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Home , Genitofemoral nerve, Peritoneum

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SURGICALTECHNIQUES

THE RETROPERITONEAL SPACE Keeping vital structures out of harm’s way Knowledge of the retroperitoneal space is critical, to avoid unnecessary loss and injury of the , bladder, bowel, and

he accomplished gynecologic sur- Kenneth D. Hatch, MD The “landmark” Professor, Department geon must know the anatomy of of Obstetrics and Gynecology, T the retroperitoneal space in order umbilical Arizona Health Sciences Center Tucson, Ariz to avoid damage to normal structures, as® Dowden Health Media well as remove pathology. Many disease The umbilical ligament was the umbilical processes involve the pelvic peritoneum, artery in fetal life and courses along the uterosacral , rectosigmoidCopyrightFor or edgepersonal of the bladder use to theonly anterior abdom- ovarian pedicles, and require the surgeon inal wall up to the umbilicus. It is a useful to enter the retroperitoneal space to iden- guide into the perivesicle space. Lateral to it tify the and blood vessels and are the iliac vessels, and medial is the blad- keep them out of harm’s way. The chal- der. It is also a good marker for finding the IN THIS ARTICLE lenges are complex: right spot to open the round ligament. • Badly distorted anatomy and the ante- ❙ may rior and posterior cul-de-sac necessi- imperil the ureter tate mobilization of the rectosigmoid Page 20 and bladder. • Intraligamentous fibroids require ❙ Preventing ureteral knowledge of the blood supply in the retroperitoneal space. Malignant disor- injury ders mandate that the nodes be Page 23 dissected to determine extent of disease and as part of treatment. ❙ Protecting pelvic nerves ❚ Is training adequate? Page 24 Every training program should teach the FIGURE 1 surgical anatomy of the retroperitoneal Opening the round ligament space, since every surgeon needs to be over the umbilical ligament comfortable exposing the anatomy, both The round ligament is the key to exposing to prevent injury and to accomplish the the retroperitoneal space. It should be open needed surgery. Videotapes and cadaver at the pelvic sidewall, just medial to the courses can prepare the resident for the external iliac vessels. The umbilical ligament operating room. can be used as a landmark.

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The “landmark” umbilical ligament continued

FIGURE 2 FIGURE 3 Opening lateral Right pelvic sidewall anatomy to the ovarian vessels Medial traction of the peritoneum around the The divided round ligament is retracted ovarian vessels at the pelvic brim will expose ventrally and medially to place the ovarian the ureter coming over the iliac vessels at vessels under traction. The peritoneum lateral their bifurcation into external and internal to the ovarian vessels is divided up to the branches. pelvic brim.

FAST TRACK The ureter and anterior branch of the internal iliac artery are nearly parallel as they course through the pelvis FIGURE 4 FIGURE 5 Relationship of ureter Hypogastric to the umbilical ligament The anterior branch of the internal iliac artery The ureter comes off medial with the fold gives off the uterine artery and the middle of peritoneum. Once the space is developed, and superior vesicle arteries before continu- the operator’s finger or the laparoscopic ing on as the umbilical ligament. probe can be introduced along the medial side of the internal iliac artery and ventral to the curve of the sacrum. This will open the pararectal space. The ureter and the anterior branch of the internal iliac artery are nearly parallel as they course through the pelvis.

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Endometriosis may imperil the ureter

Endometriomas and peritoneal implants are among the most common reasons for access- ing the retroperitoneal space. Frequently the peritoneum between the ovarian vessels and the uterosacral ligaments (ovarian fossa) is thickened and retracted within the endometrio- sis implants. This alters the pelvic anatomy and puts the ureter at risk for injury. Definitive surgical treatment for endometriosis includes removal of this diseased peri- toneum. The ureter is best identified using the technique described, and then dissected off the peritoneum down to the uterine artery.

FIGURE 6 FIGURE 7 Finding the ureter Relationship of ureter lateral to an endometrioma to the umbilical ligament

FAST TRACK Definitive surgical treatment of endometriosis includes removal of the diseased peritoneum FIGURE 8 FIGURE 9 Dissecting the ureter Divide uterine artery out of the lateral to endometrioma The ureter may be placed on a Penrose drain Here, the uterine artery is taken lateral to the to better isolate it and keep it under direct mass, enabling the surgeon to remove all of visualization. The cul-de-sac of Douglas is the uterosacral implants. The bladder flap will another site of endometrial implants. The fun- be developed and the bladder advanced dus of the is often adhesed to the rec- caudad. By dissecting medial to the ureter as tosigmoid reflection and even the sigmoid it courses under the uterine artery, it will be colon. Nodules of endometriosis may infiltrate retracted laterally and provide the space nec- the uterosacral ligaments and extend into the essary to resect the uterosacral implants. rectovaginal space. To manage these implants, isolate the ureter to the point where it passes under the uterine artery. CONTINUED

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Endometriosis may Preventing imperil the ureter continued ureteral injury

Ureteral injuries occur in 0.5% to 2.5% of women undergoing gynecologic surgery.1 The most common predisposing condition is previous pelvic surgery.2,3 The usual sites of injury are at the pelvic rim close to the ovarian vessels, at the level of the uterine artery, and lateral to the vaginal cuff. Neither preoperative excretory urograms nor placement of ureteral catheters preoper- atively have been found to be effective pre- FIGURE 10 vention measures.2,4–6 Using the steps Rectosigmoid reflection described above, the ureter can be identified with endometrioma nodule and mobilized. Blood supply to the ureter comes from the plexus of vessels that form a network along the length of the ureter. This plexus is fed by arteries from the renal pelvis, com- mon iliac, internal iliac, uterine artery, and the base of the bladder. Complete mobiliza- tion of the ureter away from its peritoneal attachments and these lateral blood supply sources can be accomplished as long as the vascular plexus is not disrupted by cautery, crushing, or tearing. A clean transection can be re-anastomosed or reimplanted with FAST TRACK the expectation of normal healing. FIGURE 11 Common sites Innervation of the ureter is from the inferi- Postoperative appearance or mesenteric plexus superiorly and the of ureteral injury: of endometriosis resection inferior hypogastric plexus in the pelvis. ❙ at the pelvic rim As dissection proceeds medially, use the Ureteral peristalsis will continue, even if the perirectal fatty plane to remove implants ureter is completely divided or ligated. near the ovarian between the uterosacral area and . In vessels the midline, remove implants below the rec- tosigmoid peritoneal reflexion, taking care not ❙ at the level of the to injure the rectum. Protecting pelvic uterine artery Implants above the peritoneal reflexion blood vessels are often attached to the sigmoid tinea coli ❙ lateral to and cannot be removed without taking a portion of the bowel. Thus, patients with The majority of gynecologic operations the vaginal cuff extensive endometriosis should have a bowel involve the ovarian vessels and the uterine prep with two 10-ounce bottles of magne- vessels. The operator rarely needs to sium citrate the day before surgery. explore the lateral pelvis to identify the rest If is necessary, consult a of the vessels. When faced with a large general surgeon or gynecologic oncologist. endometrioma or cancer, knowledge of the A history of painful defecation or a finding of anatomy of the lateral blood vessels is vital. nodules in the cul-de-sac with rectal dimpling Since the pathology is usually deeper in warrants preoperative consultation with a the pelvis, it is wise to identify the anatomy specialist skilled at bowel resection. of the pelvis starting at the pelvic brim,

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where the common iliac bifurcates into Hypogastric artery ligations are rarely the external and internal iliacs. There is a performed today, as interventional radiolo- safe dissection plane medial to the internal gy is the standard of care for patients with iliac artery all the way to the uterine postoperative and postpartum bleeding. artery. This exposes the pararectal space, When it becomes necessary, the hypogastric which can be opened without risk of artery can be isolated and tied using the major bleeding (FIGURE 5). right-angle clamp to pass the tie. The supe- The obliterated umbilical vessel is the rior gluteal artery branches so close to the other friendly marker just distal to the uter- bifurcation of the common iliac artery that ine artery. It can be placed on traction and it is not visualized. The inferior gluteal the uterine artery isolated. The inferior and artery is the largest distal branch, which superior vesical arteries are generally not might be visualized during the ligation. It is dissected, as they are adjacent to the blad- not necessary to identify it. der and the surgery takes place medial to them in the prevesical fascial space.

Protecting pelvic nerves

FAST TRACK The hypogastric artery is rarely ligated today FIGURE 12 FIGURE 13 because of Right genitofemoral nerve Right pelvic sidewall anatomy increasing reliance The genitofemoral nerve runs along the The is in the obturator space on interventional medial aspect of the body of the psoas mus- and typically far lateral to the usual dissec- cle. It is sometimes injured by the self-retain- tion. Metastatic cancer to the obturator lymph radiology for ing retractors placed at the time of laparoto- nodes may entrap it, or it may be injured postpartum and my.This leads to some numbness and during a node dissection, causing loss of postop bleeding burning of the skin of the anterior thigh. internal rotation of the anterior thigh. The is seen only during exenterative surgery. Pressure on the lateral pelvis by advanced pelvic tumors can lead to sciatic pain and motor weakness—even loss of motor function to the lower leg, which commonly leads to foot drop.

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hysterectomy or endometriosis resection is a high priority. Laparoscopic uterosacral nerve ablation procedures divide the uterosacral ligament medial and caudad to the ureter and do not disrupt the main hypogastric nerve. Only the medial branches to the uterus are affected. Successful uterosacral nerve ablation has been reported in approximately 44% of women who have dysmenorrhea without visi- FIGURE 14 ble endometriosis and approximately 62% of women who have visible endometriosis.7, 8 The Superior hypogastric nerve bundle efficacy of this procedure is controversial, The hypogastric plexus of nerves is however. Removal of the superior hypogastric sometimes damaged during surgery for plexus (presacral neurectomy) has not proved endometriosis or for malignancy.The superior to be more effective in controlling pelvic pain hypergastric plexus can be identified than conservative surgery that only destroys between the 2 common iliac arteries at the endometrial implants. Presacral neurectomy sacral promontory.The left common iliac vein is no longer advised.9 ■ runs underneath it.

REFERENCES 1. American College of Obstetricians and Gynecologists. Educational Bulletin #238: Lower Urinary Tract Operative Injuries. Washington, DC: ACOG; 1985:1. 2. Daly JW, Higgins KA. Injury to the ureter during gynecolog- ic surgical procedures. Surg Gynecol Obstet. 1988;167:19–22. 3. Selzman AA, Spirnak JP. Iatrogenic ureteral injuries: a 20- year experience in treating 165 injuries. J Urol. 1996;155:878–881. 4. Symmonds RE. Ureteral injuries associated with gynecolog- FAST TRACK ic surgery: prevention and management. Clin Obstet Gynecol. 19676;19:623–644. Presacral 5. Higgins CC. Ureteral injuries during surgery: a review of 87 neurectomy cases. JAMA. 1967;199:82–88. FIGURE 15 6. Fry DE, Milholen L, Harbrecht PJ. Iatrogenic ureteral injury. is no longer Hypogastric nerve Options in management. Arch Surg. 1983;118:454–457. 7. Lichten EM, Bombard J. Surgical treatment of primary dys- advised descending into the right pelvis menorrhea with laparoscopic uterine nerve ablation. J The right and left hypogastric nerves leave Reprod Med. 1987;32:37–41. the hypogastric plexus and descend into the 8. Sutton CJG, Ewen SP, Whitelaw N, Haines P. Prospective, pelvis parallel to the ureter and 2 cm medial. randomized, double-blind, controlled trial of laser in the treatment of pelvic pain associated with It passes dorsal to the ureter as it goes minimal, mild, and moderate endometriosis. Fertil Steril. through the cardinal ligament (FIGURE 5). 1994;62:696. This plexus then supplies autonomic 9. Candiani GB, Fedele L, Vercellini P, Bianchi S, Di Nola G. innervation of the bladder, rectum, uterus, Presacral neurectomy for the treatment of pelvic pain asso- ciated with endometriosis: a controlled study. Am J Obstet and ureter. Complete disruption of the Gynecol. 1992;167:100–103. hypogastric nerve will lead to a hypertonic, noncontractile bladder and the necessity for Dr. Hatch receives research/grant support from Merck; is a consultant to self-catheterization to eliminate urine. Ethicon, Merck, and Quest Laboratory; and is a speaker for Cytyc, Digene, Preservation of this nerve during radical Ethicon, and Merck.

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