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Sponsored by
AAGLAdvancing Minimally Invasive Gynecology Worldwide
Didactic: Pelvic Anatomy Directed to the Prevention and Management of Complications
PROGRAM CHAIR
Javier F. Magrina, MD
Marcello Ceccaroni, MD, PhD Paul M. Magtibay, MD Paul P.G., MD
Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.
Table of Contents
Course Description ........................................................................................................................................ 1
Disclosure ...................................................................................................................................................... 2
Navigating through the Pelvic Wall: Opening Spaces to Control Bleeding (Uterine and Hypogastric Artery Ligation) and Prevent Nerve Injury J.F. Magrina ................................................................................................................................................... 3
Presacral Space: Important Anatomy to Prevent Hemorrhage, Safe Dissection, Management of Presacral Bleeding, from Mild to Severe P.M. Magtibay ............................................................................................................................................... 8
Sigmoidorectal Anatomy: Blood Supply, Layers of the Bowel, and Importance for Closure of injuries; Is Bowel Prep necessary? What to Do Differently with Colon vs. Small Bowel Injury P. P.G. ......................................................................................................................................................... 11
How to Find and Preserve Pelvic Autonomic Nerves Resecting Endometriosis; Consequences of Transection of Sympathetic vs. Parasympathetic Innervation M. Ceccaroni .............................................................................................................................................. 14
The Difficult Parametrial Ureter Made Easy; Anatomy of the Parametrial Tunnel, from Easy to Difficult J.F. Magrina ................................................................................................................................................ 19
A Must for All Gynecologists: Bladder Anatomy: Blood Supply, Layers of the Bladder Wall and Importance for Closure; Prevention and Repair of Bladder and Ureteral Injuries; How to Perform Cystoscopy and Ureteral Stents P. P.G. .......................................................................................................................................................... 24
Vascular Disasters: The Large Pelvic Vessels: How to Avoid at Entry and during Surgery, What to Do and Not to Do; Handling of Vascular Injuries to Prevent Major Blood Loss and Death P.M. Magtibay ............................................................................................................................................ 30
Identification and Preservation of Pelvic Somatic and Sensory Nerves in Course of Pelvic Surgery: How to
Prevent Severe Neural Injuries
M. Ceccaroni .............................................................................................................................................. 33
Cultural and Linguistics Competency ......................................................................................................... 38
ANAT‐607: Didactic:
Pelvic Anatomy Directed to the Prevention and Management of Complications
Javier F. Magrina, Chair
Faculty: Marcello Ceccaroni, Paul M. Magtibay, Paul P.G. This course provides a review of the intraperitoneal and retroperitoneal pelvic anatomy applied to
minimally invasive gynecologic surgery with emphasis on preventing and correcting injuries. The
discussion on retroperitoneal anatomy will focus on opening lateral spaces for the prevention of
ureteral injury by demonstrating ureteral dissection (from easy to difficult), prevention and control of
severe pelvic hemorrhage (large vessels and presacral area), preservation of pelvic autonomic nerves
during resection of endometriosis, and prevention of motor nerve injury. In addition, anatomy applied
for the management of urologic and bowel injuries will be demonstrated.
Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Dissect the lateral
pelvic spaces and the ureters; 2) identify the different retroperitoneal vessels and nerves; and 3) apply
the principles of prevention and management of urologic (bladder and ureter) and intestinal (small
bowel and sigmoidorectal) injuries.
Course Outline
7:00 Welcome, Introductions and Course Overview J.F. Magrina
7:05 Navigating through the Pelvic Wall: Opening Spaces to Control Bleeding (Uterine and Hypogastric Artery Ligation) and Prevent Nerve Injury J.F. Magrina
7:30 Presacral Space: Important Anatomy to Prevent Hemorrhage, Safe
Dissection, Management of Presacral Bleeding, from Mild to Severe P.M. Magtibay
7:55 Sigmoidorectal Anatomy: Blood Supply, Layers of the Bowel, and
Importance for Closure of injuries; Is Bowel Prep necessary?
What to Do Differently with Colon vs. Small Bowel Injury P. P.G.
8:20 How to Find and Preserve Pelvic Autonomic Nerves Resecting Endometriosis;
Consequences of Transection of Sympathetic vs. Parasympathetic Innervation
and New Nerve‐Sparing Approaches M. Ceccaroni
8:45 Questions & Answers All Faculty
8:55 Break
9:10 The Difficult Parametrial Ureter Made Easy; Anatomy of the Parametrial
Tunnel, from Easy to Difficult J.F. Magrina
9:35 A Must for All Gynecologists: Bladder Anatomy: Blood Supply, Layers of
the Bladder Wall and Importance for Closure; Prevention and Repair of Bladder
and Ureteral Injuries; How to Perform Cystoscopy and Ureteral Stents P. P.G.
10:00 Vascular Disasters: The Large Pelvic Vessels: How to Avoid at Entry and
during Surgery, What to Do and Not to Do; Handling of Vascular Injuries
to Prevent Major Blood Loss and Death P.M. Magtibay
10:25 Identification and Preservation of Pelvic Somatic and Sensory Nerves in
Course of Pelvic Surgery: How to Prevent Severe Neural Injuries M. Ceccaroni
10:50 Questions & Answers All Faculty
11:00 Adjourn
1
PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Javier F. Magrina* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As-Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock Ownership: Titan Medical Karen C. Wang* FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Marcello Ceccaroni* Javier F. Magrina* Paul M. Magtibay* Paul P.G. Other: Honorarium for lecture: Ethicon Women’s Health & Urology Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.
2
Navigating through the Pelvic Wall: Opening Spaces to Control Bleeding (Uterine and Hypogastric Artery Ligation) and Prevent Nerve Injury
Javier F Magrina, MDMayo Clinic Arizona
Disclosures
• I have no financial relationships to disclose
Objectives
Discuss how to navigate and safely identify:
Lateral spaces
Vessels
Nerves
Enemies
• external and common iliac art.
• obturator nerve
• lumbosacral trunk
• ureters
Friends
• Superior vesical artery
• Uterine artery
• Internal iliac artery
3
Practical branching of internal iliac artery
• Anterior: superior vesical, uterine
• Lateral: int. pudendal, inf. gluteal
• Posterior: superior gluteal
Which internal iliac branch has the most different origins?
obturator artery
Ashley FL, Anson BJ. Am J Phys Anthropol28:381, 1941
Which internal iliac branch has the largest diameter?
4
• Which internal iliac branch has the largest diameter?
Superior gluteal (known as posterior branch)
5 mm diameter
2.7 cm distal to common iliac bifurcation
Posterior trunk right side
Internal iliac branches right side Internal iliac branches right side
Internal iliac artery identification
5
Uterine artery divisionWhy do you need to know pelvic
nerve anatomy?
6
R superior hypogastric plexus
Pelvic autonomic nerves
References
• Ashley FL, Anson BJ. Am J Phys Anthropol 28:381, 1941
Thank you
7
©2016 MFMER | slide-1
Presacral Space: Important Anatomy to Prevent Hemorrhage, Safe Dissection, Management of Presacral Bleeding, from Mild to Severe
Paul M Magtibay, MDMayo Clinic ArizonaNovember 14, 2016
©2016 MFMER | slide-2
I have no financial relationship to disclose.
©2016 MFMER | slide-3
Objectives
• Define the vascular anatomy and anatomic borders of the presacral space
• Discuss reasons for dissection of the space
• Discuss management of presacral bleeding*
• Demonstrate the dissection of the presacral space
©2016 MFMER | slide-4
• Boarders & Vasculature• Sacral Venous
Plexus• 2Lateral / 1Middle
• Internal Vertebral• Basivertebral
• Presacral Venous Plexus
• Retraction• Valveless system Harrison; Dis Colon Rectum 2003
©2016 MFMER | slide-5
Presacral Bleeding (1)
–Prevention• Know anatomic landmarks• Practice developing the space• Be smart
–Sacrocolpopexy–Rectal resection: benign versus malignant
versus presacral tumors–Use available technology: sealing devices–Be aware of hemostatic agents available
©2016 MFMER | slide-6
Presacral Bleeding (2)
• Preparation & Stabilization• Pressure• IV access• Massive Transfusion Protocol• Suction x 2 or x 3• Hands / Help
8
©2016 MFMER | slide-7
Presacral Bleeding (3)
• Control• Pressure ***• Electrocautery• Suture: caution
©2016 MFMER | slide-8
Presacral Bleeding (4)
• Control• Topical hemostatic agents:
• Floseal (bovine gelatin/human thrombin), Collagen hemostat (instat, avitene), Oxidized cellulose (surgicel, oxycel), Gelatin foam/sponge (gelfoam, surgifoam), Vasopressin (soaked packing), Fibrin glue, Thrombin, Arista
• Thumb tacks: nope• Bone wax: nope
©2016 MFMER | slide-9
Harrison; Dis Colon Rectum 2003
• 4 x 2 cm segment of rectus abdominis muscle
• Hold over bleeding with forceps
• Cautery at 100 Hz
• Vigorous suctioning
• Fragment may not “stick”
Presacral Bleeding (4)
©2016 MFMER | slide-10
Presacral Bleeding (5)
• Control• Tightly pack• Leave abdomen open• ICU
• Correct DIC• Bring back when more stable
©2016 MFMER | slide-11
Videos
©2016 MFMER | slide-12
9
©2016 MFMER | slide-13
Videos
©2016 MFMER | slide-14
©2016 MFMER | slide-15
References
• Harrison JL, Hooks VH, Pearl RK, et al; Muscle Fragment Welding for Control of Massive Presacral Bleeding During Rectal Mobilization: A Review of Eight Cases; Dis Colon Rectum 2003
©2016 MFMER | slide-16
Evaluation Question
• What is the best first move when you encounter a significant presacral bleed?
1. Utilize the muscle fragment welding technique
2. Place additional large bore IV’s
3. Apply direct pressure to bleeding site
4. Apply topical hemostatic agents
5. Utilize thumb tacks or bone wax
10
Sigmoidorectal Anatomy
Paul PG.MBBS,DGO
Paul’s Hospital, Kochi, India
Other: Honorarium for lecture: Ethicon Women’s Health & Urology
Objectives
Review the anatomy of sigmoid colon & rectum
Discuss the closure of large bowel & small bowel injuries
Describe the differences
Discuss the role of Bowel preparation
Sigmoid
S‐shaped distal portion of colon about 40 cm long
Definite mesentery
inferior mesenteric vessels(IMA), superior hypogastric plexus ,nerves & lymph nodes
Opening mesosigmoid window
fundamental surgical step of colorectal surgery
Rectum
Extends from S3 to upper limit of anal canal(10-15 cm) Proximal third intraperitoneal
Middle third covered by peritoneum continuous with POD
Distal third retroperitoneal
Rectum expands to rectal ampulla under Cul de sac
Blood supply
Sigmoid Sigmoid arteries (2-4) - branches of IMA
Rectum Superior rectal (branch of IMA) Middle rectal ( branch of hypogastric artery)
- anastomose with superior rectalMiddle rectal ‐minor blood supply‐ compromise of IMA blood supply (rectal dissection )‐ leakage at the colorectal anastomosis*
*Patricio J etal 1988
11
Blood supply
Small intestine Branches of superior mesenteric artery
Anastomose to form a series of arcades
Each branch of arcade supplies a small segment of intestine with little overlap of blood supply
Layers of colon
4 layers – mucosa, submucosa, muscularis and serosa
Submucosa contains blood vessels & Meissner plexus
Muscularis ‐ inner circular, outer longitudinal muscles and myenteric (Auerbach)nerve plexus
Teniae coli are formed by outer longitudinal muscles. 3 Teniaecoli coalesce to form complete longitudinal layer over rectum
Layers of small bowel
2 layers of muscle oriented at right angles Thin continuous longitudinal layer
Thicker circular inner layer
This 2 layer muscular arrangement provides safe guard against small perforating injuries (Muscular contraction seals off)
Closure of Small bowel injuries
Trocar injuries - check for through and through perforation
Repaired in 2 layers transversely to minimize stenosis
Laceration > half diameter - resection ,anastomosis
If mesenteric blood supply is interrupted - resection is done regardless the size of laceration*
*DeCherny AH 1988
Small bowel Trocar Injury Closure of small bowel injury
12
Rectosigmoid injury Is bowel prep necessary?
Mechnical bowel preparation prior to colorectal surgery Lower the risk of contamination - fewer infectious complications* Recent Cochrane review(4599 patients - majority open surgeries)** Patients who did not undergo bowel preparation , there was no difference in
rates of anastomotic leakage, mortality, peritonitis, reoperation, or wound infection.
Laparoscopy - effect of gravity on fecal matter within the bowel may provide a better surgical view***
*Hughes 1972**Guenega etal 2011***Bucher P etal 2005
Is bowel prep necessary?
Bowel without fecal and gaseous contents are easier to handle.
In deep endometriosis where bowel surgery is indicated an enema the night before is recommended
An additional enema 2-3 hours before surgery( colorectal surgeons*
*Fernandez R etal 2016
References
1. Bucher P,GervazP,SaroviaC etal.Randomized clinical trial of mechanical bowel preperationversus no preperation before elective left sided colorectal surgery.Br.J Surg2005;92:409-41
2. DeCherny AH. Laparoscopy with unexpected viscus penetration. In Nicholas DH ed.Clinical Problems, injuries and complications of gynecologic surgery. Baltimore:Williams & Wilkins, 1988:62-3
3. Guenega KF,Matos D,Wille-Jorensen P.Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2011.CD 0001544
4. Fernandez R et al. Exposure in laparoscopic surgery. In Jon Einarsson ed.Minimallyinvasivegyncologic surgery. London. JP Medical publishers,2016:9-15
5. Patricio J etal.Surgical anatomy of the arterial blood-supply of the human rectum. SurgRadiol Anat.1988;10(1):71-5Hughes ESR. Asepsis in large –bowel surgery.Ann R CollSurg Engl 1972;51:347-356
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Marcello Ceccaroni, M.D., Ph.D.
“How to find and preserve pelvic and autonomic nerves resecting endometriosis;consequences of transection of sympathetic VS parasympathetic innervation”
Director, Department of Obstetrics & Gynecology,Gynecologic Oncology and
Minimally-Invasive Pelvic Surgery Sacred Heart Hospital – Negrar (Verona), Italy
International School of Surgical Anatomy
mceccaroni@libero.it www.issaschool.com
The author of this presentation declares to have no conflict of
interest or financial relationships to disclose
ObjectivesReview the surgical anatomy of the visceral innervation of the female pelvis
Discuss operative technique to avoid damages to these structures during endometriosis surgery
WHAT CHANGED IN THE LAST CENTURYLaparoscopic/RoboticOncologic Surgery
Radical Surgery for Deep Endometriosis
and Cancer
Nerve Sparing Techniques
New and ModernRadical Pelvic Surgery
New anatomical studies(cadavers, human living models)
New anatomical nerve sparing landmarks (Middle Rectal Artery, Deep Uterine Vein,Superior Vesical Vein)
Laparoscopic/RoboticMagnification
Pelvic Neuro-NavigationImprovement of Electric surgery
Endometriotic foci sorrounding a nerve
CD10 highlights the endometriotic stroma
S100 positive nerve fibers
Severe Endometriosis andnerves-involvement
Radical surgery for Genital Cancer and Deep Infiltrating Endometriosis:an “onco-mimetic” surgery
(Ceccaroni M. et al, 2006)
Visceral resections:Ovarian Cancer
Parametrial resections:Cervical Cancer
Cancer Endometriosis
14
Laparoscopic dissection of left lateral and medial para-vesical space in DIE Laparoscopic dissection of left medial and lateral para-rectal space in DIE
Lympho-Vascular and Parametrial tissues of female pelvis
Anterior Parametrium
Uterus
Bladder
Ureter
Posterior ParametriumLateral Parametrium
Anterior Parametrium
Cranialportion of VUL
Caudalportion of VUL
Ceccaroni M., et al. CIC ed., 2006.
Recto-Vaginalligament
Uterus Bladder
Ureter
Promontorium
Cardinalligament
Postero-lateral parametrium:Recto-vaginal ligaments, Lateral Rectal Ligaments,
Cardinal ligament/Paracervix
(Ceccaroni M et al, 2006, 2013)
“..the so-called rectal pillar(otherwise referred to as dorsal or posterior parametrium) is defined after surgical opening of the rectovaginal septum and pararectal spaces. The rectal pillarcorresponds to the uterosacral ligament plus the rectouterine and rectovaginal ligament.It can be separated surgically from the hypogastric nerve that runs lateral to it..”
D. Querleu, C.P. Morrow,Lancet Oncol 2008; 9: 297–303
“..the so-called rectal pillar(otherwise referred to as dorsal or posterior parametrium) is defined after surgical opening of the rectovaginal septum and pararectal spaces. The rectal pillarcorresponds to the uterosacral ligament plus the rectouterine and rectovaginal ligament.It can be separated surgically from the hypogastric nerve that runs lateral to it..”
D. Querleu, C.P. Morrow,Lancet Oncol 2008; 9: 297–303
Laparoscopic surgical anatomy of Autonomic visceral pelvic nerves
(Ceccaroni M et al, 2006)
SHP
HN
RLLR
SB
WHeHe
IMP
IMV
A SB
SHP
HN HN
WHe
PSN PP LLR
R
IV
RVL
RVL
IV
IV
IV
R
IVPM
PM
Ceccaroni M, et al. “Neuro-anatomy of posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery”; Surg Endosc. 2013
Postero-lateral parametrium and its ligaments
15
R
V
SB
RLLR
O
PR
U
USRVL
LLR
LLR
W
CB
CB
U
UR
US
RVLLLR
R
D
PSN
PP
CL
ASB
PSNSR
PP
LLR
SB
Ur
Postero-lateral parametrium and its ligaments
M
SHP
SB
HN
HN
WR
He
LLR
PSN
PP
PP
HePSN
He
UR MRA
R
DUV RVL
LLR
M
M
U B
R
US
LLR
RVL
US
Ceccaroni M, et al. “Neuro-anatomy of posteriorparametrium and surgical considerations for a
nerve-sparing approach in radical pelvic surgery”;Surg Endosc. 2013
CL
Postero-lateral parametrium and its ligaments
Classical Technique for DSELaparoscopic surgical anatomy recto-vaginal space
www.issaschool.com
Nerve-Sparing Technique for DSE Sparing visceral innervationin radical pelvic surgery
IIAP
Rectum
Hypogastric Nerves
UreterSHP
HN
SHP
PSN
IHP
(Ceccaroni M, et al, J Spinal Disord Tech. 2011; Ceccaroni M, et al. JMIG 2010, Ceccaroni M, et al. AJOG 2010; Ceccaroni M, et al, Surg Rad Anat 2010; Landi S, Ceccaroni M, et al. Hum Reprod 2006; Ceccaroni M, et al, Eur J Ob & Gyn Reprod Biol.2010; Volpi E, et al, Surg Endosc 2004; Possover M, et al, Obstet Gynecol 2000, Kavallaris A., et al, Arch Gynecol Obstet 2010, Ceccaroni M et al, Surg Endosc 2012)
16
(Nerve Sparing Technique) (“Classical” Technique)
www.issaschool.com
Relationships btw fasciae and planes: Heald’s “Holy Plane”,Recto-Sacral space and Waldeyer’s fascia
Ercoli A, Delmas V, Fanfani F, Gadonneix P, Ceccaroni M, Fagotti A, Mancuso S, Scambia G. Am J Ob & Gyn, 193(4):1565-73, October 2005
Rectum-mesorectum wrapped
into fascia recti
(M. Ceccaroni, A. Maggioni, Paris 2008)
(Ceccaroni M. et al, 2006)
Surgical parametrial steps and sites at higher risk of denervation during
Radical Pelvic Surgery
D) Separation of the lateral sheet of the presacral Visceral Pelvic Fasciawhich contains the nerve structures, from the deep portions of recto-vaginal and vesico-uterine ligaments fibers
B) Identification of nerve roots and fibers
F) Functional cartography of Pelvic Plexus
A) Development of real and virtualavascular spaces and fascial planes
I) Know-how/nerve-sparing “Good Manners”
G) Selective neuro-ablation
E) Identification of nerve-sparingSurgical Landmarks(Middle Rectal Artery, Deep Uterine Vein, Superior Vesical Vein)
C) Knowledge of anatomy of pelvicneural pathways
(Ceccaroni M, et al, 2006)
Principles and tricks forNerve-Sparing Radical Pelvic Surgery
H) Tailoring the level of resection/colpectomy
« The Negrar Method »: Nerve-Sparing laparoscopic radical excision of deep endometriosis with
segmental rectal and parametrial resection
(Ceccaroni M, et al, J Spinal Disord Tech. 2011; Ceccaroni M, et al, Eur J Ob & Gyn Reprod Biol.2010; Ceccaroni M, et al. JMIG 2010; Ceccaroni M, et al. AJOG 2010;
Ceccaroni M, et al, Surg Rad Anat 2010; Landi S, Ceccaroni M, et al. Hum Reprod 2006; Volpi E, et al, Surg Endosc 2004; Possover M, et al, Obstet Gynecol 2000, Kavallaris
A., et al, Arch Gynecol Obstet 2010, Ceccaroni M et al, Surg Endosc 2012)
17
Laparoscopic retroperitoneal dissection of visceral innervationof the pelvis in pre-sacral space
Laparoscopic retroperitoneal dissection of visceral innervationof the pelvis in pre-sacral space
“The Negrar Method”: Nerve-Sparing laparoscopic radical excision of deep endometriosis with segmental rectal and parametrial resection
“The Negrar Method”: Nerve-Sparing laparoscopic radical excision of deep endometriosis with segmental rectal and parametrial resection
THANK YOU
Aknowledgements:
Dr. R. Clarizia, Dr. G. Roviglione,
Dr. F. Bruni,Dr. M. Mabrouk,
Dr. M. Lamanuzzi,Dr. C. Kiefert
Prof. L. Bovicelli
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Tunnel, from Easy to Difficult
Javier F Magrina, MDMayo Clinic Arizona
The Difficult Parametrial Ureter Made Easy;Anatomy of the ParametrialTunnel, from Easy to Difficult
Disclosures
I have no financial relationships to disclose
Objectives
• Parametrial ureteral anatomy
• Prevention of injury at endoscopic hysterectomy
• Ureterolysis: mild, severe, impossible
\
The incidence of ureteral injuries in gynecologic laparoscopic surgery during the past 15 years has:
• A. decreased
• B. remained the same
• C. increased
• D. don’t know
Laparoscopic ureteral injuriesYear %
2002 0.03‐0.5* (1.7)
2009 0.03‐0.7** (1.6)
2014 0.02‐0.4***
*Clin Obstet Gynecol 45: 469, 2002
**Clin Obstet Gynecol 52:201, 2009
***JMIG 21:558, 2014 (only hyst)
Open + vaginal hyst 1984‐90 0.3‐1.5%
Complex robotic hyst 1.7% Obstet Gynecol 114:585, 2009
URETERAL INJURIES IN GYNECOLOGIC SURGERY 1939‐98
No. %
Post‐operative 107,068 0.1
Intra‐operative 3,235 0.6
1939-9829 studiesObstet Gynecol, 1999; 94:883
19
Intra vs postoperative diagnosis of ureteral injury : is there a difference for the necessity of surgical repair?
intraop dx : 14 % 9 %
postop dx : 86 % 61%
N=157 Lit review
JMIG 2014; 21:558
Parametrial ureter
How close can the ureter be to the cervix?
• A. < 0.5 cm
• B. 1 cm
• C. 1.5 cm
• D. 2.0 cm
20
How close are the ureters to the cervix?
12% of ureters are within 0.5 cm
=
1 in 8 patients
Obstet Gynecol 184:336, 2001
Identifiying ureter at cardinal lig
Identifiying ureter at cardinal lig
21
R ureter at colpotomy R ureter at colpotomy
Blocked L ureter vaginal cuff
Laparoscopic ureteral injuriesNeed for ureteral
surgery
intraop dx : 14 % 9 %
postop dx : 86 % 61%
N=157 Lit review
JMIG 2014; 21:558
Your patient has low urinary output and flank pain after
hysterectomyOptions to check for ureteral obstruction
• Serum creatinine
• Renal ultrasound
• Retrograde ureteral stent
• Antegrade ureteral stent
22
Parametrial ureteral dissection
References
Clin Obstet Gynecol 45: 469, 2002
Clin Obstet Gynecol 52:201, 2009
JMIG 21:558, 2014
Obstet Gynecol 114:585, 2009
Obstet Gynecol 184:336, 2001
Thank you
23
A Must For All GynaecologistsBladder Anatomy
Paul PG. MBBS,DGO
Paul’s Hospital, Kochi, India
Other: Honorarium for lecture: Ethicon Women’s Health & Urology
Objectives
To review Bladder anatomy
Discuss methods for Prevention of Bladder & ureter injuries
Video demonstration of repair of bladder& ureteric injuries
Video demonstration of Cystoscopy & insertion of ureteral stents
Bladder – Muscle layers
Dome (β cholinergic)& Base (α adrenergic) Detrusor – Mesh work of intertwining muscle bundles Internal longitudinal Median circular External longitudinal
Base – Trigone & U shaped band of musculature(Detrusor Loop)
Trigone is made of muscle that arises from ureters & continues as vesical neck & urethra
Blood supply
Superior vesical artery from non obliterated portion of
umbilical artery
Supply Dome of bladder
Inferior vesical artery Branch of Internal iliac
Supply Base & Trigone
Bladder InjuriesRisk Factors
Placement of suprapubic trocars full bladder, Previous caesarean
During adhesiolysis
LAVH Inadequate dissection of bladder & Vaginal closure*
Total Lap hysterectomy
Previous caesarean ***Kadar Netal1994 **Rooney CM, 2005
24
Trocar Injury Prevention
Empty bladder before suprapubic trocars
identify the upper border of bladder
Bladder to be displaced 2-3cm beyond colpotomy site(LAVH/TLH)
PP
Prevention
Identifying Bladder Margins Distend bladder with 200 ml with or without dye stained lactated
Ringers solution
Limiting blunt dissection*
Sheth’s uterocervical broad ligament space for previous caesarean**
*Utrie JW Jr. 1998
**Sheth SS.2005
Bladder dissection‐Previous Cesareanuterocervical broad ligament space
Recognition
Gas in the urinary bag
Retrograde instillation of dye
Cystoscopy Only 35% are recognized during hysterectomy before
cystoscopy*
*Vakili B etal2005,
Bladder Diathermy injuryprevious caesarean section
25
Slide 8
PP1 Paul PG, 9/10/2016
PP2 Paul PG, 9/10/2016
26
Repair
Delineation of injury Trigone, ureters vaginal cuff proximity
Laparoscopic closure Water tight full thickness closure 2-0/3-0 vicryl continuous or interrupted sutures 1-2 cm apart Avoiding mucosa is difficult & unnecessary* 2 Layer closure demonstrate decreased rate of vesicovaginal
fistula in animal model***Wohlrab KJ 2011**Sokol AI2004
Bladder injuryPelvic abscess
Other considerations
Injuries close to other suture lines Increased chance of fistula
Omental graft / peritoneal imbrication
Fibrin sealants more inflammation & poor strength*
EndoGIA stapler,Lapra-Ty,Barbed sutures Not recommended
*Borin JF2008
Postoperative management
Continuous bladder drainage Foley’s catheter -2 weeks or less*
Prophylactic antibiotics ?
Role of cystography before removal
Wohlrab etal.2011
Ureteral InjuriesPrevention
Common sites of injury
80% occur at the ureteral jn with uterine artery*
Risk factors
Previous pelvic surgery
Adhesions ,endometriosis
Enlarged uterus, cervical/broad ligament fibroids,
Urinary tract Anomalies
*Ibeanu OA 2009
Ureteral InjuriesPrevention
Identification Visual identification, ureterolysis in extensive pelvic disease Ureteral stents –No significant differences in incidence of
surgery*
cephalad pressure with Cervical cup of uterine manipulator.
Careful closure of vaginal cuff – Avoid anchoring stitch lateral to cuff margin
*Chou MT 2009
27
Ureteric transection Ureteric repair
Standard TreatmentLaparotomy - Ureter implantation with or without Boari Flap Intraoperative recognition – immediate Postoperative recognition Ureteral stents if partial Reapiar 6 wks later with percutaneous nephrostomy tube if not fit
Mode of Repair Upper third – ureteroureterostomy Middle third –ureteroureterostomy with or without Boari Flap Pelvic ureter - Ureteroneocystostomy with psoas hitch
Laparoscopic Anastomosis
Laparoscopic ureteral repair is comparable to open repair*
Laparoscopic reanastomosis of 29 women with ureteral transection was succesful in all. Laparoscopic management could become the prefered first line of mangement**
*Cholkeri-Singh A etal2007
**Cicco CD etal.2009
Laparoscopic ureteric anastomosis
Cystoscopy - Instrumentation
Diagnostic hysteroscopy instrumentation
Distention medium - Normal Saline
Full bladder survey - Bladder dome & base
Ureteric orifices for urine reflux Intravenous indigo carmine / Methylene blue / None
Cystoscopy
28
Universal cystoscopy
Detection of urinary tract injury 25.6% to 97.4% after universal cystoscopy*
Negative cystoscopy doers not guarantee lack of injury –partial obstruction**
Recommended when bladder or ureters may be injured****Ibeanu OA etal 2009
**Dandolu V etal 2003
***ACOG Committee Opinion 2007
Ureteral stenting
References1. ACOG Committee Opinion #372. The role of cystourethroscopy in the generalist obstetrician-
gynecologist practice. Obstet Gynecol. 2007;110:221–224.
2. Borin JF, Deane LA, Sala LG, et al. Comparison of healing after cystotomy and repair with fibrin glue and sutured closure in the porcine model. J Endourol. 2008;22:145–150
3. Cholkeri-Singh A, Narepalem N, Miller CE. Laparoscopic ureteral injury and repair: case reviews and clinical update. J Minim Invasive Gynecol. 2007;14: 356-361.
4. Cicco CD etal. Laparoscopic mangement of ureteral lesions in gynecology.Fertl Sterl 2009;92:1424-7
5. Chou MT, Wang CJ, Lien RC. Prophylactic ureteral catheterization in gynecologic surgery: a 12- year randomized trial in a community hospital. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(6):689-693.
6. Dandolu V, Mathai E, Chatwani A, et al. Accuracy of cystoscopy in the diagnosis of ureteral injury in benign gynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunct.
7. Ibeanu OA, Chesson RR, Echols KT, Nieves M, Busangu F, Nolan TE. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol. 2009;113(1):6-10
8. Kadar N, Lemmerling L. Urinary tract injuries during laparoscopically assisted hysterectomy: causes and prevention. Am J Obstet Gynecol. 1994;170:47–48
References
7. Rooney CM, Crawford AT, Vassallo BJ, et al. Is previous cesarean section a risk for incidental cystotomy at the time of hysterectomy? A case-controlled study. Am J Obstet Gynecol. 2005;193:2041–2044
8. Sokol AI, Paraiso MF, Cogan SL, et al. Prevention of vesicovaginal fistulas after laparoscopic hysterectomy with electrosurgical cystotomy in female mongrel dogs. Am J Obstet Gynecol. 2004;190:628–633.
9. Utrie JW Jr. Bladder and ureteral injury: prevention and management. Clin Obstet Gynecol. 1998;41(3):755‐763
10. Vakili B, Chesson RR, Kyle BL, et al. The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol. 2005;192:1599–1604.
11. Wohlrab KJ , Sung VW, Rardin CR. Management of laparoscopic bladder injuries. JMIGS.2011;18:4‐8
29
©2016 MFMER | slide-1
Vascular Disasters: The Large Pelvic Vessels: How to Avoid at Entry & during Surgery, What to Do and Not to Do; Handling Vascular Injuries to Prevent Major Blood Loss & Death
Paul M Magtibay, MDMayo Clinic ArizonaNovember 14, 2016
©2016 MFMER | slide-2
I have no financial relationship to disclose.
©2016 MFMER | slide-3
Objectives
• Review pros of open technique versus closed laparoscopy
• Demonstrate the technique for open laparoscopy
• Identify important vascular anatomy of the pelvis
• Discuss management of vascular injuries
• Demonstrate some potential vascular catastrophes
©2016 MFMER | slide-4
How To Avoid Vascular Injury At Entry
©2016 MFMER | slide-5
Anatomy Clamente 3rd
edition
©2016 MFMER | slide-6
30
©2016 MFMER | slide-7 ©2016 MFMER | slide-8
Mayo DataLong 2008
©2016 MFMER | slide-9
Meta-analysisLarobina 2005
• 22,500 open versus 761,000 closed cases• Enterotomy rate same (0.049% versus 0.067%)• Vascular injuries
• 0% open versus 0.044% closed (p=0.003)• No fatal vascular injuries in open laparoscopy• Most litigation
©2016 MFMER | slide-10
Technique• Hasson Technique.mp4
©2016 MFMER | slide-11
What to Do and Not to Do
©2016 MFMER | slide-12
Vascular InjuryWhat to Do
• Direct pressure: sponge with suction
• Increase abdominal pressure: 20-25 mm Hg• Alert anesthesia, MTP, vascular surgery & tray
• If controlled, assess trocar placement• Clips (caution); suture with Lapra-Ty; bull dogs
or Satinsky; hemostatic agents
31
©2016 MFMER | slide-13
Vascular InjuryWhat to Do
• Low threshold to CONVERT to laparotomy• Keep pneumoperitoneum while opening• Exposure, pack, catch-up and calm down
©2016 MFMER | slide-14
Vascular InjuryWhat NOT to Do
• Panic
• Blindly cauterize or suture
• Use crushing clamps
• Slow to convert
• Not rehearse
©2016 MFMER | slide-15
Vascular InjuryWhat NOT to Do
©2016 MFMER | slide-16
References• Anatomy: A Regional Atlas of the Human Body. Clamente CD. 3rd
edition
• Long JB, Giles DL, Cornella JL et al: Open Laparoscopic Assessment Technique: Review of 2010 Patients. JSLS 2008; 12:372.
• Larobina M, Nottle P. Complete evidence regarding major vascular injuries during laparoscopic access. Surg Laparosc Endosc PercutanTech 2005; 15:119
©2016 MFMER | slide-17
32
Marcello Ceccaroni, M.D., Ph.D.
“Identification and preservation of pelvic somatic motor and sensory nerves in course of pelvic
surgery: how to prevent severe neural injuries”
Director, Department of Obstetrics & Gynecology,Gynecologic Oncology and
Minimally-Invasive Pelvic Surgery Sacred Heart Hospital – Negrar (Verona), Italy
International School of Surgical Anatomymceccaroni@libero.it www.issaschool.com
The author of this presentation declares to have no conflict of interest or financial
relationship to disclose
Objectives
Review the surgical anatomy of the somatic innervation of the female pelvis
Discuss operative technique to avoid damages to these structures during endometriosis surgery
Neurological complications
• NEUROABLATIVE DAMAGE (due to radicality)
• IATROGENIC DAMAGE (due to a mistake)
• TYPE OF DAMAGE: Visceral/Somatic/Mixed (due to the type of nerve), Functional/Anatomical
• Neurological complications can often be overlapped to pre-existing neurological dysfunctions related to disease and/or previous surgery
• Neuroablative and Iatrogenic damages can be associated
5
Vegetative visceral compartment
Somatic compartment
Inferior mesenteric plexus
Superior hypogastric plexus (SHP)
Hypogastric nerves (HN)
Ortosymphatetic lumbar chain
Pelvic splanchnic nerves
Inferior hypogastric plexus (IH) or pelvic plexus (PP)
Lumbar plexus
Sacral plexus
Lumbo-sacral trunk
Pudendal nerve
Obturator nerve
Genito-femoral nerve
Sciatic nerve
Femoral nerve
International School of Surgical Anatomy, 2009 International School of Surgical Anatomy, 2009
Nervous SystemNervous System Anatomical remarksAnatomical remarks Sacral PlexusNerve Segment Innervated muscles
Cutaneous branches
Superior gluteal L4-S1Gluteus mediusGluteus minimusTensor fasciae latae
Inferior gluteal L5-S2 Gluteus maximus
Posterior cutaneous femoral
S1-S3
Posterior cutaneous femoral • Inferior cluneal nerves• Perineal branches
Direct branches from plexus
• Piriformis S1-2 Piriformis
• Obturator internus
L5, S1-2Obturator internus and Superior gemellus
• Quadratus femoris
L4-5, S1Quadratus femoris and Inferior gemellus
Sciatic
Sciatic L4-S3
Semitendinosus (Tib)Semimembranosus (Tib)Biceps femoris• Long head (Tib)• Short head (Fib) Adductor magnus(medial part, Tib)
Common fibular L4-S2
Lateral sural cutaneousCommunicating fibular
• Superficial fibular
Peroneus longusPeroneus brevis
Medial dorsal cutaneousIntermediate dorsal cutaneous
• Deep fibular
Tibialis anteriorExtensor digitorum longusExtensor digitorum
Lateral cutaneous nerve of big toe
POSITION located on the border of piriformis muscle
33
7
Anatomical remarksAnatomical remarks
Somatic compartment
Lumbar plexus
Sacral plexus
Lumbo-sacral trunk
Pudendal nerve
Obturator nerve
Genito-femoral nerve
Sciatic nerve
Femoral nerve
Endometriosis and somatic nerves
Endometriosis and somatic nerves
• Endometriotic or fibrotic involvement of somatic nerves,sacral plexus and sacral roots are very common causes ofpelvic and ano-genital pain (39%)Nehme-Schuster et al., Lancet 2005; Possover et al., Fertil Steril 2007
• When endometriosis develops as parametrial diseaseextending to the pelvic wall, a frequent involvement ofsomatic nerves is found
•Possover et al., J Urol 2009, Ceccaroni et al., Surg Rad Anat 2010
• Often difficult differential diagnosis• Patients observed after years of disease’s progression without a
precise diagnosis• “Pilgrimage” between orthopaedics, neurosurgeons and
gynaecologists
•Often resistant pain, not healed by NSAIDs (FANS) or opioids
Robert et al., Eur Urol 2005; Possover et al., Min Invas Neurosurg 2007;
Ceccaroni, Clarizia et al., Surg Rad Anat 2010,
Ceccaroni, Clarizia et al., J Spin Disorders 2011,
Ceccaroni, Clarizia et al., Eur J Obst Gyn 2011
•Surgical decompression/neurolysis revealed to be effectivein pain relief, comparable to neuromodulation
DiagnosisDiagnosis
Endometriosis and somatic nervesEndometriosis and somatic nerves
Trans-perineal approach
Trans-gluteal approach
“Open” approach
Laparoscopic approach
Laparoscopic Neuro Navigation (LANN)
Sacral Neuromodulation
Endometriosis and somatic nerves
Endometriosis and somatic nerves
Surgical ApproachSurgical Approach
Ceccaroni M, Clarizia R, Cosma S, Pesci A, Pontrelli G, Minelli L.
Laparoscopic neurolisys for deep endometriosis infiltrating pelvic wall and somatic nerves: a retrospective study on 216 patients
Ceccaroni M. et al., WCE, San Paulo, May 2014
Laparoscopic neurolisys for deep endometriosis infiltrating pelvic wall and somatic nerves: a retrospective study on 216 patients
Ceccaroni M. et al., WCE, San Paulo, May 2014
EvidencesEvidences
ORIGIN Sacral plexus (S2‐S4)
TYPEmixed, sensitive and motor, somatic and visceral
COURSEGreat sciatic foramen, small sciatic foramen, Alcock canal, Perineum
FUNCTION
sensitive innervation to the perineum, external genitalia, anal region; motor innervation to the uro‐genital diaphragm muscles and clitoris; orgasm
LESIONSAlcock’s canal syndrome, ano‐genital pain, reduced sexual arousability/orgasm
Anatomical remarksAnatomical remarks
PUDENDAL NERVE
34
Endometriosis and somatic nerves
Endometriosis and somatic nerves
Medial Approach
PARARECTAL AND
RETRORECTAL SPACES
LaparoscopicSurgical Approaches
LaparoscopicSurgical Approaches
Lateral approach
ILEOLUMBAR SPACE
Ceccaroni M., 2010 Ceccaroni M., 2011
(Right side-wall)
(Ceccaroni M, et al 2006)
(Ceccaroni M, et al. Surg Rad Anat, 2010)
(Right side-wall)
(Right side-wall)
(Possover M, et al. Minim Invas Neurosurg; Possover M, et al. FertilSteril 2007; Ceccaroni M, et al. Surg Rad Anat 2010;Ceccaroni M, et al, Eur J Ob & Gyn Reprod Biol.2010;Ceccaroni M, et al, J Spinal Disord Tech. 2010, in press; )
Laparoscopic Neurolysis of the Sacral Plexus and the Sciatic Nervefor extensive endometriosis of the pelvic wall
Laparoscopic Neurolysis of the Sacral Plexus and the Sciatic Nervefor extensive endometriosis of the pelvic wall
(Possover M, et al. Minim Invas Neurosurg; Possover M, et al. Fertil Steril 2007;Ceccaroni M, et al. Surg Rad Anat 2010; Ceccaroni M, et al, Eur J Ob &Gyn Reprod Biol.2010, Ceccaroni M, et al, J Spinal Disord Tech. 2010, in press;)
(Right side-wall)
(Leftt side-wall)
(Ceccaroni M, et al 2006)
(Right side-wall)
Laparoscopic Neurolysis of the Sacral Plexus and the Sciatic Nervefor extensive endometriosis of the pelvic wall
Laparoscopic Neurolysis of the Sacral Plexus and the Sciatic Nervefor extensive endometriosis of the pelvic wall
(Possover M, et al. Minim Invas Neurosurg; Possover M, et al. Fertil Steril 2007;Ceccaroni M, et al. Surg Rad Anat 2010; Ceccaroni M, et al, Eur J Ob & Gyn ReprodBiol.2010, Ceccaroni M, et al, J Spinal Disord Tech. 2011)
www.issaschool.com
Laparoscopic Neurolysis of the Sacral Plexus and the Sciatic Nervefor extensive endometriosis of the pelvic wall
Laparoscopic Neurolysis of the Sacral Plexus and the Sciatic Nervefor extensive endometriosis of the pelvic wall
(Ceccaroni M, et al 2006)
(Right side-wall)
17
ORIGIN L1‐L2 Roots
TYPE pure sensitive somatic
COURSEPsoas muscle genital branch inguinal canal femoral branch beneath inguinal ligament
FUNCTIONSsensitive innervation genital branch Mons Veneris, medial thighfemoral branch cranial and lateral thigh
LESIONS hypoaesthesiaCeccaroni M, Fanfani F, Ercoli A, Scambia G. Innervazione viscerale e somatica della
pelvi femminile. Testo-Atlante di anatomia chirurgica. CIC editore 2006.
GENITO-FEMORAL NERVE
Iatrogenic LesionsIatrogenic Lesions
Ceccaroni M., 2013
Obturator nerve repair after debulking surgery and neurolysis,by end end-to end anastomosis
Obturator nerve repair after debulking surgery and neurolysis,by end end-to end anastomosis
LESIONS Abductor hyposthenia; enlarged march
35
(Ceccaroni M, et al, 2006, 2009, 2010)
Iatrogenic lesions of visceral and somatic nerves: Sacral Plexus, Sacral roots, Pelvic Plexus and Pudendal nerve
Iatrogenic lesions of visceral and somatic nerves: Sacral Plexus, Sacral roots, Pelvic Plexus and Pudendal nerve
LESIONS
-Impaired flexo-extension of thigh/leg, sciatica, hypoaesthesia,-Chronic pain refractory to opioids-Impaired pelvic floor muscular functions/hypo-hyperthonus-Impaired bladder, rectal functions-Alcock’s canal syndrome, ano-genital pain, reduced sexual arousability/orgasm
ORIGIN Lumbo‐sacral plexus (L4‐S3)
TYPEmixed, sensitive and motor, somatic
COURSEgreat sciatic notch, buttock, thigh, leg, tibial/common peroneal
FUNCTIONS
sensitive innervation of buttock, thigh, leg, foot;motor innervation to the posterior thigh, leg and foot muscles.
LESIONSSciatica, hypoaesthesia, flexion defect of the leg
Anatomical remarksAnatomical remarks
SCIATIC NERVE
21
ORIGIN Lumbar plexus, L2‐L4 roots
TYPEmixed somatic, sensitive and motor
COURSEPsoas dorsal margin; interior obturator muscle; obturator foramen
FUNCTIONSsensitive innervation medial thigh; motor innervation abtuctor muscles of the thigh
LESIONS Abductor hyposthenia; enlarged march
OBTURATOR NERVE
Anatomical remarksAnatomical remarks
22
ORIGIN Lumbar plexus, L2‐L4 roots
TYPEmixed somatic, sensitive and motor
COURSEPsoas lateral margin; iinguinal ligament; Scarpa triangle; articular branches
FUNCTIONS
sensitive innervation anteromedial thigh; medial leg and footmotor innervation extension muscles of the knee (quadriceps femoralis), flexor muscles of the hip (pectineus, sartorius, iliacus)
LESIONS Leg extension deficit, knee flexor deficit
Anatomical remarksAnatomical remarks
FEMORAL NERVE
Iatrogenic lesions of somatic nerves: Femoral nerve
Iatrogenic lesions of somatic nerves: Femoral nerve
LESIONS-Leg extension deficit,- Knee flexor deficit,- Impaired march
(Ceccaroni M et al, 2006)
www.issaschool.com
Laparoscopic surgical anatomy of Autonomic visceral pelvic nervesLaparoscopic surgical anatomy of Autonomic visceral pelvic nerves
36
(Ceccaroni M, et al, J Spinal Disord Tech. 2011;Ceccaroni M, et al, Eur J Ob & Gyn Reprod Biol.2010; Ceccaroni M, et al AJOG 2010;Ceccaroni M, et al, JMIG 2010;Ceccaroni M, et al, Surg Rad Anat 2010;Landi S, Ceccaroni M, et al, Hum Reprod 2006;Volpi E, et al, Surg Endosc 2004;Possover M, et al, Obstet Gynecol 2000)
Right Hypogastric nerve injury
Superior Hypogastric Plexus and Hypogastric nerves preservation
Iatrogenic and radicality-related lesions of visceral pelvic nervesIatrogenic and radicality-related lesions of visceral pelvic nerves
Laparoscopic rectal resection for DIE
(Classical Technique)
(Ceccaroni M, et al, J Spinal Disord Tech. 2011; Ceccaroni M, et al, Eur J Ob & Gyn Reprod Biol; Ceccaroni M. et al, JMIG 2010, Ceccaroni M. et al, Surg Rad Anat 2010; Ceccaroni M, et al, AJOG 2010; Landi S,Ceccaroni M, et al, Hum Reprod 2006)
(Ceccaroni M, et al, 2006)
Iatrogenic lesions ofvisceral nerves
Iatrogenic lesions ofvisceral nerves
The “dark side” of radical pelvic surgeryThe “dark side” of radical pelvic surgery
Unrecoverable neurologic damage,Sacral neuromodulation,
Psycho-social burden
Unrecoverable neurologic damage,Sacral neuromodulation,
Psycho-social burden
(Possover 2000, 2002, 2003, 2005, Volpi 2004, Darai 2005, Fanfani 2009, Landi 2006, Dubernard 2006, 2007, 2008, Deffieux 2007,
Ceccaroni , 2006, 2009, 2010, 2011, 2012, Roman , 2010, Kovoor, 2011)
Bladder Dysfunctions (0-20%)Ano-Rectal Dysfunctions (7-27%)
Sexual Dysfunctions (8-54%)
Bladder Dysfunctions (0-20%)Ano-Rectal Dysfunctions (7-27%)
Sexual Dysfunctions (8-54%)
ConclusionsConclusions
2) Anatomical knowledge is a key for a better know-how and for a safe endoscopic surgery, minimizing the risks of neurological complications
4) Laparoscopic approach is the less invasive and the more accurate and effective treatment offering p
7) Gynecologist is supposed to be the most indicated and expert specialist do diagnose/treat this condition and to offer the adequate care to these “orphan” patients
8) Considering that this kind of surgery requires uncommon surgical skills and anatomical knowledge, it should be performed only in selected reference centres
6) Involvement of somatic nerves in DIE is not an uncommon condition, undiagnosed or misdiagnosed in the majority of cases
5) Repair of some neurological damages is feasible by laparoscopy if promptly recognised
1) Neurological damage during laparoscopic pelvic surgery may lead to unrecoverable motoric/sensorial or functional impairment in young women treated also for benign conditions (i.e. DIE)
3) Nerve-Sparing procedures successfully treat the disease with an adequate radicality, offering good
Aknowledgements:Dr. R. Clarizia, Dr. G. Roviglione,
Dr. F. Bruni, Dr. M. Mabrouk,Dr. M. Lamanuzzi,Prof. L. Bovicelli
THANK YOU
37
CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as
the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians
(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which
recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).
California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws
identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org
Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from
discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national
origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the
program, the importance of the services, and the resources available to the recipient, including the mix of oral
and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.
Executive Order 13166,”Improving Access to Services for Persons with Limited English
Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,
including those which provide federal financial assistance, to examine the services they provide, identify any
need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.
Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every
California state agency which either provides information to, or has contact with, the public to provide bilingual
interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.
~
If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.
A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
US Population
Language Spoken at Home
English
Spanish
AsianOther
Indo-Euro
California
Language Spoken at Home
Spanish
English
OtherAsian
Indo-Euro
19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%
38
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