stay medial to medial to the iliac vesselsthe iliac vessels. .

Opening the pelvic sidewall triangles:Opening the pelvic sidewall triangles:

The uterus is deviated to one side to de-The uterus is deviated to one side to de-lineate the triangle in the opposite wall. lineate the triangle in the opposite wall.

The The basebase of the triangle is the round lig., of the triangle is the round lig., the the lateral border lateral border is the external iliac a., is the external iliac a., the the medial bordermedial border is the infundibulopelvic is the infundibulopelvic lig, and the lig, and the apexapex is where the infundibul- is where the infundibul- opelvic ligament crosses the common opelvic ligament crosses the common iliac artery. iliac artery.

The peritoneum in the middle of the triangle is The peritoneum in the middle of the triangle is incised and the broad lig is opened by bluntly incised and the broad lig is opened by bluntly separating the extraperitoneal areolar tissue.separating the extraperitoneal areolar tissue.

Even tiny vessels should be coagulated. Even tiny vessels should be coagulated.

The incision is extended to the round ligament The incision is extended to the round ligament which is not divided at this time and then to which is not divided at this time and then to the apex of the triangle lateral to the the apex of the triangle lateral to the infundibulopelvic ligament. infundibulopelvic ligament.

The paravesical space is opened and the infundibulopelvic ligament is pulled medially.

Conclusion Conclusion

Retroperitoneal approaches might be the Retroperitoneal approaches might be the magic key to navigate through the magic key to navigate through the darkness of frozen or severely distorted darkness of frozen or severely distorted pelvis. pelvis.

Retroperitoneal navigation should be con-Retroperitoneal navigation should be con-ducted very cautiously to avoid injury to ducted very cautiously to avoid injury to important structures, particularly veins. important structures, particularly veins.

Thanks profThanks prof

morad k hasanein morad k hasanein