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Presacral Neurectomy
PRESACRAL NEURECTOMY CORNELIUS
E.
SEDGWICK
In 1921, Leriche introduced periarterial sympathectomy of the internal iliac (hypogastric) artery for the relief of pelvic pain, and obtained good results. In 1924, Cotte found that by sectioning the superior hypogastric plexus (presacral nerve of Latarjet) equally good results were obtained. As superior hypogastric plexus excision is a simpler procedure it has supplanted the more difficult operation of periarterial sympathectomy. Since the work of Cotte many series of cases have been reported with consistently good results. The results from this clinic have previously been reported. Marshall and Kennedy, in 1945, in a study of 100 consecutive cases reported 90 per cent complete relief of all symptoms associated with menstruation in patients with primary dysmenorrhea and 80 per cent in patients with secondary dysmenorrhea. ANATOMY AND PHYSIOLOGY
Latarjet, in 1913, described and named the presacral nerve as a distinct nerve. Other investigators (Hovelacque, Leriche, Elaut) found the nerve to be more often a plexiform formation or network of fibers and preferred the name superior hypogastric plexus, first used by Hovelacque. However, common usage and acceptance of the terms presacral nerve and presacral neurectomy have established these terms permanently in the literature. The fibers of the presacral nerve arise in the aortic plexus between the superior and inferior mesenteric arteries. They run over the anterior surface of the aorta and are covered by a layer of loose connective tissue and parietal peritoneum. At about the level of the bifurcation of the aorta the plexus appears as two more or less distinct trunks. The trunks deviate as a mass slightly to the left, cross the left iliac vein and follow the curve of the sacrum into the pelvis. It is important to remember that some of the fibers run posterior as well as anterior to the iliacs. The superior hypogastric plexus ends with the formation of the hypogastric nerves in the hypogastric plexus. The presacral nerve consists of preganglionic and postganglionic fibers of the sympathetic nervous system. The preganglionic fibers come from the lower thoracic and upper lumbar levels of the intermediolateral column. The postganglionic fibers originate in the sympathetic trunks and in the preaortic ganglions. The nerves of the sympathetic system are generally considered efferent (motor) in function. According to Kuntz, there is no conclusive evidence that the sympathetic system 861
862
CORNELIUS E. SEDGWICK
contains afferent neurons. However, since excision of the superior hypogastric plexus in many instances relieves pelvic pain, it must be assumed that visceral afferent fibers are associated with the sympathetic nerves and that these fibers are capable of transmitting pain impulses to the central nervous system from pelvic visceral receptors. Apparently division of the presacral nerve does not appreciably alter any normal physiology of the pelvic organs. Fontaine and Herrmann stated that section of the superior hypogastric plexus does not alter the normal menstrual cycle, does not interfere with spontaneous parturition, does not produce glandular atrophy, chronic pelvic congestion or any . disturbances of motor function of the bladder or rectum. Meigs noted minor changes in the menstrual cycle following presacral neurectomy. SELECTION OF CASES
It is not the purpose of this paper to discuss types of dysmenorrhea and indications for presacral neurectomy. Our indications for presacral neurectomy have been described by Marshall and Kennedy (1945). Suffice it to say that patients with dysmenorrhea should be carefully selected. They should have complete study and thorough trial with conservative medical measures before the patients are subjected to this procedure. Although Haman showed that patients with dysmenorrhea have a lower pain threshold than normal women it must be remembered that dysmenorrhea is a symptom and not a disease--that presacral neurectomy is symptomatic treatment and not a form of therapy dealing directly with the cause of the symptom. ASSOCIATED PELVIC DISEASE
All abnormalities of the pelvic organs encountered during presacral neurectomy should be treated by corrective surgery. In cases of cervical stenosis an adequate dilatation or curettage should be performed. When ovarian tumors or cysts are found, partial oophorectomy and excisIon of cysts are indicated. Endometriosis is searched for and when found, especially in young individuals, is treated conservatively by cauterization of implants. Retroverted uteri are suspended. The appendix is removed routinely. Phaneuf pointed out that pain occasioned by mechanical disturbance of the appendix, such as that accompanying a retrocecal appendix or frequently from an appendix which is adherent to the pelvic organs, may increase at the time of menstruation. PROCEDURE
Presacral neurectomy is performed most often at this clinic under spinal anesthesia. A dilatation and curettage precedes the laparotomy.
PRESACRAL NEURECTOMY
863
The patient is then placed in the Trendelenburg position and the abdominal cavity is entered through a lower midline incision extending from the umbilicus to the symphysis. A careful exploration is performed.
Fig. 328.-Incision of posterior peritoneum.
All pelvic abnormalities are noted and any corrective surgical procedures that are indicated, especially the removal of a large tumor which may interfere with exposure, may be dealt with at this time. The intestine is packed above so that the promontory of the sacrum, the bifurcation of the aorta, and the iliac vessels are well exposed. The sigmoid may be
864
CORNELIUS E. SEDGWICK
redundant and extend to the midline, in which case it should be mobilized and retracted laterally. If the patient is thin, the presacral nerve
.Fig. 329.-Exposure of plexus.
may be seen and palpated beneath the posterior parietal peritoneum. In obese patients, however, it may be hidden in fatty tissue. The posterior parietal peritoneum is divided in the midline from just above the bifurcation of the aorta down to the level of the bifurcation of the common iliacsJFig. 328). The peritoneum is separated from the underlying loos
PRESACRAL NEURECTOMY
865
sutures. The triangle formed by the bifurcation of the aorta and the common iliac arteries is then well exposed. The left common iliac vein is seen medial to the left common iliac artery. The right common iliac vein is not visualized as it runs lateral to the right common iliac artery outside the field of dissection. The right ureter is usually exposed, the left ureter is rarely exposed. The midsacral artery parallels the presacral nerve and occasionally is divided to facilitate freeing the plexus. A tape is placed around the plexus and the adjacent closely attached areolar tissue so that the plexus may be lifted from its bed, thus making dissection easier (Fig. 329). The dissection must be meticulous and hemostatic so that all of the fibers of the plexus and the closely adjacent connective tissue are excised, and so that there is no possible chance of injuring the important neighboring structures. The upper aspect of the plexus is freed to about 2 to 3 cm. above the bifurcation of the aorta and is divided and ligated at this level. The dissection is then continued caudad over the left iliac vein to the bifurcation of the common iliacs. It is well to remember that the fibers from the upper ganglions may pass posterior as well as anterior to the iliac vessels. As the lower aspects of the plexus are approached it may be found to divide into two more or less distinct branches, the so-called hypogastric nerves. At the level of the bifurcation of the common iliacs the plexus is excised and the distal branches ligated. The field is examined for hemostasis and the posterior peritoneum closed. If indicated corrective procedures have not been performed earlier, they should be carried out at this time and appendectomy performed. The abdomen is closed in layers. The operation is a simple procedure with practically no mortality. Postoperative complications are few. Presacral neurectomy, however, is associated with the same hazards and complications of any laparotomy under general anesthesia and because of this it should be elected only after careful thought and deliberation. By proper selection of cases and complete, careful excision of the plexus, gratifying results may be obtained. . REFERENCES 1. Colcock, B. P.: Presacral neurectomy for the relief of severe primary dysmenorrhea. S. CLIN. NORTH AMERICA it1: 855-863 (June) 1941. 2. Cotte, M. G.: Sur Ie traitement des dysmlmorrhees rebelles par la sympathectomie hypogastrique peri-arterielle ou Ia section du nerf presacre. Lyon med. 135: 153159 (Feb. 8) 1925. 3. EIaut, L.: The surgical anatomy of the so called presacral nerve. Surg., Gynec. & Obst.55: 581-589 (Nov.) 1932. 4. Fontaine, R. and Herrmann, L. G.: Clinical and experimental basis for surgery of thE' pelvic sympathetic nerves in gynecology. Surg., Gynec. & Obst. 54: 133-163 (Feb.) 1932.
866
CORNELIUS E. SEDGWICK
5. Haman, J. 0.: Pain threshold in dysmenorrhea. Am. J. Obst. & Gynec. 47: 686-691 (May) 1944.
6. Hovelacque, A.: Anatomie des nerfs craniens et rachidiens et du systeme grand sympathique ches l'homme. Paris, G. Doin, 19~6. 7. Kuntz, A.: Autonomic nervous system. Philadelphia, Lea & Febiger, 1945, pp. 687. 8. Latarjet, A. and Bonnet, P.: Le plexus hypogastrique chez l'homme. Lyon chirurg. 9: 619-644, 1918.
9. Leriche, R.: Favorable results from periarterial sympathectomy on hypogastric and ovarian arteries. Presse med. 33: 465 (April 11) 19~5. 10. Marshall, S. F. and Kennedy, R. J.: Postoperative results following presacral neurectomy. S. CLIN. NORTH AMERICA 25: 518-5~9 (June) 1945. 11. Marshall, S. F. and Poppen, J. L.: Presacral neurectomy in the treatment of dysmenorrhea. S. CLIN. NORTH AMERICA 17: 9~7-985 (June) 1987. 1~. Meigs, J. V.: Excision of the superior hypogastric plexus (presacral nerve) for primary dysmenorrhea. Surg., Gynec. & Obst. 68: 7~8-78~ (April) 1989. 18. Phaneuf, L. E.: Surgical measures in dysmenorrhea. New England J. Med. 231: 87~878 (Dec. ~8) 1944.
E.
SEDGWICK
In 1921, Leriche introduced periarterial sympathectomy of the internal iliac (hypogastric) artery for the relief of pelvic pain, and obtained good results. In 1924, Cotte found that by sectioning the superior hypogastric plexus (presacral nerve of Latarjet) equally good results were obtained. As superior hypogastric plexus excision is a simpler procedure it has supplanted the more difficult operation of periarterial sympathectomy. Since the work of Cotte many series of cases have been reported with consistently good results. The results from this clinic have previously been reported. Marshall and Kennedy, in 1945, in a study of 100 consecutive cases reported 90 per cent complete relief of all symptoms associated with menstruation in patients with primary dysmenorrhea and 80 per cent in patients with secondary dysmenorrhea. ANATOMY AND PHYSIOLOGY
Latarjet, in 1913, described and named the presacral nerve as a distinct nerve. Other investigators (Hovelacque, Leriche, Elaut) found the nerve to be more often a plexiform formation or network of fibers and preferred the name superior hypogastric plexus, first used by Hovelacque. However, common usage and acceptance of the terms presacral nerve and presacral neurectomy have established these terms permanently in the literature. The fibers of the presacral nerve arise in the aortic plexus between the superior and inferior mesenteric arteries. They run over the anterior surface of the aorta and are covered by a layer of loose connective tissue and parietal peritoneum. At about the level of the bifurcation of the aorta the plexus appears as two more or less distinct trunks. The trunks deviate as a mass slightly to the left, cross the left iliac vein and follow the curve of the sacrum into the pelvis. It is important to remember that some of the fibers run posterior as well as anterior to the iliacs. The superior hypogastric plexus ends with the formation of the hypogastric nerves in the hypogastric plexus. The presacral nerve consists of preganglionic and postganglionic fibers of the sympathetic nervous system. The preganglionic fibers come from the lower thoracic and upper lumbar levels of the intermediolateral column. The postganglionic fibers originate in the sympathetic trunks and in the preaortic ganglions. The nerves of the sympathetic system are generally considered efferent (motor) in function. According to Kuntz, there is no conclusive evidence that the sympathetic system 861
862
CORNELIUS E. SEDGWICK
contains afferent neurons. However, since excision of the superior hypogastric plexus in many instances relieves pelvic pain, it must be assumed that visceral afferent fibers are associated with the sympathetic nerves and that these fibers are capable of transmitting pain impulses to the central nervous system from pelvic visceral receptors. Apparently division of the presacral nerve does not appreciably alter any normal physiology of the pelvic organs. Fontaine and Herrmann stated that section of the superior hypogastric plexus does not alter the normal menstrual cycle, does not interfere with spontaneous parturition, does not produce glandular atrophy, chronic pelvic congestion or any . disturbances of motor function of the bladder or rectum. Meigs noted minor changes in the menstrual cycle following presacral neurectomy. SELECTION OF CASES
It is not the purpose of this paper to discuss types of dysmenorrhea and indications for presacral neurectomy. Our indications for presacral neurectomy have been described by Marshall and Kennedy (1945). Suffice it to say that patients with dysmenorrhea should be carefully selected. They should have complete study and thorough trial with conservative medical measures before the patients are subjected to this procedure. Although Haman showed that patients with dysmenorrhea have a lower pain threshold than normal women it must be remembered that dysmenorrhea is a symptom and not a disease--that presacral neurectomy is symptomatic treatment and not a form of therapy dealing directly with the cause of the symptom. ASSOCIATED PELVIC DISEASE
All abnormalities of the pelvic organs encountered during presacral neurectomy should be treated by corrective surgery. In cases of cervical stenosis an adequate dilatation or curettage should be performed. When ovarian tumors or cysts are found, partial oophorectomy and excisIon of cysts are indicated. Endometriosis is searched for and when found, especially in young individuals, is treated conservatively by cauterization of implants. Retroverted uteri are suspended. The appendix is removed routinely. Phaneuf pointed out that pain occasioned by mechanical disturbance of the appendix, such as that accompanying a retrocecal appendix or frequently from an appendix which is adherent to the pelvic organs, may increase at the time of menstruation. PROCEDURE
Presacral neurectomy is performed most often at this clinic under spinal anesthesia. A dilatation and curettage precedes the laparotomy.
PRESACRAL NEURECTOMY
863
The patient is then placed in the Trendelenburg position and the abdominal cavity is entered through a lower midline incision extending from the umbilicus to the symphysis. A careful exploration is performed.
Fig. 328.-Incision of posterior peritoneum.
All pelvic abnormalities are noted and any corrective surgical procedures that are indicated, especially the removal of a large tumor which may interfere with exposure, may be dealt with at this time. The intestine is packed above so that the promontory of the sacrum, the bifurcation of the aorta, and the iliac vessels are well exposed. The sigmoid may be
864
CORNELIUS E. SEDGWICK
redundant and extend to the midline, in which case it should be mobilized and retracted laterally. If the patient is thin, the presacral nerve
.Fig. 329.-Exposure of plexus.
may be seen and palpated beneath the posterior parietal peritoneum. In obese patients, however, it may be hidden in fatty tissue. The posterior parietal peritoneum is divided in the midline from just above the bifurcation of the aorta down to the level of the bifurcation of the common iliacsJFig. 328). The peritoneum is separated from the underlying loos
PRESACRAL NEURECTOMY
865
sutures. The triangle formed by the bifurcation of the aorta and the common iliac arteries is then well exposed. The left common iliac vein is seen medial to the left common iliac artery. The right common iliac vein is not visualized as it runs lateral to the right common iliac artery outside the field of dissection. The right ureter is usually exposed, the left ureter is rarely exposed. The midsacral artery parallels the presacral nerve and occasionally is divided to facilitate freeing the plexus. A tape is placed around the plexus and the adjacent closely attached areolar tissue so that the plexus may be lifted from its bed, thus making dissection easier (Fig. 329). The dissection must be meticulous and hemostatic so that all of the fibers of the plexus and the closely adjacent connective tissue are excised, and so that there is no possible chance of injuring the important neighboring structures. The upper aspect of the plexus is freed to about 2 to 3 cm. above the bifurcation of the aorta and is divided and ligated at this level. The dissection is then continued caudad over the left iliac vein to the bifurcation of the common iliacs. It is well to remember that the fibers from the upper ganglions may pass posterior as well as anterior to the iliac vessels. As the lower aspects of the plexus are approached it may be found to divide into two more or less distinct branches, the so-called hypogastric nerves. At the level of the bifurcation of the common iliacs the plexus is excised and the distal branches ligated. The field is examined for hemostasis and the posterior peritoneum closed. If indicated corrective procedures have not been performed earlier, they should be carried out at this time and appendectomy performed. The abdomen is closed in layers. The operation is a simple procedure with practically no mortality. Postoperative complications are few. Presacral neurectomy, however, is associated with the same hazards and complications of any laparotomy under general anesthesia and because of this it should be elected only after careful thought and deliberation. By proper selection of cases and complete, careful excision of the plexus, gratifying results may be obtained. . REFERENCES 1. Colcock, B. P.: Presacral neurectomy for the relief of severe primary dysmenorrhea. S. CLIN. NORTH AMERICA it1: 855-863 (June) 1941. 2. Cotte, M. G.: Sur Ie traitement des dysmlmorrhees rebelles par la sympathectomie hypogastrique peri-arterielle ou Ia section du nerf presacre. Lyon med. 135: 153159 (Feb. 8) 1925. 3. EIaut, L.: The surgical anatomy of the so called presacral nerve. Surg., Gynec. & Obst.55: 581-589 (Nov.) 1932. 4. Fontaine, R. and Herrmann, L. G.: Clinical and experimental basis for surgery of thE' pelvic sympathetic nerves in gynecology. Surg., Gynec. & Obst. 54: 133-163 (Feb.) 1932.
866
CORNELIUS E. SEDGWICK
5. Haman, J. 0.: Pain threshold in dysmenorrhea. Am. J. Obst. & Gynec. 47: 686-691 (May) 1944.
6. Hovelacque, A.: Anatomie des nerfs craniens et rachidiens et du systeme grand sympathique ches l'homme. Paris, G. Doin, 19~6. 7. Kuntz, A.: Autonomic nervous system. Philadelphia, Lea & Febiger, 1945, pp. 687. 8. Latarjet, A. and Bonnet, P.: Le plexus hypogastrique chez l'homme. Lyon chirurg. 9: 619-644, 1918.
9. Leriche, R.: Favorable results from periarterial sympathectomy on hypogastric and ovarian arteries. Presse med. 33: 465 (April 11) 19~5. 10. Marshall, S. F. and Kennedy, R. J.: Postoperative results following presacral neurectomy. S. CLIN. NORTH AMERICA 25: 518-5~9 (June) 1945. 11. Marshall, S. F. and Poppen, J. L.: Presacral neurectomy in the treatment of dysmenorrhea. S. CLIN. NORTH AMERICA 17: 9~7-985 (June) 1987. 1~. Meigs, J. V.: Excision of the superior hypogastric plexus (presacral nerve) for primary dysmenorrhea. Surg., Gynec. & Obst. 68: 7~8-78~ (April) 1989. 18. Phaneuf, L. E.: Surgical measures in dysmenorrhea. New England J. Med. 231: 87~878 (Dec. ~8) 1944.