RESUMO
OBJECTIVE: This video tutorial identifies key anatomic landmarks useful in identifying the path of the most commonly encountered pelvic nerves in benign gynecologic surgery. DESIGN: This is a narrated overview of commonly encountered pelvic nerves during benign gynecology, their origin, sensory, and motor function, as well as sequelae related to injury. SETTING: The unintended injury of pelvic neural connections can be a complication of any pelvic surgery, however, surgery for malignancy or endometriosis may increase the likelihood of encountering these nerves. The majority of focus surrounding surgical nerve injury, however, relates to patient positioning [1]. Injury to the pelvic nerves can lead to lifelong sexual, bladder, and defecatory dysfunction [2]. INTERVENTIONS: We review the Genitofemoral, Lateral Femoral Cutaneous, Ilioinguinal, Obturator, Superior and Inferior Hypogastric nerves, Pelvic Splanchnic nerves, and the Sacral nerves. Surgical illustrations are used (Fig. 1) alongside real-time narrated video to help viewers recognize the normal course of commonly encountered pelvic nerves at the time of gynecologic surgery (Figs2-3). CONCLUSION: The surgical management of complex pelvic disease can unfortunately carry significant patient morbidity [3]. The neural pathways traveling through the pelvis via the hypogastric nerves are responsible for proprioception, vaginal lubrication, and proper functioning or the urethral and anal sphincters [4]. Sparing these nerves during pelvic surgery, and especially when anatomic planes are distorted by pelvic disease, requires surgical expertise and an immense understanding of pelvic neuroanatomy [4,5]. Preservation of the pelvic neural pathways is necessary to deliver the best patient outcomes while minimizing unwanted surgical complications. This video tutorial also highlights the origin of these nerves, their anatomic location, procedures in which these nerves may be encountered, and what sequelae occur from their unintended injury.
Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Pelve/anatomia & histologia , Pelve/inervação , Endometriose/patologia , Endometriose/cirurgia , Feminino , Neoplasias dos Genitais Femininos/patologia , Neoplasias dos Genitais Femininos/cirurgia , Humanos , Laparoscopia/métodos , Plexo Lombossacral/anatomia & histologia , Plexo Lombossacral/patologia , Plexo Lombossacral/cirurgia , Pelve/patologia , Pelve/cirurgia , Nervos Esplâncnicos/anatomia & histologia , Nervos Esplâncnicos/patologia , Nervos Esplâncnicos/cirurgia , Neoplasias Urológicas/patologia , Neoplasias Urológicas/cirurgiaRESUMO
Laparoscopic radical hysterectomy has been widely performed for patients with early-stage cervical cancer. The operative techniques for nerve-sparing to avoid bladder dysfunction have been established during the past three decades in abdominal radical hysterectomy, but how these techniques can be applied to laparoscopic surgery has not been fully discussed. Prolonged operation time or decreased radicality due to less accessibility via a limited number of trocars may be a disadvantage of the laparoscopic approach, but the magnified visual field in laparoscopy may enable fine manipulation, especially for preserving autonomic nerve tracts. The present review article introduces the practical techniques for sparing bladder branches of pelvic nerves in laparoscopic radical hysterectomy based on understanding of the pelvic anatomy, clearly focusing on the differences from the techniques in abdominal hysterectomy.
Assuntos
Medicina Baseada em Evidências , Histerectomia/efeitos adversos , Complicações Intraoperatórias/prevenção & controle , Laparoscopia/efeitos adversos , Bexiga Urinaria Neurogênica/prevenção & controle , Sistema Urinário/lesões , Neoplasias do Colo do Útero/cirurgia , Adulto , Vias Autônomas/lesões , Vias Autônomas/patologia , Vias Autônomas/fisiopatologia , Feminino , Humanos , Plexo Hipogástrico/lesões , Plexo Hipogástrico/patologia , Plexo Hipogástrico/fisiopatologia , Histerectomia/métodos , Pelve/lesões , Pelve/inervação , Pelve/patologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Nervos Esplâncnicos/lesões , Nervos Esplâncnicos/patologia , Nervos Esplâncnicos/fisiopatologia , Ureter/lesões , Ureter/inervação , Ureter/patologia , Bexiga Urinária/lesões , Bexiga Urinária/inervação , Bexiga Urinária/patologia , Bexiga Urinaria Neurogênica/etiologia , Bexiga Urinaria Neurogênica/patologia , Bexiga Urinaria Neurogênica/fisiopatologia , Sistema Urinário/inervação , Sistema Urinário/patologia , Sistema Urinário/fisiopatologiaRESUMO
BACKGROUND: Little information is available about the clinical history of patients with incidentally detected splanchnic vein thrombosis and its therapeutic management remains controversial. The aim of this study was to assess the risk factors, therapeutic strategies, and long-term outcomes of incidentally detected splanchnic vein thrombosis. METHODS: We analysed data from patients with incidentally detected splanchnic vein thrombosis who were enrolled in an international, multicentre, prospective cohort study of splanchnic vein thrombosis between 2008 and 2012. The study was done at 31 centres in 11 countries (Italy, South Korea, Germany, Canada, Belgium, the Netherlands, Brazil, USA, France, Israel, UK). Information about demographic characteristics, risk factors, and treatment was collected. The study outcomes during the 2-year follow-up were major bleeding (International Society on Thrombosis and Haemostasis definition plus the need for hospital admission), thrombotic events (venous or arterial thromboses), and mortality. The primary analysis period was from the diagnosis of incidentally detected splanchnic vein thrombosis until the first adjudicated clinical outcome or the end of follow-up. FINDINGS: Between May 2, 2008, and Jan 30, 2012, we enrolled 177 patients with incidentally detected splanchnic vein thrombosis (median age 57 years [IQR 49-66], 118 [67%] men, 138 [78%] patients with portal vein thrombosis). The most common underlying diseases were liver cirrhosis (82 [46%] patients) and solid cancer (62 [35%] patients). Anticoagulant treatment was prescribed to 109 (62%) patients. Median duration of anticoagulation was 6 months (IQR 5-12) for patients who received parenteral anticoagulants alone and 24 months (IQR 12-24) for patients treated with vitamin K antagonists. During a median follow-up of 2 years (IQR 1-2), the incidence of major bleeding was 3·3 events (95% CI 1·7-6·3) per 100 patient-years and the incidence of thrombotic events was 8·0 events (95% CI 5·2-12·1) per 100 patient-years. On-treatment incidence was 3·2 events (95% CI 1·2-8·4) per 100 patient-years for major bleeding and 3·9 events (95% CI 1·6-9·5) per 100 patient-years for thrombotic events. In multivariate analysis, anticoagulant treatment as a time-dependent variable reduced the incidence of thrombotic events (hazard ratio 0·85, 95% CI 0·76-0·96) without increasing the risk of major bleeding (p>0·05). In patients with clinically suspected splanchnic vein thrombosis, the incidence of major bleeding was 3·9 events (95% CI 2·6-5·7) per 100 patient-years and the incidence of thrombotic events was 7·0 events (95% CI 5·2-9·3) per 100 patient-years. INTERPRETATION: Our results show that the prognosis of incidentally detected splanchnic vein thrombosis is similar to that of clinically suspected splanchnic vein thrombosis and suggest that similar treatment strategies should be applied. FUNDING: Pfizer Canada research grant.
Assuntos
Anticoagulantes/uso terapêutico , Sistema de Registros , Nervos Esplâncnicos/efeitos dos fármacos , Trombose Venosa/tratamento farmacológico , Trombose Venosa/epidemiologia , Adulto , Idoso , Feminino , Seguimentos , Humanos , Incidência , Agências Internacionais , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Nervos Esplâncnicos/patologia , Taxa de Sobrevida , Trombose Venosa/patologiaRESUMO
Excessive activation of the greater splanchnic nerve (GSN) has previously been determined to contribute to the progression of gastric ischemiareperfusion (GIR) injury. The present study was designed to estimate the protective effects of GABAA receptor (GABA(A)R) overexpression in the lateral hypothalamic area (LHA) against GIR injury. The GIR injury model was induced in rats by clamping the celiac artery for 30 min and then reperfusing for 1 h. Microinjection of recombinant adenoviral vectors overexpressing GABA(A)R (AdGABA(A)R) or control adenoviral vectors (AdCon) into the LHA was conducted in GIR and normal control rats. Significant protective effects were observed on day 2 after AdGABA(A)R treatment in the GIR injury rats. AdGABA(A)R treatment reduced plasma norepinephrine levels, plasma angiotensin II levels and peripheral GSN activity, but increased the gastric mucosal blood flow, as compared with AdCon treatment. These results indicate that adenoviral vectorinduced GABA(A)R overexpression in the LHA blunts GSN activity and subsequently alleviates the effects of gastric injury in GIR rats.
Assuntos
Região Hipotalâmica Lateral/metabolismo , Receptores de GABA-A/metabolismo , Traumatismo por Reperfusão/patologia , Adenoviridae/genética , Angiotensina II/sangue , Animais , Velocidade do Fluxo Sanguíneo , Modelos Animais de Doenças , Mucosa Gástrica/irrigação sanguínea , Vetores Genéticos/metabolismo , Imuno-Histoquímica , Masculino , Norepinefrina/sangue , Ratos , Ratos Sprague-Dawley , Receptores de GABA-A/genética , Traumatismo por Reperfusão/metabolismo , Nervos Esplâncnicos/metabolismo , Nervos Esplâncnicos/patologia , Estômago/patologiaRESUMO
Oxygen (O2) sensing by the carotid body and its chemosensory reflex is critical for homeostatic regulation of breathing and blood pressure. Humans and animals exhibit substantial interindividual variation in this chemosensory reflex response, with profound effects on cardiorespiratory functions. However, the underlying mechanisms are not known. Here, we report that inherent variations in carotid body O2 sensing by carbon monoxide (CO)-sensitive hydrogen sulfide (H2S) signaling contribute to reflex variation in three genetically distinct rat strains. Compared with Sprague-Dawley (SD) rats, Brown-Norway (BN) rats exhibit impaired carotid body O2 sensing and develop pulmonary edema as a consequence of poor ventilatory adaptation to hypobaric hypoxia. Spontaneous Hypertensive (SH) rat carotid bodies display inherent hypersensitivity to hypoxia and develop hypertension. BN rat carotid bodies have naturally higher CO and lower H2S levels than SD rat, whereas SH carotid bodies have reduced CO and greater H2S generation. Higher CO levels in BN rats were associated with higher substrate affinity of the enzyme heme oxygenase 2, whereas SH rats present lower substrate affinity and, thus, reduced CO generation. Reducing CO levels in BN rat carotid bodies increased H2S generation, restoring O2 sensing and preventing hypoxia-induced pulmonary edema. Increasing CO levels in SH carotid bodies reduced H2S generation, preventing hypersensitivity to hypoxia and controlling hypertension in SH rats.
Assuntos
Monóxido de Carbono/química , Corpo Carotídeo/fisiologia , Sulfeto de Hidrogênio/química , Hipertensão/metabolismo , Oxigênio/química , Edema Pulmonar/metabolismo , Animais , Peso Corporal , Catecolaminas/metabolismo , Cistationina gama-Liase/metabolismo , Heme Oxigenase (Desciclizante)/metabolismo , Hipóxia , Imuno-Histoquímica , Masculino , Consumo de Oxigênio , Ratos , Ratos Sprague-Dawley , Reprodutibilidade dos Testes , Respiração , Transdução de Sinais , Especificidade da Espécie , Nervos Esplâncnicos/patologiaRESUMO
PURPOSE: Endometriotic or fibrotic involvement of sacral plexus and pudendal and sciatic nerves may be quite frequently the endopelvic cause of ano-genital and pelvic pain. Feasibility of a laparoscopic transperitoneal approach to the somatic nerves of the pelvis was determined and showed by Possover et al. for diagnosis and treatment of ano-genital pain caused by pudendal and/or sacral nerve roots lesions and adopted at our institution. In this paper we report our experience and anatomo-surgical consideration regarding this technique. METHODS: Confidence with this technique was obtained after several laparoscopic and laparotomic dissections on fresh, embalmed and formalin-fixed female cadavers and is now routinely performed at our institution in all cases of extensive endometriosis of the pelvic wall, involving the somatic nerves. RESULTS: We describe two different laparoscopic transperitoneal approaches to the lateral pelvic wall in case of: (A) deep pelvic endometriosis with rectal and/or parametrial involvement extending to pelvic wall and somatic nerves; (B) isolated endometriosis of pelvic wall and somatic nerves. CONCLUSIONS: Laparoscopic transperitoneal retroperitoneal nerve-sparing approach to the pelvic wall proved to be a feasible and useful procedure even if limited to referred laparoscopic centers and anatomically experienced and skilled surgeons.
Assuntos
Endometriose/cirurgia , Laparoscopia/métodos , Plexo Lombossacral/anatomia & histologia , Invasividade Neoplásica/patologia , Neoplasias Pélvicas/cirurgia , Cadáver , Estudos de Coortes , Dissecação , Endometriose/patologia , Estudos de Viabilidade , Feminino , Humanos , Plexo Lombossacral/cirurgia , Neoplasias Pélvicas/patologia , Pelve/anatomia & histologia , Pelve/inervação , Espaço Retroperitoneal , Nervo Isquiático/anatomia & histologia , Sensibilidade e Especificidade , Nervos Esplâncnicos/patologiaRESUMO
BACKGROUND: Little is known about the morbidity associated with laparoscopic complete excision of endometriosis in terms of urinary, digestive and sexual function. METHODS: We performed a prospective non-randomized study in 45 patients with laparoscopic complete excision of all detectable foci of endometriosis with segmental bowel resection using a non nerve-sparing technique (control group-group A n=20) and a nerve-sparing technique (case group-group B n=25). At initial gynaecological evaluation, and at follow-up details on dysmenorrhoea, pelvic pain, dyspareunia and dyschezia were evaluated using an interview-based questionnaire (10-point analogue rating scale: 0=absent, 10=unbearable). RESULTS: The mean (+/-SD) follow-up period was 15.3+/-10 months (range, 8.8-23 months) for group A and 3.5+/-2.1 months (range, 0.3-5.2 months) for group B. In the immediate postoperative course, in group A three women required blood transfusion vs seven women in group B (P=0.003). The median time to resume the voiding function was significantly shorter in group B (12.5 vs 3.0 days; P<0.01). At the time of follow-up a higher proportion of patients in group B were 'very satisfied' than those in group A (87.7% vs 59.0%, P=0.013). CONCLUSIONS: Laparoscopic nerve-sparing complete excision of endometriosis seems to be feasible and offers good results in terms of bladder morbidity reduction with apparently higher satisfaction than classical technique. Larger series with longer follow-up are needed to confirm our results.
Assuntos
Endometriose/cirurgia , Endométrio/inervação , Laparoscopia/métodos , Adulto , Endometriose/patologia , Endométrio/patologia , Estudos de Viabilidade , Feminino , Humanos , Dor Pós-Operatória , Reoperação , Nervos Esplâncnicos/patologia , Inquéritos e Questionários , Resultado do TratamentoRESUMO
BACKGROUND: Segmental neurofibromatosis (NF V) is ten times less frequent than Recklinghausen disease. Would the risk of visceral involvement in this uncommon form of neurofibromatosis warrant systematic imaging procedures? CASE REPORT: A 31-year-old man consulted for a voluminous plexiform neurofibroma in the left lumbar area. More ventrally, on the left side, there was also a café au lait spot. There were no Lisch nodules. The chest and abdominopelvic computed tomography and magnetic resonance imaging showed intramuscular tumoral extension, two neurofibromas in the 9th intercostal space and a voluminous 5-cm tumor situated in the left adrenal area. After resection pathology examination of the surgical specimen confirmed the diagnosis of ganglioneuroma. DISCUSSION: In this patient, all the neurofibromas and the café of lait spot developed in the territories of the left T10 and adjacent spinal roots. This was also true for the ganglioneuroma which developed on the deep sympathetic ramus to the adrenal gland which originates essentially from roots T8 to T11. This would place this case in the second subgroup of NF V in Roth's classification. Only six other cases have been reported in the literature. Such deep localizations are very likely to be underestimated, raising the problem of their detection and the correct protocol to follow asymptomatic forms, especially to detect disease progression to malignant degeneration which has a poor prognosis. Patients with a NF V should receive genetic counselling with a search for a family history, other signs of neurofibromatosis and Lisch nodules. In young patients, the risk of deep asymptomatic spread underlines the importance of regional computed tomographic or magnetic resonance explorations.
Assuntos
Neoplasias do Sistema Nervoso Periférico/diagnóstico , Neoplasias Cutâneas/diagnóstico , Raízes Nervosas Espinhais , Nervos Esplâncnicos , Adulto , Diagnóstico Diferencial , Humanos , Imageamento por Ressonância Magnética , Masculino , Neoplasias do Sistema Nervoso Periférico/genética , Neoplasias Cutâneas/genética , Raízes Nervosas Espinhais/patologia , Nervos Esplâncnicos/patologiaRESUMO
The technique of bilateral total splanchnicectomy performed through a posterior thoracoscopic approach is described. The advantages of this route include excellent visual exposure of the neural anatomy of the sympathetic and avoidance of single lung anaesthesia. The procedure was performed for the relief of intractable pain in patients with advanced pancreatic cancer (n = 3) and patients suffering from chronic pancreatitis (n = 5). Persistent relief of pain until death was obtained in the patients with pancreatic cancer (2, 4, 6 months). In patients with chronic pancreatitis, the benefit to date has varied with the severity of the disease. In two patients with severe advanced disease and previous percutaneous blocks, the relief of pain lasted only 3 and 5 weeks and both patients required resection for renewed intractable pain. In three patients with minimal change disease, relief of pain has been good in the short term (maximum follow-up of 8 months). Bilateral thoracoscopic total splanchnicectomy merits further evaluation in patients with pancreatic pain. No complications including hypotension have been encountered.
Assuntos
Denervação/instrumentação , Dor Intratável/cirurgia , Pancreatopatias/complicações , Nervos Esplâncnicos/cirurgia , Toracoscópios , Humanos , Dor Intratável/etiologia , Pâncreas/inervação , Nervos Esplâncnicos/patologia , Instrumentos CirúrgicosRESUMO
Studies of the fetus and new-born were undertaken to determine the exact localization of the nn. erigentes in the lower pelvis. The particular topography was visualized using histological slides and a special digital imaging technique. The nn. erigentes were found to be bundled along the diaphragmatic part of the urethra before entering the two cavernous bodies of the penis. These findings suggest that a small anterior patch of rectal muscle covering the diaphragmatic part of the urethra should be left behind in male patients undergoing total proctocolectomy in order to preserve potency. This operative technique cannot be employed for carcinomas extending to the anterior rectal wall. Since 1980, the new technique has been used in 18 male patients with rectal carcinoma and sexual function was preserved in all cases.