Download - Laparoscopic anatomy
Email: [email protected] Aboubakr Elnashar
Importance
1. Placement of the primary trocars through the anterior
abdominal wall:
- Anterior abdominal wall anatomy
- Location of the retroperitoneal vessels
2. Placement of the secondary trocars :
- Abdominal wall vasculature
3. Manipulation of the peritoneal surfaces or
retroperitoneal area
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Anterior abdominal wall thickness
-Immediately below the umbilicus:
Skin
Subcutaneous tissue
Anterior rectus sheath
Rectus abdominous muscle
Posterior rectus sheath
Peritoneum
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-At the base of the umbilicus:
Skin,
SC adipose tissue,
fascia (union of ant & post rectus sheathes),
preperitoneal adipose tissue,
peritoneum
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-Intraumiblical:
Skin is attached to fascia (the anterior rectus sheath,
which is attached to the posterior rectus sheath) &
peritoneum.
No subcutaneous tissue or rectus abdominis muscle
•The thinnest part of the anterior abdominal wall
•Vertical intraumblical incision:
Thinnest part of the anterior abdominal wall
Improves the cosmetic results
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Resistance from the fascial layer
causes the inner sleeve hub to
move up
Once the VN has completely penetrated the fascial layer, the inner
sleeve moves back to its original position & produces a pop
caused by the inner sleeve striking the outer hub
The inner sleeve moves back
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Tenting of the
peritoneum
will move the
inner sleeve
upward
again
After the needle is through the
peritoneum, the inner sleeve retracts
back to its original position, producing a
second pop
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Increase abdominal wall thickness with
increase in weight
•Angle of placement of the Verres needle or trocar at the
base of the umbilicus:
-Thin (BMI <25 Kg/m2): 45º
-Normal wt (BMI 25-30 Kg/m2): 60 º
-Obese (BMI >30 Kg/m2): 75º
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Anterior abdominal wall vessels
Superficial vessels: Superficial epigastric a
Superficial circumferential iliac a
Branchs of inguinal a, course bilaterally through the SC
tissue, branching as they proceed toward the head of
the patient
Deep vessels: Inferior epigastric a
Branch of external iliac a, near the inguinal canal
courses along the peritoneum cephalad & medially until
it dives deeply into the rectus muscle, midway between
the symphysis & the umbilicus.
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Methods of localization
1. Superficial vessels: Transillumination:
Good for superficial vessels in thin patients
Of little value for the deep vessels which run beneath or
within the rectus muscle
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2. Deep vessels:
a. Abdominal localization:
Inferior epigastric: 3 cm above the symphysis &
5.5 cm from the midline
So, Safe location for trocar: 8 cm above the symphysis &
8 cm from the midline is a
b. Laparoscopic visualization: Origin: where the round ligament enters the inguinal
canal.
Runs lateral to the medial umbilical fold (oblitrated
umbilical a)
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3. External iliac vessels:
Often lie directly beneath this location
So,
Trocars must be placed
at 45º toward the midline
under direct visulization
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Retroperitoneal Structures
Bladder
The dome of the bladder is few cm s below the
symphysis
How to minimize risk of injury?
1. Routine catheterization
2. Previous low transverse skin incision: Put the
trocar above
3. Previous midline incision:
Put the trocar slightly off the mid line &
at least 3-4 cm above the symphysis Aboubakr Elnashar
Ureter
How to reduce the risk of ureteral injury during
laparoscopy?
Awareness of its general location within the
retroperitoneal space & its relationship to other
major landmarks
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Anatomy: 30 cm long
Abdominal part: from renal pelvis to the pelvic
brim
Courses along the anterior & medial aspect of
the psoas muscle until it crosses over the
common iliac vessels, approximately 1.5 cm
above the bifurcation of the internal & external
iliac vessels.
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Pelvic part: from pelvic brim till the bladder
It courses anterior to the internal iliac vessels,
crossing the obturator muscle & turning medial at the
level of the ischial spines.
It passes lateral & superior to the the uterosacral
ligaments & courses below the uterine vessels.
It runs obliquely through the cardinal ligament,
ventral to the anterior vaginal fornix
It angles upwards (forming a J) & inserts into the
bladder trigone
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How to identify the ureter during laparoscopy?
1. Ureter can often be identified through the
semitransparent peritoneum in thin patient. It is
best to identify the ureter at the bifurcation of
the common iliac vessels & trace it into the
pelvis by observing its peristaltic activity.
2. Indigo carmine or methylene blue IV to color
the urine.
3. Opening the retroperitoneal space
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Opening the retroperitoneal space: as in laparotomy
-The initial incision is made either by dividing the
round ligament or by incising the peritoneum above
the psoas muscle.
--The pararectal & paravesical spaces are then
carefully developed & the ureter identified coursing
along the medial leaf of the broad ligament
peritoneum at the level of the bifurcation of the iliac
vessels
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Laparoscopic procedures in which the ureter can
be injured:
Procedures requiring
ablation,
lysis of adhesions at the pelvic side wall, or
extensive retroperitoneal dissection or
division of the infundibulopelvic ligament
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•Treatment of endometriosis
E. Commonly involves the uterosacral ligament & the
peritoneum between the uterosacral & the broad
ligament. Because the ureter is in intimate contact with
the peritoneum in this area , it is at risk for injury during
either laser ablation or electrocautery
•During LAVH: Common sites of injury:
1. Near cardinal ligament, at the time of uterine vessel
transection
2. Near infundibulopelvic ligament, during ligation of of
the ovarian vessels.
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Diagnosis of ureteral injury
1.Observing for leakage after IV indigo
carmine
2.Intraoperative retrograde pyelogram
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Iliac vessels
1. External iliac vessels, with the artery running
lateral to the vein, course along the pelvic side wall &
exit the pelvis below the inguinal ligament.
The round ligament disappears into the peritoneum as it
enters the inguinal canal immediately above the
external iliac vessels. This consistent relationship is a
useful anatomic landmark for locating these vessels
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2. Internal iliac vessels:
course downward into the pelvis along with the ureter.
Both the internal & the external iliac vessels can
sometimes be identified through the semitransparent
peritoneum.
In presence of adhesions, the vessels may not be
visible. If extensive dissection is required, the
retroperitoneal space should be opened to avoid
injury of major vessels & the ureter.
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