Retroperitoneal surgery Retroperitoneal surgery 2 2

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 pararectal spaceThe pararectal space

Boundaries: Boundaries:

LaterallyLaterally by the levator ani, by the levator ani,

mediallymedially by the rectum & rectal pillars, by the rectum & rectal pillars,

Posteriorly Posteriorly above the ischial spine by the above the ischial spine by the anterolateral aspect of the sacrum.anterolateral aspect of the sacrum.

anteriorly and superiorly anteriorly and superiorly peripheral part of peripheral part of the cardinal ligament and the uterine the cardinal ligament and the uterine

artery divide the paravesical & the artery divide the paravesical & the pararectal spaces.pararectal spaces.

StepsSteps

To best develop the pararectal space, dissect To best develop the pararectal space, dissect between the first portion of the anterior between the first portion of the anterior division of the internal iliac artery laterally division of the internal iliac artery laterally and the ureter medially. and the ureter medially.

The uterosacral ligament and the ureter are The uterosacral ligament and the ureter are located very near to each other between the located very near to each other between the rectovaginal and pararectal spaces. rectovaginal and pararectal spaces.

Remain close to the rectum to avoid the Remain close to the rectum to avoid the internal iliac vein and its side wall tributaries. internal iliac vein and its side wall tributaries. Bleeding from these veins might kill the Bleeding from these veins might kill the patient. patient.

Laparoscopically Laparoscopically

Developing the pararectal space laparoscopically; dissecting Developing the pararectal space laparoscopically; dissecting behind the uterine artery. behind the uterine artery.

Laparoscopically Laparoscopically

The uterine artery and the round ligament are divided and the The uterine artery and the round ligament are divided and the incision is extended along the anterior broad ligament and incision is extended along the anterior broad ligament and bladder peritoneum.bladder peritoneum.

The infundibulopelvic ligament has been divided and the ureter is The infundibulopelvic ligament has been divided and the ureter is displaced laterally to extend the peritoneal incision from the broad displaced laterally to extend the peritoneal incision from the broad ligament to just below the uterosacral ligaments. The peritoneum ligament to just below the uterosacral ligaments. The peritoneum is separated from the uterosacral ligaments, and the peritoneal is separated from the uterosacral ligaments, and the peritoneal incision is continued along the posterior cul-de-sac.incision is continued along the posterior cul-de-sac.

The uterosacral ligaments are coagulated and divided (inset). The uterosacral ligaments are coagulated and divided (inset).

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.

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

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 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 medial to the iliac vesselsthe iliac vessels. .

Conclusion Conclusion

Retroperitoneal approaches might be the Retroperitoneal approaches might be the magic key to navigate through the magic key to navigate through the darkness of frozen or severely distorted darkness of frozen or severely distorted pelvis. pelvis.

Retroperitoneal navigation should be con-Retroperitoneal navigation should be con-ducted very cautiously to avoid injury to ducted very cautiously to avoid injury to important structures, particularly veins. important structures, particularly veins.

Thanks profThanks prof

morad k hasanein morad k hasanein