Abdomino-Perineal Excision for Rectal Cancer
Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams in Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
The pelvic dissection during the inter-sphincteric APE is identical to that performed for AR, described previously. In summary, the loose connective tissue plane (‘the holy plane’) separating the mesorectal fascia from the parietal pelvic structures is identified and followed first posteriorly, then to the left and right and finally anteriorly whilst the peritoneum is gradually divided. A gentle traction on the specimen and counter-traction with appropriate retractors is crucial to achieve a good view of this plane. The superior hypogastric plexus is identified at the sacral promontory and the hypogastric nerves should be identified, protected and preserved whilst the dissection gradually proceeds downwards in the pelvic cavity. Anteriorly the dissection is conducted just posterior to the seminal vesicles and prostate in the male and the vagina in the female. The lower anterior-lateral dissection is the most difficult part of the abdominal phase of the operation because the correct plane is often difficult to find here and the inferior hypogastric plexus must be carefully preserved to maintain post-operative sexual and urinary function. Reducing the angle of the Trendelenburg position or even shifting the patient to a reverse Trendelenburg position may facilitate the exposure for the anterior dissection.
Robotic Rectal Cancer Surgery
Haribhakti Sanjiv in Laparoscopic Colorectal Surgery, 2020
The autonomic nerves consist of the paired sympathetic hypogastric nerve, sacral splanchnic nerves, and the pelvic autonomic nerve plexus. The superior hypogastric plexus is located ventrally to the abdominal aorta a t the origin of IMA and later bifurcates to form right and left hypogastric nerves just proximal to at the sacral hollow. The hypogastric nerves, which derive from the superior hypogastric plexus, carry the sympathetic signals to the internal urethral and anal sphincters, as well as to the pelvic visceral proprioception. The pelvic splanchnic nerves from S2 to S4 carry nociceptive and parasympathetic signals to the bladder, rectum, and colon. The hypogastric and pelvic splanchnic nerves merge into the pararectal fossae to form the inferior hypogastric plexus [16].
Sympathetic Neural Blockade in the Evaluation and Treatment of Pain
Mark V. Boswell, B. Eliot Cole in Weiner's Pain Management, 2005
The proximity of the hypogastric nerves to the iliac vessels means that the potential for bleeding or inadvertent intravascular injection remains a distinct possibility. The relationship of the cauda equina and exiting nerve roots makes it imperative that this procedure be carried out only by those well versed in the regional anatomy and experienced in performing lumbar sympathetic nerve block. Given the proximity of the pelvic cavity, damage to the pelvic viscera including the ureters during hypogastric plexus block is a distinct possibility. The incidence of this complication will be decreased if care is taken to place the needle just beyond the anterolateral margin of the L5–S1 interspace. Needle placement too medial may result in epidural, subdural, or subarachnoid injections or trauma to the intervertebral disc, spinal cord, and exiting nerve roots. Although uncommon, infection remains an ever-present possibility, especially in the immunocompromised patient with cancer. Early detection of infection, including discitis, is crucial to avoid potentially life-threatening sequelae.
A Modification of Laparoscopic Type C1 Hysterectomy to Reduce Postoperative Bladder Dysfunction: A Retrospective Study
Published in Journal of Investigative Surgery, 2019
Wei Jiang, Meirong Liang, Douxing Han, Hui Liu, Ling Li, Meiling Zhong, Lin Luo, Siyuan Zeng
Currently, there are two schools of thought regarding NSRHs: One of these favors a traditional approach, and the other favors a modified approach. The traditional school insists on the visualized preservation of the nerve by meticulous separation of the nerve, despite the prolonged and complicated nature of the procedure.6,7,12 To cope with the complex anatomy of the nerve plexus, numerous researchers have invented multiple instruments.6,7,12 In contrast, the modified approach spares the inferior hypogastric plexus as a whole without separating the autonomic nerve by direction of defined anatomical landmarks. The inferior hypogastric plexus is formed by the hypogastric nerve, pelvic splanchnic nerve, innervating bladder, uterus and rectum. A range of anatomical landmarks has been put forward to enable the preservation of the plexus. Fujii5 and Kato13 recommended separation of the inferior vesical vein to identify and preserve the bladder branch from the inferior hypogastric plexus, however, the preservation is difficult due to the rich anatomical variation. Ditto et al.14 and Bin Li et al.15 reported that the middle rectal artery demarcated the boundary between the nervous portion and vesicular portion of the CL. However, the middle rectal artery is subjected to rich anatomical variation and is more commonly single sided than double sided.16
Topography of the pelvic autonomic nerves – an anatomical study to facilitate nerve-preserving total mesorectal excision
Published in Acta Chirurgica Belgica, 2022
Jan Gaessler, Friedrich Anderhuber, Sabine Kuchling, Ulrike Pilsl
After separation of the rectum from the sigmoid colon, the parietal peritoneum covering the lumbosacral junction was longitudinally incised via a midsagittal section. Following the detection of the hypogastric nerves arising from the superior hypogastric plexus (SHP), development of the posterior plane was pursued. This was achieved through careful separation of the presacral fascia and the posterior aspect of the MRF by use of sharp dissection. Tracking the hypogastric nerves downwards, the inferior hypogastric plexus (IHP) was reached and subsequently exposed through mobilisation of the lateral aspects of the rectum. Hereafter, the anterior aspect of the MRF was exposed via sharp dissection behind the RGS. Finally, the ureters were exposed with particular focus on their course in relation to the plane of dissection in TME.
Superior hypogastric plexus block as an effective treatment method for endometriosis-related chronic pelvic pain: an open-label pilot clinical trial
Published in Journal of Obstetrics and Gynaecology, 2021
Sepideh Khodaverdi, Mahmoud Reza Alebouyeh, Kambiz Sadegi, Abolfazl Mehdizadehkashi, Mania Kaveh, Saeid Reza Entezari, Hossein Mirzaei, Mojdeh Khaledi, Maryam Khodaverdi
The superior hypogastric plexus (SHP), as a retroperitoneal structure, is located bilaterally between the fifth lumbar and the first sacral vertebra in a sacral promontory. This network innervates the pelvic floor and genitalia through the nerves of hypogastric plexus that is the main cause of pelvic pain (Jones and Rock 2015). Safety and efficacy of SHP block have been reported in the treatment of CPP, especially in patients with pelvic cancers and secondary dysmenorrhoea (Plancarte et al. 1997; Yang et al. 2018). However, the efficacy of SHP block in pain management in patients with refractory endometriosis has not been investigated in earlier investigations. In this study, we aimed to evaluate the effect of SHP block on pain and quality of life of patients with refractory endometriosis who were irresponsive to medication therapy.
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