Retroperitoneal surgery Retroperitoneal surgery 4 4

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 presacral spaceThe presacral space

This space can be This space can be developed by developed by gently gently incisingincising the the overlying parietal overlying parietal peritoneumperitoneum. .

The sigmoid colon is The sigmoid colon is shifted to the left. shifted to the left.

SurgicalSurgical importance importance

Inside this space, Inside this space, encased in fat, is encased in fat, is the sympathetic n. the sympathetic n. plexus (the pre-plexus (the pre-sacral nerve) in add sacral nerve) in add ition to the middle ition to the middle sacral artery & veinsacral artery & vein

Sacral colpopexy

Frog-legFrog-leg position position . .

The handle of a retractor The handle of a retractor is placed into the vaginais placed into the vagina

The small intestines are The small intestines are packed superiorly and packed superiorly and the sigmoid colon is the sigmoid colon is retracted aside using a retracted aside using a spongesponge forceps forceps . .

The The apexapex of the vagina is of the vagina is graspedgrasped in the midline in the midline and the and the serosaserosal covering l covering is is denudeddenuded while the while the vaginal vaginal retractorretractor is is pushedpushed up up . .

Then, the scissors are Then, the scissors are used to used to undermineundermine the the serosaserosa . .

The The peritoneumperitoneum covering covering S2-3S2-3 is is graspedgrasped and and incisedincised . .

The scissors are used to The scissors are used to undermineundermine and and inciseincise the the peritoneum progressively until peritoneum progressively until the vaginal apex is reachedthe vaginal apex is reached . .

Denudation of the vaginal apex against handle of the vaginal retractor. Denudation of the vaginal apex against handle of the vaginal retractor. The sigmoid colon is retracted aside using sponge forcepsThe sigmoid colon is retracted aside using sponge forceps..

  

A peanut sponge is used to carefully A peanut sponge is used to carefully expose expose the middle sacral ligamentthe middle sacral ligament all all the while searching for the middle the while searching for the middle sacral artery and veins so as not to sacral artery and veins so as not to traumatise themtraumatise them . .

The glistening white ligament is The glistening white ligament is exposedexposed for 2 cm for 2 cm . .

A merselene tape is passed from the A merselene tape is passed from the vaginal vault retroperitoneally to vaginal vault retroperitoneally to appear just medial to the sigmoid appear just medial to the sigmoid mesocolonmesocolon . .

A right similar loop is taken and both A right similar loop is taken and both are fixed in the mid pieceare fixed in the mid piece of the of the sacrumsacrum

Thanks profThanks prof

morad k hasanein morad k hasanein