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Basic Clinical Retroperitoneal Anatomy for Pelvic Surgeons Pelvik Cerrahlar Için Temel Klinik Retroperitoneal Anatomi

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Basic Clinical Retroperitoneal Anatomy for Pelvic Surgeons Pelvik Cerrahlar Için Temel Klinik Retroperitoneal Anatomi Review / Derleme DOI: 10.4274/tjod.88614 Turk J Obstet Gynecol 2018;15:259-69 Basic clinical retroperitoneal anatomy for pelvic surgeons Pelvik cerrahlar için temel klinik retroperitoneal anatomi İlker Selçuk1, Burak Ersak1, İlkan Tatar2, Tayfun Güngör1, Emre Huri3 1University of Health Sciences, Ankara Dr. Zekai Tahir Burak Woman’s Health Training and Research Hospital, Clinic of Gynecologic Oncology, Ankara, Turkey 2Hacettepe University Faculty of Medicine, Department of Anatomy, Ankara, Turkey 3Hacettepe University Faculty of Medicine, Department of Urology, Ankara, Turkey Abstract Basic anatomical knowledge should be improved during residency period with clinical practice. Especially pelvic surgeons; obstetricians, gynecologists, gynecological oncologists, urologists and general surgeons must have an advanced level practise of retroperitoneal anatomy to gain surgical skills. Retroperitoneal topographic anatomy, retroperitoneal vasculature, ureteric dissection and pelvic avascular spaces are the precise points during pelvic surgery. Keywords: Surgery, anatomy, hypogastric, ureter, gynecology Öz Temel anatomik bilgi, tıpta uzmanlık için asistanlık döneminde klinik pratik ile beraber geliştirilmelidir. Özellikle pelvik cerrahlar; obstetrisyenler, jinekologlar, jinekolog onkologlar, ürologlar ve genel cerrahlar, cerrahi yetenekler kazanmak için retroperitoneal anatomiye ileri düzeyde hakim olmalıdır. Retroperitoneal topografik anatomi, retroperitoneal vaskülerizasyon, üreter disseksiyonu ve pelvik avasküler alanlar pelvik cerrahi için gerekli olan en hassas noktalardır. Anahtar Kelimeler: Cerrahi, anatomi, hipogastrik, üreter, jinekoloji Retroperitoneum retroperitoneal organs are the adrenal glands, kidneys, ureter, the abdominal aorta, inferior vena cava and their branches. 1. Topographic retroperitoneal anatomy The secondary retroperitoneal organs, which were initially intraperitoneal and became retroperitoneal structures during The posterior abdominal wall is the posterior boundary of the embryologic development due to the regression of peritoneal abdominal cavity, which is the continuous part of posterior tissue lying on the posterior wall of the abdominal cavity thoracic wall from the level of diaphragm cranially and (the mesentery of these structures fuse with the posterior posterior pelvic wall caudally. The lumbar vertebra, pelvic girdle, posterior abdominal wall muscles [musculus (m) abdominal wall), are the ascending and descending colon, quadratus lumborum, m. psoas major, m. psoas minor, m. duodenum except the bulbus part (first half of duodenum iliacus, and muscles of diaphragm] and their fascia are the segment 1) and pancreas. members of this region. Clinical tip: How to enter the retroperitoneal area? The retroperitoneum is a part of the abdominal cavity; When there is a distorted anatomy of peritoneal structures, to surrounded anteriorly by the parietal peritoneum and achieve a normal anatomy and resect all pathologic lesions, posteriorly by the transversalis fascia (Figure 1)(1). It is a wide the surgeon needs to gain access to the retroperitoneum, area from the pelvis to the diaphragm and contains numerous which is mainly safe and that leads to a comprehensive organs and structures; structures behind the peritoneum are called ‘retroperitoneal’ (Figure 2)(2). The primary dissection and visualization of the relevant anatomy. Address for Correspondence/Yazışma Adresi: İlker Selçuk, MD, University of Health Sciences, Ankara Dr. Zekai Tahir Burak Woman’s Health Training and Research Hospital, Clinic of Gynecologic Oncology, Ankara, Turkey Phone: +90 530 201 05 46 E-mail: [email protected] ORCID ID: orcid.org/0000-0003-0499-5722 Received/Geliş Tarihi: 30.07.2018 Accepted/Kabul Tarihi: 17.09.2018 ©Copyright 2018 by Turkish Society of Obstetrics and Gynecology Turkish Journal of Obstetrics and Gynecology published by Galenos Publishing House. 259 Turk J Obstet Gynecol 2018;15:259-69 Selçuk et al. Basic retroperitoneal anatomy The peritoneal reflection between the round ligament surface and cutting it either with scissors or energy devices [ligamentum (lig) teres uteri] (lateral) and infundibulopelvic is an easy and safe way of opening the retroperitoneum ligament (medial) is an easy way to enter the retroperitoneum (Figure 4). (Figure 3). Gentle traction on the lateral parietal peritoneal 2. Pelvic retroperitoneal vasculature A. Arteries Abdominal aorta The thoracic aorta is called the abdominal aorta because it enters the abdominal cavity through the diaphragm and it lies at the posterior abdominal wall, anterior to the vertebral column. The abdominal aorta is divided into the right and left common iliac arteries at the level of the L4-L5 vertebra, and the common iliac artery is divided into two parts as the external and internal iliac artery at the pelvic brim. The ovarian artery, median sacral artery, external iliac artery, internal iliac artery and its branches are important structures of pelvic retroperitoneal vasculature (Figure 5). Ovarian artery: This is located on the anterolateral surface of Figure 1. Transverse section of the anterior abdominal wall; the abdominal aorta, at the level of the L2 vertebra, generally the extraperitoneal fascia with fatty tissue under the parietal peritoneum lies on the posterior abdominal wall called the retroperitoneum (Gray’s Anatomy for Students, 3rd Edition, Churchill Livingstone/Elsevier, 2015)(1) Figure 3. Demonstration to enter the retroperitoneum between the round ligament and infundibulopelvic ligament (lateral parietal peritoneum), right pelvic side wall (cadaveric dissection) Figure 2. Pelvic viscera and retroperitoneum (Atlas of Human Figure 4. Demonstration of opening retroperitoneum, right Anatomy, 6th Edition, Saunders/Elsevier, 2014)(2) pelvic side wall (cadaveric dissection) 260 Selçuk et al. Basic retroperitoneal anatomy Turk J Obstet Gynecol 2018;15:259-69 2 cm below the level of the left renal vein. On the left side, it it crosses over the anterior surface of inferior vena cava then goes over the psoas major muscle and enters the pelvic cavity goes downward beside the ascending colon 1 cm above the by crossing the common iliac artery. On the right side, first right ureter and enters the pelvic cavity by crossing over the common iliac artery or sometimes the external iliac artery. Median sacral artery: This is the continuation of the abdominal aorta on the anterior surface of the sacrum and coccyx. It is crossed by the left common iliac vein and care should be taken during hysteropexy and colpopexy operations. Common iliac artery: The common iliac artery divides into the external and internal iliac artery. It is the point where polar renal arteries mostly arise (Figure 6); meticulous dissection is important during surgical procedures regarding this field(3). External iliac artery: This goes along the medial border of the psoas muscle to the level of femoral ring, which is below the inguinal ligament. The genitofemoral nerve is found on the lateral border of the external iliac artery (lateral border of pelvic lymphadenectomy) (Figure 7). It is the principal artery of the lower limb. Its branches are the deep circumflex femoral artery and the inferior epigastric artery. Internal iliac artery: This runs infero-medially after the pelvic brim and is the major vascular supply of the pelvic cavity. It has two trunks; posterior and anterior(4). The branches of the posterior trunk are the superior gluteal artery, lateral sacral artery, and iliolumbar artery. The branches of the anterior trunk are the umbilical, uterine, superior and inferior vesical, vaginal, obturator, middle rectal, internal pudendal and Figure 5. Paraaortic region, aorta and inferior vena cava after inferior gluteal artery (Figure 7). paraaortic lymphadenectomy (surgical archieve) Clinical tip: Internal iliac artery and peripartum bleeding During intractable pelvic hemorrhage or peripartum bleeding, ligation of the anterior trunk of the internal iliac artery bilaterally will decrease the amount of bleeding dramatically because the internal iliac artery is the major vascular supply of the pelvic cavity. Figure 6. Polar renal artery arising from the right common iliac artery and also abdominal aorta (surgical archive) Figure 7. Uterine artery, right pelvic side wall (surgical archive) VCI: Vena cava inferior, CIA: Common iliac artery 261 Turk J Obstet Gynecol 2018;15:259-69 Selçuk et al. Basic retroperitoneal anatomy Umbilical artery: This is the end artery of the internal iliac Clinical tip: Left common iliac vein artery (anterior trunk). It goes longitudinally to the abdominal It is a potential danger point during dissection of the field of wall and becomes the medial umbilical ligament. When the promontorium, which lies on the medial part of the left traction is applied to the umbilical artery during laparoscopic common iliac artery (Figure 9). During laparoscopic surgery, procedures, it will indicate the origin of the uterine artery. obesity and bad trocar angles will increase the likelihood of Uterine artery: The uterine artery arises from the anterior an injury to the left common iliac vein. trunk and goes medially through the broad ligament (lig. latum uteri) [within the cardinal ligament (lig. transversum cervicis)] towards the isthmic portion of the uterus to supply the uterus and cervix (Figure 7). It crosses the ureter close to the uterus. B. Veins Inferior vena cava The inferior vena cava (IVC) begins just inferior to the L5 vertebra, where the abdominal aorta has a bifurcation
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