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Anatomically Based Surgical Dissection for Deep Endometriosis Surgery
Published in Nazar N. Amso, Saikat Banerjee, Endometriosis, 2022
Mohamed Mabrouk, Diego Raimondo, Alessandro Arena, Renato Seracchioli
During a transperitoneal inspection, without opening the peritoneum, some retroperitoneal structures can be simply identified:Median, right and left medial, and right and left lateral umbilical folds. The median umbilical fold extends from the apex of the bladder to the umbilicus and contains the urachus; the medial umbilical fold covers the obliterated umbilical artery; the lateral umbilical fold contains the deep inferior epigastric vessels, below their entry into the rectus sheathSuperior vesical arteries, on both sides, forming the transverse vesical folds on the bladder domeUterine artery, on both sides, passing between the two peritoneal layers of the broad ligament, within the cardinal ligament (of Mackenrodt or lateral parametrium), and crossing over the ureterPelvic ureter, entering the lesser pelvis in extraperitoneal areolar tissue at the level of the sacral promontory, anterior to the end of the common iliac vessels (more frequent on the left side) or at the origin of the external iliac vessels (more frequent on the right side). In women, the pelvic part anterior to the internal iliac artery is behind the ovary, forming the posterior boundary of the ovarian fossa (of Krause). Along the broad ligament, the uterine artery is anterosuperior to the ureter for about 2.5 cm and then crosses to its medial side to ascend alongside the uterus.Uterosacral ligaments, forming the rectouterine folds, containing pelvic autonomic nerve fibers in its posterolateral part. In some patients, it is also visible a more medial and caudal folder, enveloping the hypogastric nerves and the inferior hypogastric plexus (or pelvic plexus)Bifurcation of aorta (at the level of the L4 vertebra or the L4/5 intervertebral disc, to the left of the midline) and the left common iliac vein. Caudally, middle sacral vessels and the superior hypogastric plexus are located in the interiliac triangle (or Cotte triangle) at the level of sacral promontory. The superior hypogastric plexus is a network formed by branches from the aortic plexus (sympathetic and parasympathetic); lumbar splanchnic nerves (sympathetic); and pelvic splanchnic nerves (parasympathetic), regulating rectal, low urinary tract and upper genital functionsLaterally, three somatic nerves coming from the lumbar plexus: Genitofemoral nerve, lying on the psoas major muscle, the iliohypogastric and the ilioinguinal nerves.
A minimally invasive treatment of an asymptomatic case of mesh erosion into the caecum after total extraperitoneal inguinal hernia repair
Published in Acta Chirurgica Belgica, 2019
Gert Mulleners, Frederick Olivier, Mohamed Abasbassi
An exploratory laparoscopy was performed using a 12 mm supra-umbilical port, that revealed adhesion of the caecum anteriorly to the right groin (Figure 2(b)). The clips that were previously used for peritoneal closure were no longer visible. Three additional 5 mm ports were inserted under direct vision in the left lower quadrant, the suprapubic region and the left upper quadrant. The ileum was flipped over from the pelvis to the right upper quadrant to expose the ileocolic pedicle. A retromesenteric plane was entered posterior to the ileocolic pedicle. The retromesenteric plane was further developed by blunt dissection laterally and in a cephalad direction along the duodenum. Subsequently, the hepatic flexure was mobilised by incising the hepatocolic ligament from medial to lateral to establish a connection to the previously freed retroperitoneal plane. The right colon was released from its lateral peritoneal attachments by dividing the white line of Toldt. This allowed for the complete mobilisation of the right colon and a straightforward attachment of the caecum to the mesh (Figure 2(c)). The mesh was then cut by sharp dissection, leaving a defect of 2.5 by 2 cm. A 3 cm midline incision was made by extending the supra-umbilical port cephalad. The mobilised right colon was exteriorised after insertion of an Alexis® wound protector (Figure 2(d)). Only the resection of the base of the caecum and appendix was required as the ileocecal valve was not affected by the inflammatory process. A stapled resection was performed after opening the caecum and ensuring complete removal of the mesh. After returning the colon and re-insufflating the abdomen, the lateral umbilical fold was sutured over the peritoneal defect to cover the remainder of the mesh.