didactic: pelvic anatomy roadmap: surgical navigation ... · femoral nerve psoas iliacus femoral...

Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Didactic: Pelvic Anatomy Roadmap: Surgical Navigation & Repair of Complications

PROGRAM CHAIR

Javier F. Magrina, MD

Kristina A. Butler, MD Mario M. Leitao, MD Paul M. Magtibay, 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 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 Lateral Pelvic Wall: How to Navigate through the Lateral Spaces to Safely Identify Important Vessels and Nerves, Bleeding Control: Uterine and Hypogastric Artery Ligation J.F. Magrina ................................................................................................................................................... 3 Presacral Space: Anatomy, Dissection, Management of Presacral Bleeding from Mild to Severe P.M. Magtibay ............................................................................................................................................... 6 Colorectal Anatomy, Role of Bowel Preparation and Management of Colorectal Injury M.M. Leitao ................................................................................................................................................... 8 Retroperitoneal Nerves: Dissection, Identification, Sacral Nerve Roots, Prevention and Management of Nerve Injury K.A. Butler ................................................................................................................................................... 12 Parametrial Ureter: Anatomy: Ureteral Dissection, from Easy to Difficult J.F. Magrina ................................................................................................................................................. 17 Prevention and Repair of Urologic Injuries: A Must for All Gynecologists; Use of Cystoscopy P.M. Magtibay ............................................................................................................................................. 20 Anatomy of Large Pelvic Vessels and Handling Major Vascular Injuries M.M. Leitao ................................................................................................................................................. 22 Aortic Anatomy in Gynecology: Dissection, Exposure, Vascular Anomalies K.A. Butler ................................................................................................................................................... 27 Cultural and Linguistics Competency ......................................................................................................... 32

ANAT-‐607 Didactic: Pelvic Anatomy Roadmap:

Surgical Navigation & Repair of Complications

Javier F. Magrina, Chair

Faculty: Kristina A. Butler, Mario M. Leitao, Paul M. Magtibay This course provides a review of the intraperitoneal and retroperitoneal pelvic anatomy applied to MIS gynecologic surgery. Retroperitoneal anatomy as it applies to prevention of ureteral dissection, management of pelvic bleeding including presacral bleeding, prevention of nerve injuries, and dissection of lateral pelvic spaces are some of the anatomical details to be presented. In addition, management of urologic and bowel injuries with anatomical description will be presented. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Identify the retroperitoneal anatomy for the dissection of lateral pelvic spaces; 2) describe a plan and techniques for the control of pelvic and presacral bleeding; and 3) identify and discuss the principles of prevention and management of urologic and intestinal injuries.

Course Outline 7:00 Welcome, Introductions and Course Overview J.F. Magrina

7:05 Lateral Pelvic Wall: How to Navigate through the Lateral Spaces to Safely Identify Important Vessels and Nerves. Bleeding Control: Uterine and Hypogastric Artery Ligation J.F. Magrina

7:30 Presacral Space: Anatomy, Dissection, Management of Presacral Bleeding, from Mild to Severe P.M. Magtibay

7:55 Colorectal Anatomy, Role of Bowel Preparation and Management of Colorectal Injury M.M. Leitao

8:20 Retroperitoneal Nerves: Dissection, Identification, Sacral Nerve Roots, Prevention and Management of Nerve Injury K.A. Butler

8:45 Questions & Answers All Faculty

8:55 Break

9:10 Parametrial Ureter: Anatomy: Ureteral Dissection, from Easy to Difficult J.F. Magrina

9:35 Prevention and Repair of Urologic Injuries: A Must for All Gynecologists; Use of Cystoscopy P.M. Magtibay

10:00 Anatomy of Large Pelvic Vessels and Handling Major Vascular Injuries M.M. Leitao

10:25 Aortic and Para-‐Aortic Anatomy in Gynecology: Dissection, Exposure, Vascular Anomalies K.A. Butler

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 and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Erica Dun* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Intuitive Royalty: CooperSurgical Sarah L. Cohen* Jon I. Einarsson* Stuart Hart Consultant: Covidien Speakers Bureau: Boston Scientific, Covidien Kimberly A. Kho Contracted/Research: Applied Medical Other: Pivotal Protocol Advisor: Actamax Matthew T. Siedhoff Other: Payment for Training Sales Representatives: Teleflex M. Jonathon Solnik Consultant: Z Microsystems Other: Faculty for PACE Surgical Courses: Covidien 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). Kristina A. Butler* Mario M. Leitao Other: Ad hoc speaking and lab proctor: Intuitive Surgical Javier F. Magrina* Paul M. Magtibay* Asterisk (*) denotes no financial relationships to disclose.

2

JFM031405JFM031405

Lateral Pelvic Wall: How to Navigate through the Lateral Spaces to Safely Identify Important Vessels and Nerves. Bleeding

Control: Uterine and Hypogastric Artery Ligation

Javier MagrinaClinica Mayo Arizona

Disclosure

I have no financial relationships to disclose.

Objectives

Discuss how to navigate the lateral spaces and safely identify important vessels and nerves.

Enemies

• external and common iliac art.

• obturator nerve

• lumbosacral trunk

• ureters

Friends

• Superior vesical artery

• Uterine artery

• Internal iliac artery

3

Internal iliac branching

• 9 types

• 49 subtypes

Hypogastric artery branching

“…the manner of branching departs so frequently from the so‐called standard pattern that it is usually impossible to identify the various vessels without following them for some distance to ascertain their course and destinations”

Ashley FL, Anson BJ. Am J Phys Anthropol 28:381, 1941

Most aberrant artery of internal iliac branches:

obturator artery

Ashley FL, Anson BJ. Am J Phys Anthropol 28:381, 1941

Practical branching of internal iliac artery

• Anterior: superior vesical, uterine

• Lateral: int. pudendal, inf. gluteal

• Posterior: superior gluteal

Posterior branch• 2.7 cm distal to common iliac bifurcation

• 5 mm diameter

• Branches: superior gluteal, iliolumbar, lumbosacral

4

Obturator nerve anomalies

• Distal fusion of L3‐4 ventral rami

• Proximal intrapelvic bifurcation

• Ashley FL, Anson BJ. Am J Phys Anthropol28:381, 1941

5

Presacral Space: Anatomy, Dissection Management of Presacral Bleeding from Mild to Severe

Paul M Magtibay, MD

Mayo Clinic Arizona

I have no financial relationship to disclose.

• Define the vascular anatomy and anatomic boarders of the presacral space

• Discuss reasons for dissection of the space

• Discuss management of presacral bleeding*

• Demonstrate the dissection of the presacral space

• Sacral veins

– Lateral / Middle

• Internal Vertebral

– Basivertebral

• Presacral Venous Plexus

– Retraction

– Valveless systemHarrison; Dis Colon Rectum 2003

Presacral Bleeding

– 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

Presacral Bleeding

– Preparation & Stabilization

• Pressure

• IV access

• Massive Transfusion Protocol

• Suction x 2 or x 3

• Hands / Help

6

Presacral Bleeding

• Control

– Pressure ***

– Electrocautery

– Suture: caution

Presacral Bleeding

• 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

– Thumb tacks: nope

– Bone wax: nope

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 Presacral Bleeding

• Control

– Tightly pack

– Leave abdomen open

– ICU

• Correct DIC

• Bring back when more stable

Videos

1. 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

7

Colorectal Anatomy, Role of Bowel Preparation and Management of Colorectal Injury

Mario M. Leitao, Jr., MDAssociate Professor, Weill Cornell Medical CollegeAssociate Member, Gynecology ServiceDirector, Gynecologic Oncology Fellowship ProgramDirector, Minimal Access and Robotic Surgery (MARS) ProgramDepartment of Surgery

@leitaomd

DisclosureOther: Ad hoc speaking and lab proctor: Intuitive Surgical

Objective Discuss colorectal anatomy, role of bowel preparation and the management of colorectal Injury.

Anatomy

8

Bowel preparation

9

Mechanical Bowel PrepPostop outcomes meta‐analysis

OutcomePrep

(%)

No prep

(%)OR 95%CI

Anastomotic leak

Intra‐abdominal infection

Wound infection

Re‐op rates

General M&M

Mortality

5.6

3.7

7.5

5.2

19.4

1.0

2.8

2.0

5.5

2.2

17.7

0.6

1.85

1.69

1.38

1.72

1.15

1.42

1.06 – 3.22

0.76 – 3.75

0.89 – 2.15

0.81 – 3.65

0.79 – 1.70

0.37 – 5.45

Bucher P, et al. Arch Surg 2004;139:1359‐64.

Mechanical Bowel PrepLaparoscopy

Won H, et al. Obstet Gynecol 2013;121:538‐546.





Injury management

Traumatic Colon InjuryUnprepped bowel

Cleary RK, et al. Dis Colon Rectum 2006;49:1203‐1222.

10

Traumatic Rectal InjuryUnprepped bowel

Cleary RK, et al. Dis Colon Rectum 2006;49:1203‐1222.

Major Vascular InjuryConverting considerations

• Robot can be undocked very quickly if needed

• Put all instruments in view

• Pull them all out with trocars still attached to robotic arms

• Can leave one arm attached that is grasping vessel, remove all others, pull them as far away as possible and convert

• Apply bulldog clamps over site, proximal/idstal, whatever works and then undock and convert

THANK YOU!

@leitaomd

11

Retroperitoneal Nerves: Dissection, Identification, Sacral Nerve

Roots, Prevention and Management of Nerve Injury

Kristina A. Butler, M.D.

Disclosures


Objectives

• Review pertinent retroperitoneal nerves

• Plan for safe dissection and avoid injury

• Discuss management of nerve injury

Lumbar Plexus

Sacral Plexus

Pudendal n.

Sacral Nerve Roots

Star = ischial spine, SSL sacrospinous ligament, PS pubic symphysisMahakkanukrauh. Clin Anat 2005.

12

SYMPATHETICS

Sympathetic chain (T12-L4)

Superior hypogastric plexus (aorta)

Sacral splanchnic

PARASYMPATHETICS

Pelvic splanchnic (S2-4)

Inferior hypogastric plexus

Autonomic Pelvic Nerves

Causes of Injury

• Direct injury

– Transection

– Entrapment

• Compression

• Stretch

• Ischemic

Warner M. Anesth. 2000Irvin. AJOG. 2004

Barber. AJOG. 2009

Risk factors

• Body habitus

• Age

• Vascular disease: tobacco use

• Hypotension, hypothermia

• Preexisting conditions

• Duration of surgery

13

Positioning

• Secure safety

• Maintain natural positions

• Surgical access

• Genitofemoral

– L1‐2

– Sensory: Mons, labia, thigh

• Lateral Femoral Cutaneous

– L2‐3

– Sensory: lateral thigh

• Genitofemoral

– L1‐2

– Sensory: Mons, labia, thigh

• Lateral Femoral Cutaneous

– L2‐3

– Sensory: lateral thigh

– Meralgia paresthetica

Warner M. Anesth. 2000

Femoral Nerve

Psoas

Iliacus

Femoral nerve

• L2‐4

– Lateral to psoas muscle

– Passes under inguinal ligament

– Lateral femoral triangle

Femoral Nerve Injury

• Motor innervation

– Hip flexion

– Knee extension

• Anteromedial thigh & leg numbness

• Deep tendon reflexes

14

Retractor Compression

Chan. AJOG. 2002Goldman. E J ObGRep Bio. 1985

Obturator Nerve

• L2‐4

– Formed within the psoas muscle

– Pelvic sidewall

– Exits pelvis, Obturator canal

• Motor: Adductors

• Sensory: Skin medial thigh

Warner M. Anesthesia. 2000

Sciatic Nerve

• L4‐S3

• Exits pelvis below piriformis muscle

• Beneath gluteus

• Lateral of ischial tuberosity, enters thigh

Sciatic Nerve

• Motor: hip extension, leg/foot flexion

• Sensory: posterior leg/thigh

• Injury: Foot drop, buttock/leg pain

• Avoid: hip flexion with leg extension

Management of Injury

15

Evaluation of injury

• Examination

• Sensory deficit

– Conservative measures

• Motor deficit

– Neurology consultation

– Nerve conduction study

– Physical therapy

Viswanathan. Neurosurg. 2009

Summary

• Perioperative nerve injury is often avoidable

• Nerve injury can be severe, permanent, & disabling

• Thoughtful positioning & dissection can reduce the risk of injury

References

John K. Chan, MD, and Alberto Manetta, MD. Prevention of femoral nerve injuries in gynecologic surgery. AJOG 2002;186:1‐7.

Mark A. Warner, M.D.,* David O. Warner, M.D.,* C. Michel Harper, M.D.,† Darrell R. Schroeder, M.S.,‡

Pamela M. Maxson, R.N., M.S.§. Lower Extremity Neuropathies Associated with

Lithotomy Positions. Anesthesiology 2000; 93:938–42

JONATHAN P. LITWILLER,1 ROBERT E. WELLS JR,1 JOHN R. HALLIWILL,1 STEPHEN W. CARMICHAEL,2

AND MARK A. WARNER1* Effect of Lithotomy Positions on Strain of the Obturator and Lateral Femoral Cutaneous Nerves. Clinical Anatomy 17:45–49 (2004).

Viswanathan. Neurosurg. 2009

William Irvin, MD, Willie Andersen, MD, Peyton Taylor, MD, and Laurel Rice, MD . Minimizing the Risk of Neurologic Injury in Gynecologic Surgery. Obstet

Gynecol 2004;103:374–82.

Bohrer JC, Walters MD, Park A, et al. Pelvic nerve injury following gynecologic surgery: a prospective cohort study. Am J Obstet Gynecol

2009;201:531.e1‐7.

Mahakkanukrauh, P et al. Clin Anat 2005;18:200‐205.

Richard J. Cardosi, MD, Carol S. Cox, MD, and Mitchel S. Hoffman, MD. Postoperative Neuropathies After Major Pelvic Surgery. ObstetGynecol

2002;100:240–4.

Thank youAcknowledge: M Warner, M.D.

16

Parametrial Ureter: Anatomy: Ureteral Dissection, from Easy to

Difficult

Javier F Magrina, MDMayo Clinic Arizona

Disclosure


Objectives

• Discuss parametrial ureteral anatomy

\

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

17

Intraoperative diagnosis of ureteral

obstruction is associated with :

• A. Increased permanent sequalae

• B. malpractice lawsuit

• C. Reduced need of ureteral surgery

• D. requires urological consultation

Laparoscopic ureteral injuriesNeed for ureteral surgery

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

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

What % of ureteral injuries are diagnosed at intraoperative cystoscopy?

• A. 30

• B. 40

• C. 50

• D. 60

• E. none of the above

18

Urinary injuries in laparoscopy

Diagnosis at cystoscopy

95% of ureteral injuries

85% of bladder injuries

Ob t t G l 94 883 1999

Thank you

19

Prevention and Repair of Urologic Injuries: A Must for All Gynecologists; Use of Cystoscopy

Paul M Magtibay, MD

Mayo Clinic Arizona


• Reference the incidence of lower urinary tract injury in gynecologic surgery

• Discuss the role of cystoscopy at the time of gynecologic surgery

• Demonstrate the principles in the repair of common lower urinary tract injuries

Lower Urinary Tract InjuryIt Will Occur

Lower Urinary Tract InjuryGilmour et al

• No cystoscopy (107,068)

– Bladder Injury: 2.6 / 1000

– Ureteral Injury: 1.6 / 1000

– 11.5% ureteral and 52% bladder injuries recognized intraoperatively

– 97% of bladder injuries recognized postoperatively presented as vesicovaginal fistulas

• Cystoscopy (89,754)

– Bladder Injury: 10.4 / 1000

– Ureteral Injury: 6.2 / 1000

– 90% ureteral and 85% bladder injuries recognized and managed successfully intraoperatively

Lower Urinary Tract InjuryIt Will Occur

• Immediate Recognition

– Easier to repair

– More successful repair

– Reduced morbidity to patient

– Less surgeon stress

– Advantageous legally

– Do cystoscopy

20

Cystoscopy

• Minimal

– Risk: UTI

– Expense

– Time

• Standard of Care

– Urogynecology

• Do cystoscopy

Bladder EndometriosisClosure Cystostomy

Ureteral EndometriosisUretero‐Neocystostomy

Ureteral TransectionUretero‐Ureterostomy

1. Gilmour DT, Dwyer PL, Carey MP. Lower Urinary Tract Injury During Gynecologic Surgery and Its Detection by Intraoperative Cystoscopy. Obstet Gynecol 1999; 94:883‐9.

2. Anand M, Casiano ER, Heisler CA, et al. Utility of Intraoperative Cystoscopy in Detecting Ureteral Injury During Vaginal Hysterectomy. Female Pelvic Medicine & Reconstructive Surgery 2015; 21:70‐76.

3. Frankman EA, Wang L, Bunker CH, et al. Lower Urinary Tract Injury in Women in The United States, 1979‐2006. AJOG 2010; 495.e1‐e5.

21

Anatomy of Large Pelvic Vessels and Handling Major Vascular Injuries

Mario M. Leitao, Jr., MDAssociate Professor, Weill Cornell Medical CollegeAssociate Member, Gynecology ServiceDirector, Gynecologic Oncology Fellowship ProgramDirector, Minimal Access and Robotic Surgery (MARS) ProgramDepartment of Surgery

@leitaomd

DisclosureOther: Ad hoc speaking and lab proctor: Intuitive Surgical

Objective

Discuss pelvic vascular anatomy and injury management.

• Anatomy ‐master anatomy

• Principles – master surgical principles

• Tools – master your tools

• Exposure – maximize exposure

• Structures – maximize identification of structures

• Standardize – techniques across all surgeons

Essential Basic Tips in Avoiding Complications

“APTESS”

Pelvic Vascular Anatomy

22

MIS: 2 categories of injury

At insertion= laparoscopy

• About 10‐2 to 10‐3

• 83% of injuries reported L‐scopy– 44% Veress Needle, 39% trocar (half disposable)

During MIS

Chapron et al. J Am Coll Surg 1997; 185: 461Sandadi et al. J Min InvGyn 2010; 17: 692

Gas embolusO2 sat, arryth., hypoT, mill wheelRt sided failure

Remove Veress, 100% O2, Trend, RtAtrium. Cath.

ExsanguinationImmediate Hemoperitoneum 88%

Delayed retroperitoneal hematoma 12%

About 10% mortality

Borrowed: P.Escobar, MD

InstrumentationVascular clamps

Borrowed and modified: P.Escobar, MD

MIS Bulldog Clamp


23

InstrumentationVascular Sutures


Primary Repair of Arteriotomy

• Vessel should be manipulated by grasping the peri‐arterial or adventitial tissues only –if possible

• it is advisable for the needle to pass from inside to out (i.e. from intima to adventitia)

• Non‐absorbable, monofilament suture material

• The finer the vessel, the finer the sutures required and the smaller the bites taken

• The suture line needs to be everted to result in good intimal apposition, unlike a bowel anastomosis in which the suture line tends to be inverted.


Venous Injuries

• Potential catastrophic complications and carry substantial risk for death

• Iatrogenic venous trauma appears considerably more common than arterial injury

• Nearly always is more difficult to control because venous bleeding pools directly in the field of repair

• Blood loss from injuries of the IVC or internal iliac vein may be substantial (mean 4800–7300 ml)


Oderich et al. J Vasc Surg 39:931–936

Avulsion Injury


Renal vein avulsion injury and repair

Burn Injury

Right external iliac artery injury and repair

Bottom Line

• Learn from one’s missteps

• Self‐evaluate

• Work towards improvement

• Sensor over platform pedals

• New scissor tip cover

• Better prepare for these emergent situations and have plan in mind

24

Emergent Conversion for Major Complication

Who What

Attending Surgeon 1. Call for emergent conversion to open procedure, designate person in charge of maintaining tamponade.

Circ RN 2. Push Code “blue” button / or call central desk. Turn on OR lights.

Circ RN 3. Open Robotic Emergency Tray

Anesthesia team 4. Notify anesthesia attending via Vocera

Anesthesia team 5. Initiate IV fluid resuscitation. Confirm adequacy of IV access.

Anesthesia team 6. Request blood products. Request confirmation when sent.

Bedside assistant 7. Maintain tamponade, may initiate removal of some robotic instruments at the direction of attending surgeon

Attending Surgeon 8. Undock Robot at direction of Attending Surgeon

Attending Surgeon 9. Proceed to open

Circ RN 10. Notify all available service attendings for additional help

• Mostly vascular emergencies

• Gowns and gloves always open and available for all console surgeons

• Robot emergency “team timeout” done during “Contingency Plan” section of active timeout for each case

Major Vascular InjuryBasic tips & common sense approach• Have a “timeout” process in place for each case

• Have vascular instruments handy for each case

• DO NOT start randomly moving or removing instruments

• Grasp bleeding vessel with robotic grasper

• Throw in sponge

• Relax, take charge, and plot out next steps (robot won’t move)

• Call for laparotomy set up

• Call for laparoscopic bulldog clamps, 5‐0 prolene sutures, hemostatic agents

• Find out who is around who can truly help

• Convert to laparotomy any time uncomfortable and before too late

• Obtain best exposure surrounding site of injury

• Assess extent of injury

• Attempt repair if possible

• If not, call for help if none there yet and convert

Major Vascular InjuryConverting considerations

• Robot can be undocked very quickly if needed

• Put all instruments in view

• Pull them all out with trocars still attached to robotic arms

• Can leave one arm attached that is grasping vessel, remove all others, pull them as far away as possible and convert

• Apply bulldog clamps over site, proximal/distal, whatever works and then undock and convert

25

THANK YOU!

@leitaomd

26

Aortic Anatomy in Gynecology: Dissection, Exposure, Vascular Anomalies

Kristina A. Butler, MD

Gynecologic Oncology

Mayo Clinic Arizona

Disclosures


Objectives

• Review pertinent aortic anatomy

• Plan for safe exposure of the aortic region

• Discuss minimally invasive surgical techniques for accessing the aortic area

Aortic Anatomy

• Dissection Boundaries

Aortic Anatomy


• Vessels

– Renal

– Gonadal

– Lumbar

– Sacral

– Mesenteric

• SMA

• Adrenals

• Gonadals

• IMA

27

Renal anomalies

Retroaortic renal vein Low renal vein

Very low renal veinRetroaortic renal vein

Variations

• Review Imaging Preop

• Video

Map your course before the trip

Aortic Anatomy


• Vessels

– Renal

– Gonadal

– Lumbar

– Sacral

– Mesenteric

• Nerves

• Autonomic

28

• Somatic

Aortic Anatomy


• Vessels– Renal

– Gonadal

– Lumbar

– Sacral

– Mesenteric

• Nerves: Sympathetic

• Ureters

• Video

Lymphadenectomy Techniques: MIS

• Robotic

• Supine flat

– Inferior docking (perineum, hip)

– Superior docking (shoulder, cranial)

• Lateral decubitus

• Laparoscopic

– Extraperitoneal

– Transperitoneal

Pelvic Access:hip docking (or perineal) umbilical center

C=cameraA=assist 1=right arm2=left arm3=3rd arma=5mm assist

1

2

C

A

3

Pelvic Access:hip docking (or perineal) supraumbilical center

Aortic access

Reliably reach inframesenteric, not infrarenal

1

2

C

A

3


29

Table rotationAortic Access:cranial docking low pelvic trocars, table rotation

1

2

C

A

3

a


180◦

1

2

C

A

3

a

Aortic Access:shoulder docking low pelvic trocars, table rotation

90◦


AP

#2CP #1

#3

XP

U

2cm

30 down scope

Lim 2010.

Aortic Access:perineal docking subxiphoid trocars

Aortic Dissection Steps• Incise right common iliac peritoneum, parallel vessel, midpoint of artery

• Nodal tissue separated dorsal, away from peritoneal tent

• Right ureter elevated/lateralized, attached to peritoneum

• Mobilize duodenum to reach renal vein

• Remove right aortic nodes

• Extend peritoneum toward left mid‐common iliac artery

• Left ureter lateralized

• IMA isolated

• Remove left aortic nodes to left renal vein

• Video

30

Left Lateral Approach

Jacob, Magrina, Magtibay. JLAST. 2011.

Aortic access: Left flank trocars

Extraperitoneal Approach

Magrina 2009.Dowdy 2010.

• Video

Extraperitoneal Approach References

• A‐D. JK Nam, et al. The Clinical Significance of a Retroaortic Left Renal Vein. Korean J Urol. 2010 Apr;51(4):276‐280.

• Magrina JF, Magtibay PM. The case of robotics and the infrarenal aortic nodes. Gynecol Oncol. 2011 Nov;123(2):407‐8. doi: 10.1016/j.ygyno.2011.07.013. Epub 2011 Aug 11

• Jacob KA, Zanagnolo V, Magrina JF, Magtibay PM. Robotic transperitoneal infrarenal aortic lymphadenectomy for gynecologic malignancy: a left lateral approach.. J Laparoendosc Adv Surg Tech A. 2011 Oct;21(8):733‐6. doi: 10.1089/lap.2011.0163. Epub 2011 Jul 20.

• Magrina JF, Kho R, Montero RP, Magtibay PM, Pawlina W. Robotic extraperitoneal aortic lymphadenectomy: Development of a technique. Gynecol Oncol. 2009 Apr;113(1):32‐5.

• Sean C. Dowdy �, Giovanni Aletti, William A. Cliby, Karl C. Podratz, Andrea Mariani. Extra‐peritoneal laparoscopic para‐aortic lymphadenectomy — A prospective cohort study of 293 patients with endometrial cancer. Gynecologic Oncology 111 (2008) 418–424

• Peter C. Lim, Elizabeth Kang, Do Hwan Park. A comparative detail analysis of the learning curve and surgical outcome for robotic hysterectomy with lymphadenectomy versus laparoscopic hysterectomy with lymphadenectomy in treatment of endometrial cancer: A case‐matched controlled study of the first one hundred twenty two patients. Gyn Onc. Volume 120, Issue 3, March 2011, Pages 413–418

©2013 MFMER | slide‐29

Thank you

31

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%

32

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

didactic: pelvic anatomy roadmap: surgical navigation ... · femoral nerve psoas iliacus femoral...

Documents