RESUMO
PURPOSE: Increasing importance has been attributed in recent years to the preservation of the pelvic autonomic nerves during rectal resection to achieve better functional results. In addition to improved surgical techniques, intraoperative neuromonitoring may be useful. METHODS: This single-arm prospective study included 30 patients who underwent rectal resection performed with intraoperative neuromonitoring by recording the change in the tissue impedance of the urinary bladder and rectum after stimulation of the pelvic autonomic nerves. The International Prostate Symptom Score, the post-void residual urine volume and the Low Anterior Resection Syndrome Score (LARS score) were assessed during the 12-month follow-up period. RESULTS: A stimulation-induced change in tissue impedance was observed in 28/30 patients (93.3%). In the presence of risk factors such as low anastomosis, neoadjuvant radiotherapy and a deviation stoma, an average increase of the LARS score by 9 points was observed 12 months after surgery (p = 0,04). The function of the urinary bladder remained unaffected in the first week (p = 0,7) as well as 12 months after the procedure (p = 0,93). CONCLUSION: The clinical feasibility of the new method for pelvic intraoperative neuromonitoring could be verified. The benefits of intraoperative pelvic neuromonitoring were particularly evident in difficult intraoperative situations with challenging visualization of the pelvic nerves.
Assuntos
Impedância Elétrica , Humanos , Masculino , Estudos Prospectivos , Pessoa de Meia-Idade , Idoso , Feminino , Bexiga Urinária/inervação , Bexiga Urinária/fisiopatologia , Pelve/inervação , Monitorização Neurofisiológica Intraoperatória/métodos , Neoplasias Retais/cirurgia , Monitorização Intraoperatória/métodos , Reto/cirurgia , Reto/inervação , Adulto , Idoso de 80 Anos ou mais , Vias Autônomas , Protectomia/efeitos adversosRESUMO
Urinary bladder dysfunction might be related to disturbances at different levels of the micturition reflex arc. The current study aimed to further develop and evaluate a split bladder model for detecting and analysing relaxatory signalling in the rat urinary bladder. The model allows for discrimination between effects at the efferent and the afferent side of the innervation. In in vivo experiments, the stimulation at a low frequency (1 Hz) of the ipsilateral pelvic nerve tended to evoke relaxation of the split bladder half (contralateral side; -1.0 ± 0.4 mN; n = 5), in contrast to high frequency-evoked contractions. In preparations in which the contralateral pelvic nerve was cut the relaxation occurred at a wider range of frequencies (0.5-2 Hz). In separate experiments, responses to 1 and 2 Hz were studied before and after intravenous injections of propranolol (1 mg/kg IV). The presence of propranolol significantly shifted the relaxations into contractions. Also, electrical stimulation of the ipsilateral pudendal nerve evoked relaxations of similar magnitude as for the pelvic stimulations, which were also affected by propranolol. In control in vitro experiments, substances with ß-adrenoceptor agonism, in contrast to a selective α-agonist, evoked relaxations. The current study shows that the split bladder model can be used for in vivo studies of relaxations. In the model, reflex-evoked sympathetic responses caused relaxations at low intensity stimulation. The involvement of ß-adrenoceptors is supported by the sensitivity to propranolol and by the in vitro observations.
Assuntos
Estimulação Elétrica , Propranolol , Nervo Pudendo , Bexiga Urinária , Animais , Bexiga Urinária/inervação , Bexiga Urinária/fisiologia , Bexiga Urinária/efeitos dos fármacos , Nervo Pudendo/fisiologia , Nervo Pudendo/efeitos dos fármacos , Ratos , Propranolol/farmacologia , Feminino , Relaxamento Muscular/efeitos dos fármacos , Relaxamento Muscular/fisiologia , Ratos Wistar , Pelve/inervação , Antagonistas Adrenérgicos beta/farmacologia , Masculino , Ratos Sprague-DawleyRESUMO
OBJECTIVE: To synthesize the terminology utilized in nerve-sparing surgical literature and propose standardized and nonconflicting terms to allow for consistent vocabulary. DESIGN: We performed a literature search on PubMed using the search terms "pelvis" and "nerve-sparing." Nongynecologic surgery and animal studies were excluded. A narrative review was performed, focusing on nerves, fasciae, ligaments, and retroperitoneal spaces. Terms from included papers were discussed by all authors, who are surgeons versed in nerve-sparing procedures and one anatomist, and recommendations were made regarding the most appropriate terms based on the frequency of occurrence in the literature and the possibility of overlapping names with other structures. RESULTS: 224 articles were identified, with 81 included in the full-text review. Overall, 48% of articles focused on cervical cancer and 26% on deeply infiltrating endometriosis. Findings were synthesized both narratively and visually. Inconsistencies in pelvic anatomical nomenclature were prevalent across publications. The structure with the most varied terminology was the rectal branch of the inferior hypogastric plexus with 14 names. A standardized terminology for pelvic autonomic nerve structures, fasciae, ligaments, and retroperitoneal spaces was proposed to avoid conflicting terms. CONCLUSION: Surgeons and anatomists should use consistent terminology to facilitate increased uptake of nerve-sparing techniques in gynecologic surgery through a better understanding of surgical technique description. We have proposed a standardized terminology believed to facilitate this goal.
Assuntos
Procedimentos Cirúrgicos em Ginecologia , Terminologia como Assunto , Humanos , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Pelve/inervação , Pelve/anatomia & histologia , Pelve/cirurgia , Tratamentos com Preservação do Órgão/métodos , Pontos de Referência AnatômicosRESUMO
PURPOSE: Pelvic gynecological surgeries, whether for malignant or benign conditions, frequently result in functional complications due to injuries to the autonomic nervous system. Recognizing the deep uterine vein (DUV) as an essential anatomical reference can aid in preserving these structures. Despite its significance, the DUV is infrequently studied and lacks comprehensive documentation in Terminologia Anatomica. This research endeavors to elucidate a detailed characterization of the DUV. METHODS: We undertook a systematic literature review aligning with the "PRISMA" guidelines, sourcing from PUBMED and EMBASE. Our comprehensive anatomical examination encompassed cadaveric dissections and radio-anatomical evaluations utilizing the Anatomage® Table. RESULTS: The literary exploration revealed a consensus on the DUV's description based on both anatomical and surgical observations. It arises from the merger of cervical, vesical, and vaginal veins, coursing through the paracervix in a descending and rearward direction before culminating in the internal iliac vein. The hands-on anatomical study further delineated the DUV's associations throughout its course, highlighting its role in bifurcating the uterus's lateral aspect into two distinct zones: a superior vascular zone housing the uterine artery and ureter and an inferior nervous segment below the DUV representing the autonomic nerve pathway. CONCLUSION: A profound understanding of the subperitoneal space anatomy is paramount for pelvic surgeons to mitigate postoperative complications. The DUV's intricate neurovascular interplays underscore its significance as an indispensable surgical guide for safeguarding nerves and the ureter.
Assuntos
Útero , Humanos , Feminino , Útero/irrigação sanguínea , Útero/anatomia & histologia , Pelve/inervação , Pelve/irrigação sanguínea , Pelve/anatomia & histologia , Cadáver , Veias/anatomia & histologia , Procedimentos Cirúrgicos em Ginecologia/métodosAssuntos
Excisão de Linfonodo , Metástase Linfática , Pelve , Protectomia , Neoplasias Retais , Procedimentos Cirúrgicos Robóticos , Nervos Esplâncnicos , Humanos , Pessoa de Meia-Idade , Excisão de Linfonodo/métodos , Linfonodos/patologia , Linfonodos/cirurgia , Pelve/inervação , Protectomia/métodos , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Procedimentos Cirúrgicos Robóticos/métodos , Nervos Esplâncnicos/cirurgiaRESUMO
The current treatment strategy for rectal cancer is a comprehensive treatment centered on surgery. The application of total mesorectal excision (TME) has significantly reduced the local recurrence rate and improved the survival prognosis, but a series of pelvic organ dysfunction caused by pelvic autonomic nerve injury during the operation will reduce the postoperative quality of life of patients. Pelvic autonomic nerve preserving (PANP) radical proctectomy has emerged, but the biggest challenge in the implementation process of this technology is the accurate identification of nerves. A series of studies have shown that pelvic intraoperative autonomic monitoring (pIONM) can effectively assist surgeons to identify nerves, The purpose of this article is to introduce the function of pelvic autonomic nerve, the clinical manifestation of postoperative pelvic dysfunction and its relationship with nerve injury, the key points of implementing PANP, and the current situation and research progress of pIONM technology application.
Assuntos
Qualidade de Vida , Neoplasias Retais , Humanos , Neoplasias Retais/cirurgia , Vias Autônomas/cirurgia , Pelve/cirurgia , Pelve/inervação , Sistema Nervoso Autônomo/cirurgia , Sistema Nervoso Autônomo/lesões , Reto/cirurgiaRESUMO
It has been found that rectal surgery still leads to high rates of postoperative urinary, fecal, or sexual dysfunction, which is why nerve-sparing surgery has gained increasing importance. To improve functional outcomes, techniques to preserve pelvic autonomic nerves by identifying anatomic landmarks and implementing intraoperative neuromonitoring methods have been investigated. The objective of this study was to transfer a new approach to intraoperative pelvic neuromonitoring based on bioimpedance measurement to a clinical setting. Thirty patients (16 male, 14 female) involved in a prospective clinical investigation (German Clinical Trials Register DRKS00017437, date of first registration 31/03/2020) underwent nerve-sparing rectal surgery using a new approach to intraoperative pelvic neuromonitoring based on direct nerve stimulation and impedance measurement on target organs. Clinical feasibility of the method was outlined in 93.3% of the cases. Smooth muscle contraction of the urinary bladder and/ or the rectum in response to direct stimulation of innervating functional nerves correlated with a change in tissue impedance compared with the pre-contraction state. The mean amplitude (Amax) of positive signal responses was Amax = 3.8%, negative signal responses from a control tissue portion with no stimulation-induced impedance change had an amplitude variation of 0.4% on average. The amplitudes of positive and negative signal responses differed significantly (statistical analysis using two-sided t-test), allowing the nerves to be identified and preserved. The results indicate a reliable identification of pelvic autonomic nerves during rectal surgery.
Assuntos
Neoplasias Retais , Procedimentos Cirúrgicos Robóticos , Humanos , Masculino , Feminino , Reto/cirurgia , Reto/inervação , Estudos Prospectivos , Monitorização Intraoperatória/métodos , Pelve/cirurgia , Pelve/inervação , Neoplasias Retais/cirurgiaRESUMO
BACKGROUND: Endometriosis is a chronic common condition affecting 10% of reproductive-aged women globally. It is caused by the growth of endometrial-like tissue outside the uterine cavity and leads to chronic pelvic pain, affecting various aspects of a woman's physical, mental, emotional, and social well-being. This highlights the importance of an understanding of the potential involvement of the nervous system and involved nerves as well as an effective multidisciplinary pain management. OBJECTIVES: Our aim was to assess the current understanding of pain mechanisms in endometriosis and the effectiveness of different interventional pain management strategies. STUDY DESIGN: Literature review. METHODS: A search was conducted using multiple databases, including Google Scholar, MEDLINE (Ovid), PubMed, and Embase. We used keywords such as "endometriosis," "pain," pelvic pain, "management," and "anaesthesia" along with Boolean operators and MeSH terms. The search was limited to English language articles published in the last 15 years. RESULTS: Nerve involvement is a well-established mechanism for pain generation in patients with endometriosis, through direct invasion, irritation, neuroangiogenesis, peripheral and central sensitization, and scar tissue formation. Endometriosis may also affect nerve fibers in the pelvic region, causing chronic pelvic pain, including sciatic neuropathy and compression of other pelvic nerves. Endometriosis can cause sciatica, often misdiagnosed due to atypical symptoms. Interventional pain management techniques such as superior hypogastric plexus block, impar ganglion block, S3 pulsed radiofrequency, myofascial pain trigger point release, peripheral nerve hydrodissection, and neuromodulation have been used to manage persistent and intractable pain with positive patient outcomes and improved quality of life. LIMITATIONS: The complex and diverse clinical presentations of endometriosis make it challenging to compare the effectiveness of different pain management techniques. CONCLUSION: Endometriosis is a complex condition causing various forms of pain including nerve involvement, scar tissue formation, and bowel/bladder symptoms. Interventional pain management techniques are effective for managing endometriosis-related pain. KEY WORDS: Endometriosis, chronic pain, therapeutic interventions, interventional techniques, pain injections, visceral pain, peripheral pain.
Assuntos
Endometriose , Adulto , Feminino , Humanos , Doença Crônica , Cicatriz/complicações , Endometriose/complicações , Manejo da Dor/efeitos adversos , Dor Pélvica/etiologia , Dor Pélvica/terapia , Dor Pélvica/diagnóstico , Pelve/inervação , Qualidade de VidaRESUMO
Because the classification system of radical surgery for rectal cancer has not been established, it is impossible to select the appropriate surgical method according to the clinical stage of the tumor. In this paper, we explained the theory of " four fasciae and three spaces " of pelvic membrane anatomy and then combined this theory with the membrane anatomical basis of Querleu-Morrow classification for radical cervical cancer resection. Based on this theory and the membrane anatomy of Querleu-Morrow classification of radical cervical cancer resection, we proposed a new classification system of radical rectal cancer surgery based on membrane anatomy according to the lateral lymph node dissection range of the rectum. This system classifies the surgery into four types (ABCD) and defines corresponding subtypes based on whether the autonomic nerve was preserved. Among them, type A surgery is total mesorectal excision (TME) with urogenital fascia preservation, type B surgery is classical TME, type C surgery is extended TME, and type D surgery is lateral extended resection. This classification system unifies the anatomical terminology of the pelvic membrane, validates the feasibility of using the " four fasciae and three fascial spaces " theory to classify rectal cancer surgery, and lays the theoretical foundation for the future development of a unified and standardized classification of radical pelvic tumor surgery.
Assuntos
Protectomia , Neoplasias Retais , Neoplasias do Colo do Útero , Feminino , Humanos , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Reto/anatomia & histologia , Pelve/inervaçãoRESUMO
El dolor abdominal es una de las sintomatologías que afectan con frecuencia la cavidad abdomino-pélvica. Dicha cavidad posee una inervación somática en la que intervienen del séptimo a doceavo nervios intercostales, ramos colaterales y terminales del plexo lumbar y el nervio pudendo; siendo objetivo de este trabajo la descripción anatómica del dolor abdominopélvico a través del plexo lumbar, nervios intercostales y nervio pudendo, sus diferentes patrones y variaciones de conformación, y las implicancias de éstas últimas en las distintas maniobras clínico-quirúrgicas. Se realizó un estudio descriptivo, observacional y morfométrico de la inervación somática de la cavidad abdomino-pélvica, en 50 preparaciones cadavéricas, fijadas en solución de formaldehído, de la Tercera Cátedra de Anatomía, Facultad de Medicina, Universidad de Buenos Aires, entre Agosto/2017-Diciembre/2019. La descripción clásica del plexo lumbar se encontró en 35 casos; la presencia del nervio femoral accesorio en ningún caso; así como también la ausencia del nervio iliohipogástrico en ningún caso; el nervio obturador accesorio se halló en 2 casos; el nervio genitofemoral dividiéndose dentro de la masa muscular del psoas mayor en 6 casos; el nervio cutáneo femoral lateral emergiendo únicamente de la segunda raíz lumbar en 6 casos y por último se encontró la presencia de un ramo del nervio obturador uniéndose al tronco lumbosacro en un caso. Los nervios intercostales y el nervio pudendo presentaron una disposición clásica en todos los casos analizados. Es esencial un adecuado conocimiento y descripción del plexo lumbar, nervios intercostales y nervio pudendo para un adecuado abordaje de la cavidad abdomino-pélvica en los bloqueos nerviosos.
SUMMARY: Abdominal pain is one of the symptoms that affect the abdominal-pelvic cavity. The abdominal-pelvic cavity has a somatic innervation involving the seventh to twelfth intercostal nerves, collateral and terminal branches of the lumbar plexus and the pudendal nerve. The objective of this work is the description of the lumbar plexus, intercostal nerves and pudendal nerve, its different patterns and structure variations, as well as its implications during pain management in patients. A descriptive, observational, and morphometric study of patterns and structure variations of the lumbar plexus, intercostal nerves and pudendal nerve was conducted in 50 formalin-fixed cadaveric dissections of the Third Chair of Anatomy at the School of Medicine in the Universidad de Buenos Aires from August 2017 to December/2019. The standard description of the lumbar plexus was found in 35 cases; accessory femoral nerve was not present in any of the cases; absence of the iliohipogastric nerve was also not found in any case, while the accessory obturating nerve was found in 2 cases; genitofemoral nerve dividing within the muscle mass of psoas in 6 cases; lateral femoral cutaneous nerve emerging only from the second lumbar root in 6 cases and finally, presence of a branch of the obturating nerve was found joining the lumbosacral trunk in one case. The pudendal and intercostal nerve patterns presented a typical pathway in all cases. Adequate knowledge and description of the lumbar plexus, intercostal nerves and pudendal nerve is essential for an adequate approach of the abdominal-pelvic cavity in nerve blocks.
Assuntos
Humanos , Variação Anatômica , Plexo Lombossacral/anatomia & histologia , Bloqueio Nervoso/métodos , Pelve/inervação , Dor Abdominal , Nervo Pudendo/anatomia & histologia , Abdome/inervação , Nervos Intercostais/anatomia & histologiaRESUMO
Objetivo: Identificar o impacto da histerectomia para patologias benignas sobre a sexualidade feminina. Métodos: Revisão de literatura com busca na plataforma PubMed, sendo selecionados 23 artigos em português e inglês publicados entre 2016 e 2021. Resultados: Foi descrita, majoritariamente, melhora na função sexual após histerectomia, semelhante às abordagens totais ou supracervicais e independentemente da via de acesso cirúrgico, apesar de impacto ligeiramente menor com a via laparoscópica. Na laparoscopia, houve melhor desfecho sexual no fechamento da cúpula vaginal, quando comparado ao fechamento via vaginal. Ademais, a ooforectomia concomitante apresentou resultados conflitantes e inconclusivos. Conclusão: A histerectomia afeta positivamente a saúde sexual feminina e aspectos técnicos podem interferir na função sexual, porém os dados são limitados. Devido à importância do tema, necessitam-se de mais estudos com metodologias padronizadas para possibilitar análises mais detalhadas.
Objective: To identify the impact of hysterectomy for benign pathologies on female sexuality. Methods: Literature review with search on PubMed platform, being selected 23 articles in Portuguese and English published between 2016 and 2021. Results: Improvement in sexual function after hysterectomy was mostly described, being similar in total or supracervical approaches and independent of the surgical access route, although it had slightly lower impact when laparoscopic. In the laparoscopic approach, there was better sexual outcome in the vaginal dome closure when compared to vaginal closure. In addition, concomitant oophorectomy showed conflicting and inconclusive results. Conclusion: Hysterectomy positively affects female sexual health and technical aspects may interfere with sexual function, but data are limited. Due to the importance of the theme, more studies with standardized methodologies are needed to enable more detailed analyses.
Assuntos
Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Pelve/inervação , Histerectomia/efeitos adversos , Útero/fisiopatologia , Serviços de Saúde da Mulher/estatística & dados numéricos , Laparoscopia/métodos , Sexualidade , Histerectomia Vaginal/métodosRESUMO
Colorectal cancer is one of the most common cancers in the world, and surgery is the mainstage treatment. Urogenital and sexual dysfunction after radical resection of rectal cancer has become an important problem for patients, which seriously affects the quality of life. Some patients give up radical surgery for rectal cancer because of the concerns about sexual and urinary dysfunction. The cause of this problem is intraoperative of injury pelvic autonomic nerve. The preservation of the hypogastric nerve during the surgery is important for the male ejaculation. Pelvic splanchnic nerves are mainly responsible for the male erection. The anatomical origin, distribution, and urogenital function of these two nerves are detailed described in this article. At the same time, this article introduces the classification, key points of the operation and the evaluation of autonomic nerve preservation surgery. With the rapid development of minimally invasive surgery, performing radical surgery for rectal cancer is important, we also need to fully understand the anatomical concept of pelvic autonomic nerves, and apply modern minimally invasive surgical techniques to preserve the patient's pelvic autonomic nerves as well. It is an compulsory course and an important manifestation for the standardization of rectal cancer surgery.
Assuntos
Relevância Clínica , Neoplasias Retais , Humanos , Masculino , Qualidade de Vida , Vias Autônomas/cirurgia , Neoplasias Retais/cirurgia , Pelve/cirurgia , Pelve/inervaçãoRESUMO
OBJECTIVE: The objective of the present study is to evaluate the anatomy of the inferior hypogastric plexus, correlating it with urological pathologies, imaging exams and surgeries of the female pelvis, especially for treatment of endometriosis. MATERIAL AND METHODS: We carried out a review about the anatomy of the inferior hypogastric plexus in the female pelvis. We analyzed papers published in the past 20 years in the databases of Pubmed, Embase and Scielo, and we included only papers in English and excluded case reports, editorials, and opinions of specialists. We also studied two human fixed female corpses and microsurgical dissection material with a stereoscopic magnifying glass with 2.5x magnification. RESULTS: Classical anatomical studies provide few details of the morphology of the inferior hypogastric plexus (IHP) or the location and nature of the associated nerves. The fusion of pelvic splanchnic nerves, sacral splanchnic nerves, and superior hypogastric plexus together with visceral afferent fibers form the IHP. The surgeon's precise knowledge of the anatomical relationship between the hypogastric nerve and the uterosacral ligament is essential to reduce the risk of complications and postoperative morbidity of patients surgically treated for deep infiltrative endometriosis involving the uterosacral ligament. CONCLUSION: Accurate knowledge of the innervation of the female pelvis is of fundamental importance for prevention of possible injuries and voiding dysfunctions as well as the evacuation mechanism in the postoperative period. Imaging exams such as nuclear magnetic resonance are interesting tools for more accurate visualization of the distribution of the hypogastric plexus in the female pelvis.
Assuntos
Endometriose , Plexo Hipogástrico , Humanos , Feminino , Plexo Hipogástrico/anatomia & histologia , Plexo Hipogástrico/lesões , Plexo Hipogástrico/cirurgia , Endometriose/cirurgia , Pelve/inervação , Pelve/patologia , Pelve/cirurgia , Útero , CadáverRESUMO
OBJECTIVE: Magnetic resonance imaging-based subdivision of the pelvis into 7 compartments has been proposed for pelvic exenteration. The aim of the present anatomical study was to describe the topographic anatomy of these compartments and define relevant landmarks and surgical dissection planes. BACKGROUND: Pelvic anatomy as it relates to exenterative surgery is complex. Demonstration of the topographic peculiarities of the pelvis based on the operative situs is hindered by the inaccessibility of the small pelvis and the tumor bulk itself. MATERIALS AND METHODS: Thirteen formalin-fixed pelvic specimens were meticulously dissected according to predefined pelvic compartments. Pelvic exenteration was simulated and illustrated in a stepwise manner. Different access routes were used for optimal demonstration of the regions of interest. RESULTS: All the 7 compartments (peritoneal reflection, anterior above peritoneal reflection, anterior below peritoneal reflection, central, posterior, lateral, inferior) were investigated systematically. The topography of the pelvic fasciae and ligaments; vessels and nerves of the bladder, prostate, uterus, and vagina; the internal iliac artery and vein; the course of the ureter, somatic (obturator nerve, sacral plexus), and autonomic pelvic nerves (inferior hypogastric plexus); pelvic sidewall and floor, ischioanal fossa; and relevant structures for sacrectomy were demonstrated. CONCLUSIONS: A systematic approach to pelvic anatomy according to the 7 magnetic resonance imaging-defined compartments clearly revealed crucial anatomical landmarks and key structures facilitating pelvic exenterative surgery. Compartment-based pelvic anatomy proved to be a sound concept for beyond TME surgery and provides a basis for tailored resection procedures.
Assuntos
Pelve , Neoplasias Retais , Masculino , Feminino , Humanos , Pelve/inervação , Pelve/cirurgia , Neoplasias Retais/cirurgia , Reto/cirurgia , Plexo Hipogástrico/anatomia & histologia , PeritônioRESUMO
BACKGROUND: This study evaluated the visualization of the pelvic nerves using magnetic resonance imaging (MRI) combined with computed tomography (CT) to synthesize three-dimensional (3D) reconstruction images of the pelvic organs. METHODS: The CT and MRI scans were performed for patients with rectal cancer who underwent surgery. The out-of-phase image of LAVA-Flex was used to identify the pelvic nerves. The images of the pelvic nerves were extracted from the MRI scans, and those of the arteries and rectum and pelvis were extracted from the CT scans. Each extracted organ image was used to synthesize 3D reconstruction images. RESULTS: The MRI scan allowed adequate visualization of the pelvic splanchnic nerves, inferior hypogastric plexus, and obturator nerves. The comparison of 3D reconstruction images and intraoperative findings showed matched images. CONCLUSION: We visualized the pelvic nerves using MRI and synthesized 3D reconstruction images of the pelvic organs. Preoperative confirmation of the location of the pelvic organs is important to prevent unanticipated injury during rectal cancer surgery.
Assuntos
Neoplasias Retais , Reto , Humanos , Pelve/diagnóstico por imagem , Pelve/inervação , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/cirurgia , Imageamento por Ressonância Magnética/métodos , Plexo Hipogástrico/diagnóstico por imagemRESUMO
BACKGROUND: Pelvic surgery carries an inherent risk of autonomic nerve injury leading to genitourinary and bowel dysfunction due to the close proximity of the superior hypogastric plexus (SHP). The aim of this study was to define the detailed anatomy of SHP and identify its relationship with the vascular landmarks and ureters for pelvic autonomic nerve-preserving surgery. METHODS: A cadaveric study on the detailed anatomy of the SHP was conducted in our surgical anatomy research unit. Between 02/2019 and 10/2019, macroscopic anatomical dissections were performed on 45 fresh adult cadavers (39 male, 6 female). Distances between the SHP, major vascular structures, and other anatomical landmarks were measured. RESULTS: Three types of SHP morphology were observed: mesh (64.8%), single nerve (24.4%), and fiber (10.8%). SHP bifurcation was located inferior to the aortic bifurcation in all cases; however, it was observed cranial to the promontory in 80% of the cases, whereas 18% were caudally and 2% were over the promontory. The closest vessels to the left and right of the SHP bifurcation were the left common iliac vein (LCIV) (86.2%, the mean distance was 8.49 ± 7.97 mm) and the right internal iliac artery (RIIA) (48.2%, mean distance was 13.4 ± 9.79 mm), respectively. At SHP bifurcation level, the lateral edge of the SHP was detected on the LCIV in 22 cases and on the RIIA in 10 cases for the left and right side of the plexus, respectively. The distance between the SHP bifurcation and the ureter was 27.9 mm on the right and 24.2 mm on the left. The width of the left (LHN) and right hypogastric nerves (RHN) were 4.35 mm and 4.62 mm at 2 cm below the SHP bifurcation, respectively. LHN was on the vascular structures in 13 cases, whereas RHN in only 1 case, 2 cm below the SHP bifurcation. CONCLUSIONS: Understanding the location of the SHP, including its relationship with important anatomical landmarks, might prevent iatrogenic injury and reduce postoperative morbidity in the pelvic surgery setting.
Assuntos
Plexo Hipogástrico , Ureter , Adulto , Vias Autônomas , Feminino , Humanos , Veia Ilíaca , Masculino , Pelve/inervaçãoRESUMO
Controversial surgical anatomical landmarks in the deep pelvis can be visualized and identified using current technologies. Performing the gate approach technique during deep lateral dissection for total mesorectal excision facilitates visualization of the pelvic neurovascular structures following simple dissection steps to preserve the pelvic autonomic nerves and avoid accidental vascular injuries. Here, we discuss laparoscopic exposure of an infrequent disposition of the middle rectal artery anterior to the lateral ligament of the rectum while performing the gate approach.
Assuntos
Ligamentos Colaterais , Laparoscopia , Neoplasias Retais , Artérias/cirurgia , Humanos , Laparoscopia/métodos , Pelve/inervação , Pelve/cirurgia , Neoplasias Retais/cirurgia , Reto/cirurgiaRESUMO
BACKGROUND: Total pelvic exenteration (TPE) with intent to achieve a pathological R0 resection is now considered as the only chance of a long-term survival for locally advanced rectal cancer (LARC) invading into adjacent organs. Lately, laparoscopic total pelvic exenteration (LTPE) is performed and achieved in several specialized centers and showed a promising application prospect. Although this is universally realized by surgeons, there are only few specialized centers to perform this complex surgery, due to concerns about the high morbidity and mortality. The techniques associated need to be disclosed and facilitated. OBJECTIVE: The aim of this article is to introduce a fascial space priority approach for laparoscopic TPE step by step (with video). METHODS: We describe here a fascial space priority approach for LTPE in highly selected patients with locally advanced rectal cancer. The main principle of this approach is that all of the pelvic organs are considered as a whole, the non-vascular spaces surrounding it are separated in the first place, the vascular pedicle and nerve pedicle of pelvic organs can be isolated and then transected precisely. Meanwhile, the associated key landmarks of this approach are disclosed (see the video). RESULTS: The ureterohypogastric nerve fascia (UHGNF) and the vesicohypogastric fascia (VHGF) are two vital embryological planes on the lateral compartment of pelvis. The spaces on either side of them together with the retrorectal space, the space of Retzius, are all non-vascular spaces, and dissection of these spaces in LTPE surgery can be achieved simply and practicably. The ureter, the umbilical artery, the arcus tendinous fasciae pelvis (ATFP), piriformis and the puboprostatic ligament (PPL) are all important landmarks during surgery. Step-by-step illustration with precise anatomical landmarks in the present video may lead to less intraoperative blood loss and complications. CONCLUSIONS: LTPE with fascial space priority approach might be a standard surgical procedure for total pelvic exenteration with clear anatomy and reduced blood loss.
Assuntos
Laparoscopia , Exenteração Pélvica , Neoplasias Retais , Humanos , Laparoscopia/métodos , Exenteração Pélvica/métodos , Pelve/inervação , Neoplasias Retais/patologia , Neoplasias Retais/cirurgia , Reto/cirurgiaRESUMO
The inferior hypogastric plexus (IHP) lies in the extraperitoneal pelvis, and supplies branches to pelvic and perineal viscera. In men, the rectoprostatic fascia (Denonvillier's fascia) forms a distinct double fascial layer between the seminal glands and the rectum. The hypogastric nerve projections to the prostate and seminal glands run anterior to this. An analagous fascial layer in women between the vagina and cervix posteriorly and the urinary bladder anteriorly has recently been described. The purpose of this study was to examine the anatomy of the vesicovaginal fascia (VVF) and to determine its relationship to the anterior branches of the IHP. This dissection study examined the fascial layers between the posterior urinary bladder and anterior vagina/cervix (VVF) in 15 female embalmed cadavers and three fresh specimens. Anterior branches of the IHP were identified and followed distally. The relationship between these nerve projections and the VVF was examined. In 16 dissection, the VVF was identified as a complete fascial plane extending beneath the vesicouterine pouch to the neck of the bladder inferiorly and to the endopelvic fascia laterally. Anterior projections from the hypogastric nerves and IHP maintained an extraperitoneal course passing anteriorly to the VVF towards the urinary bladder The VVF is a distinct fascial structure and projections of the hypogastric nerves pass anterior to this. This may have implications for nerve sparing hysterectomy.
Assuntos
Plexo Hipogástrico , Bexiga Urinária , Fáscia , Feminino , Humanos , Plexo Hipogástrico/anatomia & histologia , Masculino , Pelve/inervação , Reto , Bexiga Urinária/inervaçãoRESUMO
Uterine transplantation is on the rise worldwide. In contrast to its arterial anatomy, venous drainage of the uterus is poorly defined in the literature. Our aim was to provide a standardized description of uterine veins through a multimodal approach to establish anatomical landmarks for the uterine transplantation surgeon. Data were obtained from: (1) an anatomical study of eight fresh female cadavers (16 hemipelves) studied separately by an extra fascial dissection from the iliac bifurcation to the uterine pedicle, with analysis of the urinary tract and nerve structures and (2) a virtual anatomical study from the Anatomage® Table comprising a high-fidelity virtual reconstruction of two deceased female subjects by imaging and anatomical methods. An inconstant duality of uterine veins was identified: a deep uterine vein of larger caliber and a superficial uterine vein observed in 25% of cases. A close relationship of the ureter passing posterior to the superficial uterine vein and anterior to the deep uterine vein was evident in the parametrium. The inferior hypogastric plexus was identified in all cases immediately behind the deep uterine vein. The data obtained from the fresh female cadavers were validated by the Anatomage® Table. We describe the close relationship of the uterine veins with the ureter and the inferior hypogastric plexus. This knowledge represents a surgical landmark to support the success of uterine transplantation by respecting both the graft and the safety of the living donor by limiting the risk of injuries during uterus procurement.