Laparoscopic anatomy

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  • Email: elnashar53@hotmail.comAboubakr 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 Aboubakr Elnashar
  • Anterior abdominal wall thickness -Immediately below the umbilicus: Skin Subcutaneous tissue Anterior rectus sheath Rectus abdominous muscle Posterior rectus sheath Peritoneum Aboubakr Elnashar
  • -At the base of the umbilicus: Skin, SC adipose tissue, fascia (union of ant & post rectus sheathes), preperitoneal adipose tissue, peritoneum Aboubakr Elnashar
  • -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 Aboubakr Elnashar
  • 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 Aboubakr Elnashar
  • 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 Aboubakr Elnashar
  • 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 30 Kg/m2): 75 Aboubakr Elnashar
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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. Aboubakr Elnashar
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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 Aboubakr Elnashar
  • 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) Aboubakr Elnashar
  • 3. External iliac vessels: Often lie directly beneath this location So, Trocars must be placed at 45 toward the midline under direct visulization Aboubakr Elnashar
  • 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 Aboubakr Elnashar
  • 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. Aboubakr Elnashar
  • 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 Aboubakr Elnashar
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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 Aboubakr Elnashar
  • 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 Aboubakr Elnashar
  • 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 Aboubakr Elnashar
  • 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. Aboubakr Elnashar
  • Diagnosis of ureteral injury 1.Observing for leakage after IV indigo carmine 2.Intraoperative retrograde pyelogram Aboubakr Elnashar
  • 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 Aboubakr Elnashar
  • 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. Aboubakr Elnashar
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