Retroperitoneal surgery Retroperitoneal surgery 33

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- Complications in post-hysterect. 5- Complications in post-hysterect.

reserved ovaries. reserved ovaries. 6- Hypogastric artery ligation. 6- Hypogastric artery ligation.

7- Large, cervical, ligamentous myoma 7- Large, cervical, ligamentous myoma 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 vesicovaginal & the The vesicovaginal & the rectovaginal spacesrectovaginal spaces

Incise the vesicouterine peritoneal Incise the vesicouterine peritoneal fold transversely. fold transversely.

Push the bladder down bluntly or Push the bladder down bluntly or by sharp dissection. by sharp dissection.

Moist gauze packing usually Moist gauze packing usually controls any encountered slow controls any encountered slow venous bleeding. venous bleeding.

A common error is to dissect too close A common error is to dissect too close to the cervix and fail to get into the to the cervix and fail to get into the proper plane proper plane

The vesicovaginal spaceThe vesicovaginal space

SurgicalSurgical importance importance

- Developing this space gives Developing this space gives access to the vesicouterine access to the vesicouterine ligament which contains ligament which contains the ureter as it passes to the ureter as it passes to the bladder. the bladder.

- Developing this space gives Developing this space gives access to vesicovaginal access to vesicovaginal fistula & cervical fibroid. fistula & cervical fibroid.

The rectovaginal space (plane) The rectovaginal space (plane) It extends from the Douglas It extends from the Douglas

pouch to the perineal body. pouch to the perineal body.

It is bounded It is bounded

anteriorlyanteriorly by the rectovaginal by the rectovaginal septum (firmly adherent to the septum (firmly adherent to the vagina), and vagina), and

posteriorlyposteriorly by the anterior rectal by the anterior rectal wall. wall.

How to develop?How to develop?

Incise the peritoneum between the Incise the peritoneum between the insertion of the 2 uterosacral lig. insertion of the 2 uterosacral lig.

Bluntly dissect the vagina from the Bluntly dissect the vagina from the rectum by sweeping the palm rectum by sweeping the palm along the posterior vaginal wall. along the posterior vaginal wall.

For adherent areas, sharp dissection For adherent areas, sharp dissection against the vagina is used. against the vagina is used.

SurgicalSurgical importance importance

-Rectocele often results from -Rectocele often results from a defect or avulsion of the a defect or avulsion of the septum from the perineal septum from the perineal body.body.

-Enterocele -congenital type- -Enterocele -congenital type- results from maldevelop-results from maldevelop-ment of the rectovaginal ment of the rectovaginal septum. septum.

The vesicovaginal and The vesicovaginal and rectovaginal spaces may rectovaginal spaces may be considerably altered. be considerably altered.

In such instances, In such instances, developing the paravesical developing the paravesical and the pararectal spaces and the pararectal spaces first is very helpful. first is very helpful.

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.

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 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

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The lateral psoas approach

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. .

Opening the pelvic sidewall triangles:Opening the pelvic sidewall triangles:

The uterus is deviated to one side to de-The uterus is deviated to one side to de-lineate the triangle in the opposite wall. lineate the triangle in the opposite wall.

The The basebase of the triangle is the round lig., of the triangle is the round lig., the the lateral border lateral border is the external iliac a., is the external iliac a., the the medial bordermedial border is the infundibulopelvic is the infundibulopelvic lig, and the lig, and the apexapex is where the infundibul- is where the infundibul- opelvic ligament crosses the common opelvic ligament crosses the common iliac artery. iliac artery.

The peritoneum in the middle of the triangle is The peritoneum in the middle of the triangle is incised and the broad lig is opened by bluntly incised and the broad lig is opened by bluntly separating the extraperitoneal areolar tissue.separating the extraperitoneal areolar tissue.

Even tiny vessels should be coagulated. Even tiny vessels should be coagulated.

The incision is extended to the round ligament The incision is extended to the round ligament which is not divided at this time and then to which is not divided at this time and then to the apex of the triangle lateral to the the apex of the triangle lateral to the infundibulopelvic ligament. infundibulopelvic ligament.

The paravesical space is opened and the infundibulopelvic ligament is pulled medially.

Thanks profThanks prof

morad k hasanein morad k hasanein