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Laparoscopic Dissection and Anatomy of Sacral Nerve Roots and Pelvic Splanchnic Nerves
S64 198
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S50–S94 Video Session 5dLaparoscopy (11:00 AMd11:05 AM)
Laparoscopic Dissection and Anatomy of Sacral Nerve Roots and Pelvic Splanchnic Nerves Zanatta A,1 Rosin MM,2 Machado RL,2 Cava L,2 Possover M.3 1Pelvi Uroginecologia e Cirurgia Ginecologica, Brasilia, Distrito Federal, Brazil; 2Instituto de Laparoscopia e Robotica, Sao Paulo, SP, Brazil; 3 Neuropelveology, University of Aarhus, Aarhus, Denmark The laparoscopic neuronavigation technique is effective for approaching the main pelvic somatic and visceral nerves. In this video, we describe the necessary steps to reveal the sacral nerve roots and pelvic splanchnic nerves. She was a 31-year old patient with suspected iatrogenic sacral neuropathy. Dissection in the pelvic sidewall begins medially to the ureter and laterally to the sympathetic inferior hypogastric nerve. Gentle blunt and sharp dissection is performed caudally in the depth of the pararectal space. We identify the first splanchnic fibers emerging laterally, following their routes medially and caudally to the inferior hypogastric plexus. We proceed laterally to section the hypogastric fascia and to identify the piriformis muscle. Sacral nerve root S1 is found lying over it. Taken this root as a reference, we follow caudally to sequentially identify sacral nerve roots S2 and S3, and therefore, the emergence of the parasympathetic splanchnic nerves from them. 199
Video Session 5dLaparoscopy (11:06 AMd11:13 AM)
Retroperitoneal Dissection of the Uterine Artery in Common Surgical Scenarios von Walter Gonzalez A, Robinson JK, Moawad G. Obstetrics & Gynecology, The George Washington University, Washington, District of Columbia The retroperitoneal approach in open surgery is a helpful way to access difficult anatomy that might surround a large uteri or in endometriosis. This also translates to laparoscopy. Knowing how to access the retroperitoneum in the pelvis laparoscopically is a helpful and important technique to master. This video begins with a review of anatomy and the structures that need to be identified in a four-step technique to access the uterine vessels at their origin. Then the video moves on to show a large 1300gram uterus, which has multiple myomas and would be difficult to access the uterine arteries at the isthmus where the vessels are traditionally transected. Explanation of important spaces are discussed, including the paravesical and pararectal spaces. Another scenario is described where retroperitoneal dissection is important; resection of endometriosis. This final clip explains tips and tricks that can increase success of retroperitoneal access. 200
Video Session 5dLaparoscopy (11:14 AMd11:21 AM)
Laparoscopic Resection of the Large Broad Ligament Fibroid Song JY. Women’s Health, TLC Medical Group, S.C., Saint Charles, Illinois; Gynecology, Presence Mercy Medical Center, Aurora, Illinois; Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois The objective of this video is to demonstrate the technique and instrumentation used to laparoscopically resect a 36 cm right broad ligament fibroid safely in an infertility patient. Proper trocar placement, intracorporeal suturing and removal of large specimen, is covered in detail. 201
Video Session 5dLaparoscopy (11:22 AMd11:29 AM)
video demonstrates three different cases of laparoscopic appendectomy using three different techniques. The advanced surgeon should feel comfortable performing non-appendicitis appendectomy and this video should help them reach that goal. 202
Video Session 5dLaparoscopy (11:30 AMd11:37 AM)
Laparoscopic Cervical Myomectomy Song JY. Women’s Health, TLC Medical Group, S.C., Saint Charles, Illinois; Gynecology, Presence Mercy Medical Center, Aurora, Illinois; Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois Fibroids involving the cervix are rare, comprising approximately 5% to 8% of all leiomyoma cases in general. Given it’s closer proximity to the rectum, bladder and ureters compared to uterine fibroids, careful attention must be applied in order to remove these cervical tumors safely. The objective of this video is to demonstrate technique and instrumentation of carefully removing a 12 cm cervical fibroid laparoscopically, in an infertility patient. 203
Video Session 5dLaparoscopy (11:38 AMd11:43 AM)
Technique to Minimize Spillage during Ovarian Cystectomy of Dermoid Cyst Davis M, Manoucheri E, Schilling S, Wang K. Minimally Invasive Gynecology, Brigham & Women’s Hospital, Boston, Massachusetts One of the concerns regarding dermoid cystectomy is to decrease the amount of spillage that may inadvertently occur during the procedure. Here, we show our method of minimizing spillage by placing a 15mm EndoCatch bag through a posterior colpotomy incision. This allows for the cystectomy to occur with any spillage that occurs be contained within the EndoCatch bag. Once dissection is complete, the dermoid cyst can be removed through the posterior colpotomy with repair of the incision either laparoscopically or vaginally. 204
Video Session 5dLaparoscopy (11:44 AMd11:52 AM)
Endoscopic Treatment of Diaphragmatic Endometriosis Ribeiro DM, Ribeiro GM, Santos TP, Cretella CM, Bellintani LF, Werebe E. Hospital S~ao Luiz, S~ao Paulo, Brazil The surgical treatment of catamenial pneumothorax (CP) in ovulating women approaches 25% when excluding chronic obstructive pulmonary disease and the right sided CP approaches 91.7% among 210 reviewed cases. Characteristic operative findings associated with CP include diaphragmatic defects described as holes, perforations, and fenestrations; and/or spots, endometriosis nodules on the diaphragm, and in the parietal pleura. Diaphragmatic defects and nodules are more frequently found than visceral and parietal pleura nodules. Endometriosis tissue may or may not be found in the characteristic lesions. The spots and nodules are usually found to be endometrial implants but endometrial tissue has been also found at the edges of the diaphragmatic defects, which may represent cyclical breakdown of endometrial implants. Based on current knowledge of surgical eradication of endometriotic lesions, this work attempted to minimize/eliminate diaphragmatic pain and lesions with endoscopic treatment as fulguration, partial or full thickness resection as well as restoring normal anatomy. 205
Video Session 5dLaparoscopy (11:53 AMd12:00 PM)
Laparoscopic Appendectomy for the Gynecologist Kondrup JD. Ob/Gyn, Lourdes Hospital, Binghamton, New York
Segmental Bladder Resection for Endometriosis Stevens A,1 Parsa A,1 Payne C,2 Nezhat C.1 1Center for Speial Minimally Invasive Surgery, Stanford University, Palo Alto, California; 2Urology, Stanford University, Stanford, California
The Minimally Invasive Gynecological Surgeon may encounter an abnormal appendix or choose to do an incidental appendectomy from time to time. This
Genitourinary system is involved in 1-2% of endometriosis cases. The bladder is most commonly involved, followed by ureters and kidneys in the ratio of
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S50–S94 Video Session 5dLaparoscopy (11:00 AMd11:05 AM)
Laparoscopic Dissection and Anatomy of Sacral Nerve Roots and Pelvic Splanchnic Nerves Zanatta A,1 Rosin MM,2 Machado RL,2 Cava L,2 Possover M.3 1Pelvi Uroginecologia e Cirurgia Ginecologica, Brasilia, Distrito Federal, Brazil; 2Instituto de Laparoscopia e Robotica, Sao Paulo, SP, Brazil; 3 Neuropelveology, University of Aarhus, Aarhus, Denmark The laparoscopic neuronavigation technique is effective for approaching the main pelvic somatic and visceral nerves. In this video, we describe the necessary steps to reveal the sacral nerve roots and pelvic splanchnic nerves. She was a 31-year old patient with suspected iatrogenic sacral neuropathy. Dissection in the pelvic sidewall begins medially to the ureter and laterally to the sympathetic inferior hypogastric nerve. Gentle blunt and sharp dissection is performed caudally in the depth of the pararectal space. We identify the first splanchnic fibers emerging laterally, following their routes medially and caudally to the inferior hypogastric plexus. We proceed laterally to section the hypogastric fascia and to identify the piriformis muscle. Sacral nerve root S1 is found lying over it. Taken this root as a reference, we follow caudally to sequentially identify sacral nerve roots S2 and S3, and therefore, the emergence of the parasympathetic splanchnic nerves from them. 199
Video Session 5dLaparoscopy (11:06 AMd11:13 AM)
Retroperitoneal Dissection of the Uterine Artery in Common Surgical Scenarios von Walter Gonzalez A, Robinson JK, Moawad G. Obstetrics & Gynecology, The George Washington University, Washington, District of Columbia The retroperitoneal approach in open surgery is a helpful way to access difficult anatomy that might surround a large uteri or in endometriosis. This also translates to laparoscopy. Knowing how to access the retroperitoneum in the pelvis laparoscopically is a helpful and important technique to master. This video begins with a review of anatomy and the structures that need to be identified in a four-step technique to access the uterine vessels at their origin. Then the video moves on to show a large 1300gram uterus, which has multiple myomas and would be difficult to access the uterine arteries at the isthmus where the vessels are traditionally transected. Explanation of important spaces are discussed, including the paravesical and pararectal spaces. Another scenario is described where retroperitoneal dissection is important; resection of endometriosis. This final clip explains tips and tricks that can increase success of retroperitoneal access. 200
Video Session 5dLaparoscopy (11:14 AMd11:21 AM)
Laparoscopic Resection of the Large Broad Ligament Fibroid Song JY. Women’s Health, TLC Medical Group, S.C., Saint Charles, Illinois; Gynecology, Presence Mercy Medical Center, Aurora, Illinois; Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois The objective of this video is to demonstrate the technique and instrumentation used to laparoscopically resect a 36 cm right broad ligament fibroid safely in an infertility patient. Proper trocar placement, intracorporeal suturing and removal of large specimen, is covered in detail. 201
Video Session 5dLaparoscopy (11:22 AMd11:29 AM)
video demonstrates three different cases of laparoscopic appendectomy using three different techniques. The advanced surgeon should feel comfortable performing non-appendicitis appendectomy and this video should help them reach that goal. 202
Video Session 5dLaparoscopy (11:30 AMd11:37 AM)
Laparoscopic Cervical Myomectomy Song JY. Women’s Health, TLC Medical Group, S.C., Saint Charles, Illinois; Gynecology, Presence Mercy Medical Center, Aurora, Illinois; Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois Fibroids involving the cervix are rare, comprising approximately 5% to 8% of all leiomyoma cases in general. Given it’s closer proximity to the rectum, bladder and ureters compared to uterine fibroids, careful attention must be applied in order to remove these cervical tumors safely. The objective of this video is to demonstrate technique and instrumentation of carefully removing a 12 cm cervical fibroid laparoscopically, in an infertility patient. 203
Video Session 5dLaparoscopy (11:38 AMd11:43 AM)
Technique to Minimize Spillage during Ovarian Cystectomy of Dermoid Cyst Davis M, Manoucheri E, Schilling S, Wang K. Minimally Invasive Gynecology, Brigham & Women’s Hospital, Boston, Massachusetts One of the concerns regarding dermoid cystectomy is to decrease the amount of spillage that may inadvertently occur during the procedure. Here, we show our method of minimizing spillage by placing a 15mm EndoCatch bag through a posterior colpotomy incision. This allows for the cystectomy to occur with any spillage that occurs be contained within the EndoCatch bag. Once dissection is complete, the dermoid cyst can be removed through the posterior colpotomy with repair of the incision either laparoscopically or vaginally. 204
Video Session 5dLaparoscopy (11:44 AMd11:52 AM)
Endoscopic Treatment of Diaphragmatic Endometriosis Ribeiro DM, Ribeiro GM, Santos TP, Cretella CM, Bellintani LF, Werebe E. Hospital S~ao Luiz, S~ao Paulo, Brazil The surgical treatment of catamenial pneumothorax (CP) in ovulating women approaches 25% when excluding chronic obstructive pulmonary disease and the right sided CP approaches 91.7% among 210 reviewed cases. Characteristic operative findings associated with CP include diaphragmatic defects described as holes, perforations, and fenestrations; and/or spots, endometriosis nodules on the diaphragm, and in the parietal pleura. Diaphragmatic defects and nodules are more frequently found than visceral and parietal pleura nodules. Endometriosis tissue may or may not be found in the characteristic lesions. The spots and nodules are usually found to be endometrial implants but endometrial tissue has been also found at the edges of the diaphragmatic defects, which may represent cyclical breakdown of endometrial implants. Based on current knowledge of surgical eradication of endometriotic lesions, this work attempted to minimize/eliminate diaphragmatic pain and lesions with endoscopic treatment as fulguration, partial or full thickness resection as well as restoring normal anatomy. 205
Video Session 5dLaparoscopy (11:53 AMd12:00 PM)
Laparoscopic Appendectomy for the Gynecologist Kondrup JD. Ob/Gyn, Lourdes Hospital, Binghamton, New York
Segmental Bladder Resection for Endometriosis Stevens A,1 Parsa A,1 Payne C,2 Nezhat C.1 1Center for Speial Minimally Invasive Surgery, Stanford University, Palo Alto, California; 2Urology, Stanford University, Stanford, California
The Minimally Invasive Gynecological Surgeon may encounter an abnormal appendix or choose to do an incidental appendectomy from time to time. This
Genitourinary system is involved in 1-2% of endometriosis cases. The bladder is most commonly involved, followed by ureters and kidneys in the ratio of