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The Female Inferior Hypogastric (= Pelvic) Plexus: Anatomical and Radiological Description of the Plexus and Its Averences—Applications to Pelvic Surgery

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The Female Inferior Hypogastric (= Pelvic) Plexus: Anatomical and Radiological Description of the Plexus and Its Averences—Applications to Pelvic Surgery Surg Radiol Anat (2007) 29:55–66 DOI 10.1007/s00276-006-0171-3 ORIGINAL ARTICLE The female inferior hypogastric (= pelvic) plexus: anatomical and radiological description of the plexus and its aVerences—applications to pelvic surgery B. Mauroy · X. Demondion · B. Bizet · A. Claret · P. Mestdagh · C. Hurt Received: 20 October 2005 / Accepted: 2 November 2006 / Published online: 21 December 2006 Springer-Verlag 2006 Abstract is superior, comes after the SHP (hypogastric nerve or Aim of the study We wanted to determine the ana- presacral nerve Wlament); its anterior inferior angle is tomical features of the inferior hypogastric plexus located exactly at the ureter’s point of entry into the (IHP), and the useful landmarks for a safe surgical posterior layer of the broad ligament. This is the top of approach during pelvic surgery. the IHP; its posterior inferior angle is located at the Materials and methods We dissected the IHP in 22 point of contact with the fourth sacral root. At its formolized female anatomical subjects, none of which entrance at the base of the parametrium the pelvic ure- bore any stigmata of subumbilical surgery. ter is the anterior, fundamental positional reference for Results The inferior hypogastric plexus (IHP) is a tri- the IHP. The vaginal eVerences come out of the top of angle with a posterior base and an anterior inferior top. the IHP through branches leading to the bladder, the It can be described as having three edges and three vagina and the rectum, which originate through two angles; its inferior edge stretches constantly from the trunks exactly underneath the crossing point of the ure- fourth sacral root to the ureter’s point of entry into the ter and the uterine artery: (i) one trunk leading to the posterior layer of the broad ligament; its cranial edge is bladder runs along and underneath the ureter and strictly parallel to the posterior edge of the hypogastric divides into two groups, which are lateral and medial, artery, along which it runs at a distance of 10 mm; its trigonal. (ii) the trunk leading to the vagina runs along posterior (dorsal) edge is at the point of contact with the the inferior edge of the uterine artery. At the point of sacral roots, from which it receives its aVerences. They contact with the lateral edge of the vagina, it splits into most frequently originate from S3 or S4 (60%) and then, two groups: anterior thin and posterior voluminous. in one or two branches, often from S2 (40%), never Some of its branches perforate the posterior wall of the from S1 and in exceptional cases from S5 (20%). There vagina and are distributed to the rectovaginal septum in are sympathetic aVerences in 30% of cases, usually a tooth comb pattern. The inferior branches, which through a single branch of the second, third or fourth emerge from the inferior edge of the IHP, reach the rec- sacral ganglion. All IHPs have at least one sacral aVer- tum directly. The dissection of the 22 specimens allowed ence and sometimes there may be up to three aVerences us to describe three eVerent plexuses: a vaginal rectal from the same sacral root. Its dorsal cranial angle, which plexus, a vesical plexus and a inferior rectal plexus. So the IHP’s anterior, fundamental positional reference is B. Mauroy · X. Demondion · B. Bizet · A. Claret · C. Hurt the pelvic ureter at the point where it enters at the base Faculty of Medicine, Anatomy Laboratory, Lille, France of the parametrium, then at the crossing point of the V P. Mestdagh uterine artery. The ureter is the vector for vesical e er- Centre Radio-Liberté, Lille, France ences, the uterine artery is the vector for vaginal eVer- ences, which are thus sent into the vesicovaginal septum B. Mauroy (&) and the rectovaginal septum. This surgical point of ref- Department of Urology, Hôpital Saint Philibert, Rue du Grand But, BP 249, 59462 Lomme Cedex, France erence is of vital importance in nerve sparing during the e-mail: [email protected] course of a simple or extended hysterectomy. Any 1 3 56 Surg Radiol Anat (2007) 29:55–66 dissection carried out underneath and outside of the ablation of the ventral and ventrolateral abdominal wall ureter inevitably carries a risk of lesions to its eVerent, following a longitudinal incision made from the umbili- lateral vesical or medial, rectovaginal Wbres. cus to the pubis, which will then be continued opposite the inguinal ligament and beyond it as far as the top of Keywords Hysterectomy · Urinary incontinence · the iliac wing. There then follows the exeresis of the Pelvic autonomous innervation · digestive tract in a block as far as the sigmoid. The dis- Innervation of the bladder · Pelvic plexus · section then continued as far as the rectosigmoid junc- Autonomous nervous system tion, which was ligated and severed. The ablation of the remaining peritoneum and that of the rectouterine excavation (Douglas pouch) was performed. Introduction We identiWed the nerve Wlament of the intermesen- teric plexus which is in a pre-aortic position. This nerve In 1898, Wertheim described the Wrst total abdominal Wlament did act as “the guide” for the remainder of our hysterectomy technique combined with a pelvic exci- dissection hence the importance of revealing it at an sion in the surgical treatment of cancer of the cervix. early stage. Continuing on from the intermesenteric Schauta described the operation he performed vagi- plexus, the superior hypogastric plexus was located nally in 1902. Whether this so-called extended hysterec- underneath the aortic bifurcation, in a ventral position tomy is performed abdominally or vaginally, in a good in relation to the sacral promontory. number of cases it is followed by the occurrence of post- At this stage in our progress, a further deep freezing operative bladder problems, which can sometimes be was performed allowing a median sagittal cut to be incapacitating and prolonged. These problems may be made. This cut oVered a median approach to the hemi- of types involving either retention or incontinence and pelvis for a precise dissection, taking care over the loss of bladder sensitivity, which are all the more positional references and structure of the nerves being unpleasant when they occur in young female patients. studied as well as their aVerences. The superior hypo- A number of hypotheses have been put forward gastric plexus caudally and laterally leaded to the right with regard to the cause of these postoperative mic- and left hypogastric nerves. These nerves did expand tional disorders [5]. The Wrst, posited by Latarget and taking on the appearance of a triangular nerve Wlament Rocher in 1922, mentioned the possibility of a lesion of with a ventral top, the IHP. The homolateral hypogas- the hypogastric plexus, which would explain the blad- tric nerve arrives at the dorsal cranial angle of the IHP. der problems observed. Over the years, these latter The dissection continues dorsally to complete the have been connected to a more or less complete surgi- study of the aVerences, moving in the direction of the cal denervation of the bladder by a section of the hypo- sacral roots and cranially. gastric plexus and/or its vesical branches. We used the natural cleavage plane between the We aimed to specify the precise topography of the genital organs and the lateral wall of the pelvis where inferior hypogastric plexus and, above all, in order to we were able to descend as far as the pelvic Xoor. A deWne the points of reference which would help us to wide incision was made through the pelvic Xoor at this deal with this when performing a hysterectomy. level, around the endopelvic base of the genital organs. We could then pull back the genital organs in order to make it easier to dissect the inferior hypogastric plexus Materials and methods on the lateral surface of the genital organs and to do this more accurately. Repositioning the genital organs In order to study the inferior hypogastric plexus (IHP), into their anatomical position allowed a precise analy- we dissected 22 female formolised hemipelvises, none sis of the positional references and the position of the of which showed any stigmata of subumbilical surgery. inferior hypogastric plexus. Twenty one subjects had undergone no pelvic or At each of the stages of the dissection, in addition to abdominal surgery, one subject had undergone a hys- a careful dissection of the nerve structures being stud- terectomy which had been performed vaginally. ied, we made every eVort to conserve and identify the The dissection was always performed in the following vascular elements along with the ureter. These ana- manner: the Wrst stage consists of disarticulating the tomical structures allowed us to specify the positional lower limbs. Then the subjects were cut transversally references and location of the inferior hypogastric using a band saw, after congelation, as far as the umbili- plexus and its aVerences (pelvic splanchnic nerves or cus in order not to damage the superior hypogastric erector nerves of ECKHARDT), of the eVerent plex- plexus. We then performed the opening followed by the uses and the nerve anastomoses. 1 3 Surg Radiol Anat (2007) 29:55–66 57 MRI study Hypogastric nerves (presacral nerves) Having deWned the anatomical landmarks for the IHP, Underneath the promontory, the SHP divides into two we can get a better understanding of the IHP using Wlaments of variable width (4–7 mm depending upon magnetic resonance imaging. The study was carried out the subject which are called presacral (or hypogastric) with Wve female patients who had not undergone hys- nerves (Fig. 1). terectomies on standard cuts in the three planes of This plexus leads laterally to the point of contact space: the strict axial, coronal and sagittal planes.
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