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Laparoscopy
Published in J. Richard Smith, Giuseppe Del Priore, Robert L. Coleman, John M. Monaghan, An Atlas of Gynecologic Oncology, 2018
Farr Nezhat, Carmel Cohen, Nimesh P. Nagarsheth
In addition to the primary intraumbilical trocar which is used for introduction of the video laparoscope, two ancillary 5-mm ports in the right and the left lower quadrants lateral to the inferior epigastric vessels at the level of the iliac crest and an additional 10-mm port in the midline 5 cm above the symphysis pubis are required. The lymphadenectomy may be performed either before or after hysterectomy. The procedure begins with an incision of the peritoneum between the round and infundibulopelvic ligaments, parallel to the axis of the external iliac vessels (Figure 26.48). The round ligament is electrodesiccated and cut, the broad ligament between the round and the infundibulopelvic ligament is opened, and the psoas muscle, genitofemoral nerve, iliac vessels, and ureter are identified. Next, the paravesical space is entered and widened by blunt dissection between the umbilical artery medially and external iliac vessels laterally. Caution should be exercised to avoid injuries to the external iliac vein and aberrant obturator veins (Figures 26.49 and 26.50).
Management of pelvic congestion syndrome and perineal varicosities
Published in Peter Gloviczki, Michael C. Dalsing, Bo Eklöf, Fedor Lurie, Thomas W. Wakefield, Monika L. Gloviczki, Handbook of Venous and Lymphatic Disorders, 2017
The obturator veins of the lateral pelvis are also interconnected with the femoral venous system. The small veins that collect blood from the adductor muscle groups may flow into the medial circumflex vein of the deep femoral venous system or into the obturator veins that coalesce with the small veins draining the bladder, traverse the pelvic floor, and empty into the internal iliac vein. These pathways link the anteromedial thigh with the pelvis.
Practical guide for pelvic insufficiency scanning
Published in Joseph A. Zygmunt, Venous Ultrasound, 2020
The pelvic venous evaluation can be taken a step further by connecting varices on the lower extremities or genitals with the pelvic venous system by evaluating pelvic leak points or pelvic escape points [26,27]. The interconnection between varices on the lower extremity with the veins of the pelvis has been described in cases of isolated and combined iliac vein stenosis/reflux and ovarian vein reflux. These pelvic source veins on the lower extremity typically appear in the vulva, high medial thigh, gluteal fold, and posterolateral thighs [28]. The connection between the pelvis and the lower extremity has been explored and organized into five areas of evaluation which can be added to both the lower extremity and pelvic venous ultrasound examinations [26–29]. Inguinal, perineal, obturator, superior gluteal, and inferior gluteal points can be evaluated depending on the distribution of lower extremity or genital varices (Figure 7.17) [27]. The inguinal point is located at the superficial inguinal orifice and fed by the round ligament vein, and can link with veins of the abdominal wall and the tributaries of the saphenous arch. The inguinal leak point can be imaged with a transverse linear probe in the groin, identifying the saphenofemoral junction and angling the transducer in a superior motion (Figure 7.18). Perineal point is located at the perineal membrane and fed by the pudendal vein, and can be linked to vulvar, perineal, and scrotal varices. Perineal leak point is identified by placing the transducer in a transverse orientation on the perineal space on the very medial thigh and angling the transducer superiorly (Figure 7.19). Obturator point is located in the thigh associated with the common femoral vein, fed from the obturator vein and commonly connected to the deep venous system but also may be connected with the saphenous arch (great saphenous junctional area). Obturator leak point can be identified by moving the transducer from the inguinal leak point slightly medially and looking for connection with the deep venous system. Superior gluteal leak point is located at the mid-portion of the buttock and typically linked to congenital varices that can involve the small saphenous vein. Inferior gluteal leak point is located at the infragluteal fold and can feed varices of the sciatic nerve. Superior and inferior gluteal leak points can be identified on the buttock, inferior at the inferior gluteal fold in a transverse scanning plane (Figure 7.20) and superior at the mid buttock. B-mode evaluation of varices of at these locations as well as color Doppler and pulsed wave Doppler with Valsalva maneuver can be utilized to identify varices and demonstrate reflux with the patient in the standing position.
Is the endovascular embolization of tributaries of the internal iliac veins essential in the treatment of isolated pelvic-perineal reflux?
Published in Current Medical Research and Opinion, 2019
Sergei G. Gavrilov, I. S. Lebedev
A specific feature of ultrasound pattern in the studied patients was the absence of valvular insufficiency in the superficial and perforating venous trunks of the lower extremities. The PPR according to the DUS data was determined based on the presence of retrograde blood flow in the varicose veins of the perineum and posterior thigh, which runs from the tributaries of the internal iliac vein. In this study, we did not ask an ultrasound specialist to “track” a direct communication of the dilated vein of the thigh with any tributary of the internal iliac vein using an ultrasonic device. In order to prove the presence of the PPR, the anatomical landmarks were used. Pelvic venous reflux was accompanied by retrograde blood flow from vaginal veins (69.7%), the obturator vein (7%), or the inferior gluteal vein (23.3%). The dilation of the veins of the vulva and perineum was left-side in 20 patients, and right-side in 13 patients. The dilation of the superficial veins of the posterior thigh was present on the left thigh in six patients and on the right thigh in four patients.
Arterial-enteric fistula after pelvic lymphadenectomy in secondary cytoreductive surgery for recurrent ovarian cancer
Published in Journal of Obstetrics and Gynaecology, 2019
Francesco Cosentino, Luigi Carlo Turco, Anna Fagotti, Stefano Cianci, Valerio Gallotta, Andrea Rosati, Francesco Corbisiero, Giovanni Scambia, Gabriella Ferrandina
In February 2018, the patient underwent laparoscopic SCS and a left pelvic lymphadenectomy with complete removal of the lymph nodes at our institution. Since PDS, the patient still had the loop ileostomy. During surgery, tenacious adhesions between the transverse and the descending colon as well as the anterior abdominal wall and the left lateral pelvic wall were noticed. The surgeon performed, after a cautious adhesionlysis, an opening on the left pelvic retro-peritoneum, which was challenging, because of fibrotic tissue due to previous treatments. All left external iliac lymph nodes, suspected for recurrence, were excised. The frozen section confirmed ovarian cancer nodal recurrence. In a second surgical step, the ileo-lumbar fossa was developed and the complete lymphatic metastatic recurrence in the left obturator space was identified and excised. The lymphatic recurrence appeared to compress circumferentially the left obturator nerve. Additionally, the recurrence was tenaciously adherent superiorly to the left external iliac vessels, inferiorly to the left glutaeal vein and the lumbosacral trunk and medially to the left obturator vein. Therefore, a cautious and accurate dissection of the retro-peritoneal tissues and vascular planes was under difficulties performed (Figure 1(a,b,c)). The exploration of the entire abdominal cavity did not reveal further localizations of metastasis. In particular, the pelvic para-anastomotic region was cancer-free despite the preoperative work-up. During surgery, a laparoscopic ultrasonic device was adopted to be used as bipolar forceps and laparoscopic scissor for the most delicate dissection procedures.