16 GYNECOLOGY AUGUST 2010 • OB.GYN. NEWS MASTER CLASS Keys to the Obliterated Cul-de-Sac

lthough the best ap- ident of the AAGL and who is now the immediate past Shepherd is also completing her MBA at the Universi- proach to treatment of president of that organization. Dr. Pasic is professor of ty of Louisville. She is currently a member of the AAGL Athe obliterated cul-de- obstetrics and gynecology, the director of the section of and serves on the ad hoc review committee for the Jour- sac and excision of rectovaginal operative gynecologic endoscopy, and a codirector of the nal of Minimally Invasive Gynecology. endometriosis is surgical, this fellowship in laparoscopy and minimally invasive surgery Dr. Hudgens obtained his medical degree from the laparoscopic procedure can be at the department of ob.gyn. and women’s health at the University of Arkansas, Little Rock, in 2005. He com- a daunting task for even the University of Louisville (Ky.). pleted his residency training in ob.gyn. at the Universi- BY CHARLES E. most experienced minimally in- As the director of the postgraduate course on advanced ty of Louisville in 2009. Dr. Hudgens recently complet- MILLER, M.D. vasive gynecologic surgeon. laparoscopic anatomy, dissection, and reparative pelvic ed a fellowship in minimally invasive gynecology in 2010 The potential risk to the rec- surgery on unembalmed female cadavers, Dr. Pasic’s ex- and has joined the Center for Women’s Health at Owens- tum and ureter must be immediately recognized. It is pertise in anatomy and minimally invasive gynecologic boro Medical Health System in Owensboro, Ky. Dr. Hud- for this reason that Dr. Harry Reich, one of the leg- surgery makes him an excellent candidate to lead the dis- gens also is currently an active member of the AAGL and endary pioneers in minimally invasive gynecologic cussion of the systematic approach to the obliterated cul- serves as a member of the ad hoc review committee for surgery, stated over 20 years ago that dissection of the de-sac and excision of rectovaginal endometriosis. the Journal of Minimally Invasive Gynecology. ■ obliterated cul-de-sac and excision of deep rectovagi- Joining Dr. Pasic as coauthors for this Master Class nal endometriosis was the most difficult procedure in are Dr. Jessica A. Shepherd and Dr. Joseph L. Hudgens, DR. MILLER is clinical associate professor at the University of the gynecologist’s armamentarium. the current clinical fellows in the division of gyneco- Chicago and the University of Illinois at Chicago, and vice Obviously, the anatomy has remained unchanged, logic endoscopy at the University of Louisville. president of the International Society for Gynecologic but safety has been enhanced through the creation of a Dr. Shepherd obtained her medical degree from Endoscopy. He is a reproductive endocrinologist in private strategic approach for dealing with this unique surgical Ross University in Roseau, Dominica, in 2005 and then practice in Schaumburg, Ill., and Naperville, Ill.; the director dilemma. For this current issue of the Master Class in completed her internship and residency at Drexel Uni- of minimally invasive gynecologic surgery at Lutheran Gynecologic Surgery, I have called upon Dr. Resad Pa- versity in Philadelphia. In addition to her current in- General Hospital in Park Ridge, Ill.; and the medical editor of sic, who was my vice president during my tenure as pres- volvement as a fellow in gynecologic endoscopy, Dr. this column. He said he had no relevant conflicts of interest. Obliterated Cul-de-Sac Dissection

ndometriosis palpated on bimanual exam and can in- posed of spherical nodules. The largest di- ment, which provides a means of access Eaffects about volve uterosacral ligaments, the posteri- mension of these lesions is located under from the pararectal space into the recto- 2.5%-3.3% of re- or vaginal wall, the anterior rectal wall, the peritoneal fold of the rectouterine vaginal space. productive-aged and the posterior fornix. pouch of Douglas. The cranial movement women and is Preoperative imaging, especially trans- of these posterior fornix lesions eventual- Instrumentation and Process characterized by vaginal and transrectal ultrasound and ly causes the nodules to join the anterior Surgical management of DIE is essential extrauterine MRI, will establish the distribution and rectal wall and creates an “hourglass”-like for restoring pelvic anatomy, relieving BY RESAD PASIC, growth of en- depth of the deep lesions. appearance. Continued on following page M.D., PH.D. dometrial tissue The presence of deeply infiltrative en- consisting of en- dometriosis and the resulting alteration Anatomy dometrial glands and stroma. Its depth of normal anatomical planes make this It is important to appreciate the rela- ranges from superficial to deep infiltration. one of the most challenging surgical cas- tionships of the avascular spaces and When described as deep infiltrating es that gynecologists encounter. Laparo- their relevance to the dissection of the endometriosis (DIE), the disease scopic treatment requires an intimate un- obliterated cul-de-sac and excision of involves lesions that are invasive and derstanding and application of pelvic rectovaginal endometriosis. Also re- that extend into areas or organs that are anatomy, and the surgical fundamentals member that the ureter enters the pelvis in direct contact with already affected ar- of visualization and traction-counter- over the bifurcation of the common ili- eas. Although the theory of migration of traction, as well as electrosurgery. ac and medial to the infundibulopelvic endometrial glands may help to explain ligament (see photo below). The pararectal space is bordered by endometriosis in general and superficial Pathophysiology The pararectal space is bordered lat- the pelvic sidewall, the cardinal disease in particular, the prevailing opin- The presence of deep endometriotic erally by the pelvic sidewall, anterolat- ligament, and the rectal pillars. ion currently is that DIE may result lesions in the posterior cul-de-sac is, again, erally by the cardinal ligament, and me- from metaplasia of remnants of likely a consequence of metaplasia of dially by the rectal pillars. The ureter Müllerian tissue. Müllerian rests, and the nodules are com- courses beneath the peritoneum and DIE lesions penetrate greater than 5 posed of smooth muscle proliferation and through the rectal pillar. mm under the peritoneal surface and can fibrosis, which is a result of infiltration. The rectovaginal space is bordered lat- cause severe pelvic pain. The lesions are The endometriotic foci migrate to the erally by the uterosacral ligaments, an- mainly composed of smooth muscle rectovaginal area, where hyperplasia of teriorly by the vaginal fascia, and poste- with active glandular epithelium, which smooth muscle incites an inflammatory riorly by the rectal fascia. causes fibrosis and eventually their response; this evolves into retraction, The potential surgical space between nodular characteristics. which then leads to pelvic fibrosis and a the ureter and uterosacral ligament is uti- In cases in which the DIE lesions affect subsequent reduction in uterine mobili- lized to transect the uterosacral liga- The rectovaginal space is bordered by areas such as the rectovaginal space (as ty and distortion of the pelvic anatomy. the uterosacral ligaments, the vaginal well as the uterosacral ligaments and DIE lesions have been classified fascia, and the rectal fascia. the rectocervical area), treatment is more through studies by Dr. Philippe Koninckx successful with a surgical approach. and his colleagues into three types based

Although rectovaginal lesions are on their depth of invasion and location. ESAD eventually diagnosed through surgical Type I lesions are conically shaped rec- . R R methods, clinical examinations and imag- tovaginal septum nodules and are located D ing should be performed to support the between the posterior and anterior walls surgical approach. of the vaginal mucosa and rectal muscu- On medical history, many of these laris, respectively. Lesions categorized as patients present with pelvic pain, dys- type II are deeply located and form from The yellow-shaded region represents ASIC MAGES PROVIDED BY menorrhea, dyspareunia, or infertility. the posterior fornix to the rectovaginal re- the ureter, the blue represents the I P Clinical examination must be done to gion. They are typically covered by ex- infundibulopelvic ligament, and the The space between the ureter and help appreciate the location of the nodu- tensive adhesions causing retraction. The red represents the bifurcation of the uterosacral ligament is utilized to lar lesion. The size of the nodule may be most severe lesions—type III—are com- right common iliac artery. transect the uterosacral ligament. AUGUST 2010 • WWW.OBGYNNEWS.COM GYNECOLOGY 17

Continued from previous page comes the pelvic ureter. It continues on continuing along the original shape the pelvic sidewall medial to the in- (triangular) of the pouch of Douglas debilitating pelvic pain, and eliminating fundibulopelvic ligament as it crosses (see photo at bottom of column). endometriotic nodular foci. Laparo- the external iliac artery. Branches of the One might find that the nodule scopic surgery provides magnified views internal iliac artery supply the descend- extends into the pararectal fascia, the of the posterior cul-de-sac and its pathol- ing portion of the ureter and move along muscularis layer of the rectum, the pos- ogy, and results in less postoperative the course of the ureter from the lateral terior vagina, or the rectal wall. The rec- pain and decreased recurrence of aspect. tal probe is used to help delineate the adhesions. The dissection of the ureter begins at rectum from the remaining lesion. Such Instruments typically utilized during the pelvic brim where the anatomy is To transect the rectovaginal septum, lesions can often be dissected with sharp these procedures include monopolar normal. The peritoneum superior to the place the uterus on stretch in the scissors or may require excision with a scissors, bipolar coagulation, and the ureter is grasped and entered, and the in- anteverted position. The rectal probe Harmonic scalpel. Harmonic scalpel. cision is extended. Medial traction is is placed in the rectum and the Energy sources that provide the least placed on the inferior edge of the peri- uterosacral septum is identified and Reconstruction amount of lateral spread are key in these toneal incision, and dissection is contin- transected with the harmonic scalpel. The last step is the reconstruction of any procedures as the relationships of the structures that were compromised dur- pelvic organs, ureters, and rectum are the prerectal fascia (see photo above). ing the dissection. The patient is given IV exceptionally close. The rectovaginal septum extends lat- indigo carmine to ensure the ureters are The systematic approach of resecting erally from the posterior cervix and not compromised, and a cystoscopy is these nodules entails restoring the nor- uterosacral ligaments to the pelvic side- performed at the conclusion of the case mal anatomic relationships of the ad- wall, where it then courses caudally to to confirm function. The rectal wall in- nexa and sigmoid, then dissecting the insert in the perineal body. This area is tegrity is confirmed with the injection of obliterated cul-de-sac and performing a dissected inferiorly until the uterosacral dilute indigo carmine through an 18 thorough excision of the rectovaginal ligaments (also known as the medial rec- french foley catheter placed in the rec- endometriotic lesions. tal pillars) are identified. At this stage, the tum or via an air leak test performed We have divided the procedure into The right ureter is seen here on the ureter, the pararectal space, the lateral with the aide of a proctoscope. four parts: ureterolysis, dissection of the medial aspect of the peritoneum. rectal pillar with associated nerves, and Because the fibers of rectovaginal sep- rectovaginal septum, excision of the rec- Ureterolysis can be done bluntly with the medial rectal pillar are seen. The tum run vertically and blend with the tovaginal nodule, and reconstruction. the graspers and scissors, or with the rectal probe will then help identify the muscular wall of the vagina, some deep- When the ureters and bowel are in- Harmonic scalpel as shown here. rectum and the dissected uterosacral infiltrating lesions are part of the vaginal volved with the disease process, the sur- wall, and in these cases excision of the af- gical approach should take into account ued in the fat/nonfat interface until the fected area of the vagina is necessary. the importance of restoring normal ureter is identified. Once these lesions are fully resected, the anatomy. The use of uterine manipula- The ureter is surrounded by a layer of vagina is reattached to the cervix by tors with a colpotomy cup can help de- loose areolar tissue; this layer is entered means of an interrupted figure of eight lineate the posterior vaginal fornix and by using a blunt dissector to dissect par- suture, and the anterior rectal wall is also allel to the ureter. Small vessels should reinforced with sutures. The pneu- be coagulated in the process to ensure moperitoneum can be maintained by us- visibility. The ureterolysis is directed to- ing a blue suction bulb in the vagina. ward the uterosacral ligaments and con- Once the reconstruction is completed, tinued until the ureter enters the cardi- Transection of the uterosacral the restoration of the pelvic anatomy nal ligament (see photo above). ligament is done after ureterolysis is should be apparent and additional When complete obliteration of the completed. (Ureter is visible in the left attention should be paid to defects to cul- de-sac is present and the uterosacral upper portion; rectum is in lower right ensure proper closure. ligaments are obscured bilaterally, corner.) The surgical management of recto- ureterolysis is carried out on the oppo- vaginal endometriosis nodules can be Use of a rectal probe and vaginal site side to improve pelvic anatomic ligaments in their respective planes. technically demanding as it can include tenaculum allows for proper plane restoration. The dissection is sufficient The potential space medial to the the repair of the vagina, bowel, bladder, appreciation when dissecting lesions when both ureters are mobilized com- ureter is used to transect the uterosacral and ureters. A systematic approach and in the rectovaginal space. ligament and thus enter the rectovaginal adequate endoscopic experience, howev- space from the lateral aspect to medial. er, can significantly decrease the risk of in- the rectum. The introduction of rectal The uterosacral ligament is again tran- jury, Taking the time to perform the and vaginal probes during the surgery sected, and the rectovaginal space ureterolysis before the beginning of the will improve the exposition and excision entered (see photo above). case, moreover, is beneficial in providing of the lesions (see figure above). If the dissection is continued too landmarks and protecting the integrity of After pneumoperitoneum is estab- superiorly, the prerectal fascia is tran- the ureters. Although long-term experi- lished and maintained at 15 mm Hg, we sected and the vagina may be entered. If ence is forthcoming, the surgical inter- have used a standard technique of plac- this occurs, then the fascia is retracted vention of DIE has proven to be bene- ing a 10-mm trocar in the umbilicus for superiorly and the rectum is retracted ficial in the short term by decreasing the laparoscope and three 5-mm ancil- Bilateral ureterolysis is done before inferiorly to help identify the correct patients’ pain and improving their lary trocars. One 5-mm trocar is placed dissection of the rectovaginal septum. dissection plane. quality of lifestyle. ■ to the right at 10 cm lateral to the um- By understanding the anatomic princi- bilicus, and two 5-mm trocars are placed pletely and when each can be traced ple that fat belongs to the rectum, one can DR. PASIC is a consultant for Ethicon to the left (10 cm lateral to the umbili- from the pelvic brim to its insertion into identify the fat/nonfat interface; this fa- Endo-Surgery Inc., Terumo Medical cus and in the left lower quadrant). the bladder (see photo above). cilitates dissection superior to this plane. Corporation, and CooperSurgical Inc. He A thorough examination of the ab- It is also important to maintain the in- also has a grant from Karl Storz domen and pelvis should be performed Dissection of Rectovaginal Septum tegrity of the vaginal and rectal spaces as Endoscopy-America Inc. to assess the disease and degree of dis- The next step is to enter and dissect the much as possible to decrease the risk of section needed to successfully access the rectovaginal septum. Prior to excision of bowel perforation. The dissection is con-

rectovaginal space. To excise the lesions, the nodule, the pouch of Douglas is first tinued until the space is fully developed. ESAD we have used the bipolar RoBi forceps accessed by freeing the area from any ad- . R R (Karl Storz), monopolar scissors, and hesions or ovarian endometriomas. Excision of the Nodule D the Harmonic scalpel. After the successful bilateral ureterol- When the uterosacral ligament is tran- ysis, the ureters can be identified and the sected, this permits a closer inspection Ureterolysis posterior fornix can be delineated with of the posterior vaginal wall and the In all of our cases thus far, ureterolysis the rectal probe and colpotomizer. ability to assess the need for further rec- ASIC MAGES PROVIDED BY was performed before resection of any The posterior fornix is then pushed tal dissection. The posterior fornix is I P DIE nodules. The ureter crosses the upward, and a transverse incision is then incised along the rectovaginal The rectal nodule is grasped and placed pelvic brim close to the bifurcation of the made over the posterior cervix superior margin, allowing the space to be on tension. The rectal probe is used to common iliac artery, at which point it be- to the rectum—an area also known as opened. The nodule is then excised by help delineate the rectal borders.