Retroperitoneal surgery-Retroperitoneal surgery-1 1

By By

Dr. Khattab Omar, MDDr. Khattab Omar, MD

Prof. & Head of Obstetrics and Gynaecology Prof. & Head of Obstetrics and Gynaecology Department Department

Faculty of Medicine, Al-Azhar University, Faculty of Medicine, Al-Azhar University, DamiettaDamietta

IntroductionRetroperitoneal space of the true pelvis differs from retro-peritoneal areas elsewhere in the abdomen by the presence of the sub-peritoneal areolar (cellular) connective tissue.

We can recognize about 6 We can recognize about 6 retroperitoneal spaces. retroperitoneal spaces.

Cardinal lig

The subperitoneal area of the pelvis is partitioned

into potential spaces by the various organs & their re-

spective fascial coverings, and by the selective thick-

enings of the endopelvic fascia into ligaments and

septa.

Vesical fascia

Cut edge of the peritoneum

Vesicovaginal lig. & space

1- Malignancy & lymphadenectomy. 1- Malignancy & lymphadenectomy. 2- Endometriosis. 2- Endometriosis. 3- Chronic PID. 3- Chronic PID. 4- Tubo-ovarian abscess. 4- Tubo-ovarian abscess. 5- Large or interligamentous myoma 5- Large or interligamentous myoma 6- Complications in post-hysterect. 6- Complications in post-hysterect.

reserved ovaries. reserved ovaries. 7- Hypogastric artery ligation. 7- Hypogastric artery ligation.

8-Vaginally-inaccessible urinary fistula 8-Vaginally-inaccessible urinary fistula 9- Colpopexy.9- Colpopexy.10- Laparoscopic hysterectomy. 10- Laparoscopic hysterectomy.

Indications for development of retroperitoneal surgical approaches

The paravesical space The paravesical space

It is limitedIt is limited

laterallylaterally by the obturator internus and levator by the obturator internus and levator ani Ms, ani Ms,

mediallymedially by the bladder pillars, by the bladder pillars,

inferiorlyinferiorly by the endopelvic fascia, by the endopelvic fascia,

superiorlysuperiorly by the lateral umbilical ligament, by the lateral umbilical ligament,

and and posteriorlyposteriorly by the uterine artery. by the uterine artery.

This space can be developed This space can be developed by dissecting between by dissecting between thethe external iliacexternal iliac vessels and the vessels and the anterior division of the anterior division of the internal iliacinternal iliac artery (precisely, artery (precisely, the superior vesical artery) the superior vesical artery) lateral to the bladder. lateral to the bladder.

StepsSteps

First, exposeFirst, expose the external the external iliac vessels iliac vessels anteriorly anteriorly near their entrance into near their entrance into the femoral canal by the femoral canal by dividing the dividing the round round ligamentligament near the deep near the deep inguinal ring. inguinal ring.

Note where the Note where the circumflex iliac vein circumflex iliac vein crosses the external crosses the external iliac arteryiliac artery. The anterior . The anterior division of division of the internal the internal iliac arteryiliac artery lies just lies just medial. medial.

Cut round ligament

going through the deep inguinal ring

LaparoscopicallyLaparoscopically

The space can be developed The space can be developed laparoscopically, but in laparoscopically, but in different steps. different steps.

Developing the space Developing the space laterallateral to the obliterated to the obliterated umbilicalumbilical artery. artery. Note direction of the pull exerted through the dissecting Note direction of the pull exerted through the dissecting forceps (arrow)forceps (arrow)

Developing the space Developing the space medialmedial to the obliterated to the obliterated umbilicalumbilical artery. artery. Note direction of the pull exerted through the dissecting Note direction of the pull exerted through the dissecting forceps (arrow)forceps (arrow)

SurgicalSurgical importance importance

On the lateral side of the para-On the lateral side of the para-vesical space lies the obturator vesical space lies the obturator fossa containing blood vessels, fossa containing blood vessels, nerve and lymph nodes. nerve and lymph nodes.

Blunt dissection following the Blunt dissection following the inward pelvic slope can be inward pelvic slope can be continued to the pelvic diaphragm. continued to the pelvic diaphragm.

GSI can be attributed to disruption of muscle and fascia of the proximal urethra bladder neck hyper-mobility (midline defect). The pubo-cervical fascia acts as a suspending hammock for the bladder and urethra.

The pravaginal fascia too plays an important role (paravaginal defect is the most common injury occurring >75%-80% of the time).

Impaired support of the anterior vaginal wall is associated with stress incontinence and prolapse of the anterior vaginal wall.

All bladder neck surgeries carry a risk of postoperative detrusor instability and long-term voiding difficulties.

All such techniques rely on creation of a "compensatory abnormality“.

Ritchardson advised repair of the paravaginal defect that was so anatomic that it almost never resulted in either short- or long-term urinary retention, and the patients remained continent over the time.

Right paravaginal defect (the vagina's antero-lateral sulcus is avulsed away from the white line). The obturator foramen is 1.5-2cm above the white line. The defect is absent in the left side.

Entering the retroperitoneum

- A preoperative IVU is recommended.

- In most cases, the round ligament may be divided and the peritoneum lateral to the infundibulopelvic ligament incised without difficulty.

- With large masses or when the anatomy is severely distorted, a paracolic or lateral psoas approach is required.

The round ligament approachThe round ligament approach

Placing a retractor near to the round Placing a retractor near to the round ligament provides upward traction on it. ligament provides upward traction on it.

The ligament is then picked up & transfixed.The ligament is then picked up & transfixed.

The broad lig. should be incised sharply in its The broad lig. should be incised sharply in its lateral portion overlying the psoas Ms.lateral portion overlying the psoas Ms.

The peritoneum can then be incised cephalad The peritoneum can then be incised cephalad lateral and parallel to the ovarian vessels. lateral and parallel to the ovarian vessels.

This is followed by sharp & blunt dissection. This is followed by sharp & blunt dissection.

The initial dissection should be bounded by The initial dissection should be bounded by the posterior leaflet of the broad ligament the posterior leaflet of the broad ligament & the ureter medially (the ureter attaches & the ureter medially (the ureter attaches to the broad lig. peritoneum) and the iliac to the broad lig. peritoneum) and the iliac vessels and the pelvic side wall laterally. vessels and the pelvic side wall laterally.

The paracolic approachThe paracolic approach

It is useful when the It is useful when the pelvic anatomy is pelvic anatomy is severely distorted severely distorted and the round lig not and the round lig not easily identified, or if easily identified, or if the pelvis is occupied the pelvis is occupied with a mass.with a mass.

The paracolic peritoneum The paracolic peritoneum is elevated and incised. is elevated and incised.

The incision begins over The incision begins over the psoas muscle lateral the psoas muscle lateral to the ureter and ovarian to the ureter and ovarian vessels. vessels.

This is followed by combined sharp This is followed by combined sharp and blunt dissection to mobilize and blunt dissection to mobilize medially the coecum or sigmoid medially the coecum or sigmoid colon, or to visual-ize the ureters. colon, or to visual-ize the ureters.

Dissection is continued down into Dissection is continued down into the pelvis using the ureter as the the pelvis using the ureter as the landmark (ureteric cath-eter ± landmark (ureteric cath-eter ± inserted) around which both the inserted) around which both the ovarian and the iliac vessels may ovarian and the iliac vessels may be identified. be identified.

The incision begins over the psoas muscle lateral to the ureter and ovarian vessels. The incision begins over the psoas muscle lateral to the ureter and ovarian vessels.

Post

Anter

RtLt

The psoas muscle approach:The psoas muscle approach:

The retroperitoneal space The retroperitoneal space may also be entered over may also be entered over or lateral to the psoas or lateral to the psoas muscle. muscle.

Begin and stay Begin and stay medial to the medial to the iliac vesselsiliac vessels. .

Opening the pelvic sidewall triangles:Opening the pelvic sidewall triangles:

The uterus is deviated to one side to de-The uterus is deviated to one side to de-lineate the triangle in the opposite wall. lineate the triangle in the opposite wall.

The The basebase of the triangle is the round lig., of the triangle is the round lig., the the lateral border lateral border is the external iliac a., is the external iliac a., the the medial bordermedial border is the infundibulopelvic is the infundibulopelvic lig, and the lig, and the apexapex is where the infundibul- is where the infundibul- opelvic ligament crosses the common opelvic ligament crosses the common iliac artery. iliac artery.

The peritoneum in the middle of the triangle is The peritoneum in the middle of the triangle is incised and the broad lig is opened by bluntly incised and the broad lig is opened by bluntly separating the extraperitoneal areolar tissue.separating the extraperitoneal areolar tissue.

Even tiny vessels should be coagulated. Even tiny vessels should be coagulated.

The incision is extended to the round ligament The incision is extended to the round ligament which is not divided at this time and then to which is not divided at this time and then to the apex of the triangle lateral to the the apex of the triangle lateral to the infundibulopelvic ligament. infundibulopelvic ligament.

The paravesical space is opened and the infundibulopelvic ligament is pulled medially.

Thanks profThanks prof

morad k hasanein morad k hasanein