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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
In the pelvic cavity several ‘peritoneal reflections' can be recognized. The broad ligament of the uterus is an important intraperitoneal landmark which divides the pelvic cavity, on both sides, in three ‘compartments': Anterior, lateral and posterior. Dorsally, the retrorectal peritoneal reflection is formed by the peritoneum covering the anterolateral surface of the upper rectum, a part of sacrum concavity and pelvic lateral walls. The uterus and vagina produce two other important median pouches with different depths, namely, the rectouterine pouch (of Douglas) and the vesicouterine pouch. Ventrally, the peritoneum on the dome of the bladder reflects on the posterior aspect of the anterior pelvic wall and generates the prevescical reflection.
Ultrasound in Assisted Reproductive Technology: Anatomy and Core Examination Skills
Published in Arianna D'Angelo, Nazar N. Amso, Ultrasound in Assisted Reproduction and Early Pregnancy, 2020
Finally, to conclude the examination, the pouch of Douglas (cul-de-sac) is examined by noting the following: Identify the pouch of Douglas or the rectouterine pouch, an extension of the peritoneal cavity between the rectum and back wall of the uterus, cervix, and upper vagina.Examine fully from one side of the pelvis to the other.Note any fluid collection, adhesions, endometriotic deposits, loops of bowel, or any other solid or cystic masses. A small amount of fluid is normally present around the time of ovulation and not infrequently.
SBA Answers and Explanations
Published in Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury, SBAs for the MRCS Part A, 2018
Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury
The ureters lie adjacent to the lateral fornix of the cervix. Consequently, a ureteric calculus may be felt in the lateral fornix on vaginal examination. The posterior fornix actually has overlying it the peritoneum of the recto-uterine pouch of Douglas, which is normally occupied by coils of small intestine or sigmoid colon and lies between the uterus anteriorly and the rectum posteriorly. The pouch of Douglas is the most dependent part of the pelvis. Consequently, blood may collect here in a ruptured ectopic pregnancy. A needle may be passed into this space (in an attempt to aspirate blood) in order to diagnose the condition (culdocentesis). Furthermore, the instrument used in illegal abortions, if missing the cavity of the uterus, could actually penetrate the posterior fornix and subsequently the peritoneal cavity, often leading to fatal peritonitis and sepsis.
Management of mucocele of the appendix with peritoneal dissemination in pregnant women: a case report and literature review
Published in Acta Chirurgica Belgica, 2023
Sophiane Derbal, Clemence Klapczynski, Aurélie Charissoux, Sylvaine Durand Fontanier, Abdelkader Taibi
In pregnant women with AM, it is important to distinguish two situations (Figures 2 and 3). First, the management of AM discovered intraoperatively in a pregnant woman does not differ from that in the general population. The abdominal cavity is explored, and peritoneal nodules and/or mucin are systematically removed. The PCI should then be calculated as this will guide further treatment. The principles of surgery include resection of the appendix, wide resection of the mesoappendix and complete evacuation of the intraperitoneal mucoid material [6]. Mucin deposits in AM may be acellular or contain a neoplastic epithelium [9]. A challenge in pregnant women is the exploration of the ovaries as well as the rectouterine pouch or right para-colic gutter, which are preferential areas of mucus accumulation. In our patient, the surgeon carefully performed an appendectomy that included the meso-appendix. A laparoscopic approach is possible only if the surgeon uses the ‘no touch tumour’ technique, to avoid perforation of the tumour. Otherwise, a conversion to laparotomy is necessary and the appendectomy is performed according to the same principle. Macroscopic involvement of the appendiceal base requires ileocecal resection or right hemi-colectomy (more to obtain a macroscopically complete resection and adequate lymph node dissection. The main risk of AM is progression to PMP.
Immature teratoma of the uterine cervix
Published in Journal of Obstetrics and Gynaecology, 2022
Manizheh Sayyah-Melli, Behrouz Shokohi, Shabnam Yagoobi, Ali Adili, Seyyedeh Sanaz Hosseini
Teratomas usually arise in the gonads and mainly develop in midline structures; and, extragonadal types of teratomas are infrequent (Kurman et al. 2011). (Oosterhuis et al. 2007; Misra et al. 2014). Cervical teratoma, is relatively rare (Oosterhuis et al. 2007). It is suggested that this type of tumour in the cervix and endometrium may be originated from residual foetal tissue. To our knowledge, there have been a few uterine cervical immature teratoma cases reported in the literature to date. In contrast to our case, which was presented with pelvic pressure, constipation and report of a leiomyoma behind the cervix, all reported cases had originated from the cervical canal with abnormal vaginal bleeding (AUB) (Cortes et al. 1990; Panesar and Sidhu 2007; Ito et al. 2019) (Cortes et al. 1990) (Panesar and Sidhu 2007), or the uterine fundus (Iwanaga et al. 1993; Gomez-Lobo and Burch 2008; Souza et al. 2014). In this case, the patient had no AUB. Another case reported by F Khorsandi showed a solid tumour of the left corner of the external os (Khorsandi and Anabitarte 1981). In contrast to the study of Simona Stolnicu and colleagues, in which immature solid teratomas involved uterine corpus, ovary and mature teratomas, the cervix and para-uterine tissue, in our study, the ovaries looked normal (Stolnicu et al. 2017). There was also differences between our study and the study of Zamani et al. In this study, the authors reported a necrotised mature teratoma of the uterus with aggressive behaviour (Zamani et al. 2018). In contrast, our case originated from the posterior surface of the cervix progressed to the recto-uterine pouch, parametrium and pelvic sidewall.
Disseminated peritoneal leiomyomatosis after uterine artery embolization, laparoscopic surgery, and high intensity focused ultrasound for uterine fibroids：a case report
Published in International Journal of Hyperthermia, 2020
Chunyan Liu, Bojie Chen, Xingmei Tang, Yu Xiong
During laparoscopic surgery, extensive and dense multiple gray and white nodules were found on the surface of the uterus, broad ligaments, the fallopian tubes, the anterior and lateral abdominal wall, the vesicouterine pouch, the rectouterine pouch, the ovaries, liver, cecum, sigmoid colon and greater omentum (Figure 2(A)). The size of the uterus was about 5 months of gestation and the multiple nodules were ranged from 2 mm to 9 cm in size. The largest nodule of 9 cm in diameter was located at the fundus of the uterus, the other two bigger nodules, approximately 4 and 6 cm in size, respectively, were detected in the vesicouterine pouch and the rectouterine pouch. In addition, we found that the left broad ligament, the left fallopian tube, and the left ovary were surrounded by the intestinal tube, and were closely adhered to. So we first performed a laparoscopic subtotal hysterectomy with a bilateral salpingo-oophorectomy to remove the uterus, the fallopian tubes and the ovaries, then carefully excised the two bigger nodules in the vesicouterine pouch and the rectouterine pouch, as well as the visible small lesions on the liver (Figure 2(B)), partial omentectomy was also made. No intraoperative or postoperative complications occurred and the patient was discharged 3 days after surgery. The histological exam showed the multiple nodules with typical features of uterine fibroids. Neither atypia nor necrosis was detected in the specimen (Figure 3(A,B)). Based on the findings from laparoscopic surgery and the histological exam results, a diagnosis of DPL was established in this case. In April 2020, the six months follow-up after surgery, she reported no symptoms and the color Doppler ultrasound did not show any specific findings in the pelvic cavity.