Laparoscopic anatomy of the female pelvis, from the peritoneum to the retroperitoneum Main points - know how to make the most of the anatomical advantages provided by laparoscopy, i.e. control of the environment, good ergonomics and the specific aspects of endoscopic dissection; - familiarity not only with the peritoneal operating field, but also the laparoscopic approach to the various retroperitoneal spaces in the pelvis and the anatomical structures they contain; - understand the functional organisation of the pelvic retroperitoneum using laparoscopic vision. Laparoscopy and anatomy provide a wonderful combination placed adjacent to the anterosuperior iliac spine laterally to for approaching the female pelvis. Thanks to the laparoscopic these vessels. They originate from the external iliac vessels approach, observation of the anatomy is magnified which in the femoral arch area beneath the round ligament. is of particular benefit in the pelvic retroperitoneum. This They then run up the anterior abdominal wall laterally to advantage of laparoscopy is in part the consequence of the umbilical artery and go behind the rectus abdominis progress in technology, now capable of providing high quality muscles level with the anterosuperior iliac spine. As shown images, but results above all from the specific techniques in figure 2.1, they are most often visible during laparoscopy developed for laparoscopic dissection. While the endoscope either directly through the peritoneum, or thanks to the takes the surgeon’s vision and instruments right inside peritoneal relief (lateral umbilical fold) that they form the pelvis in contact with the furthest structures, the real outside the relief of the umbilical artery (median umbilical guarantee of good anatomical visibility lies in meticulous fold). haemostasis throughout the dissection process. Haemostasis of small vessels, often neglected in a traditional approach, is Pelvic peritoneum made easier by the magnified view afforded by the endoscope and use of a bipolar power source. Figure 2.2 shows a general view of the pelvis after installation At the same time the goal of this «microsurgical» approach is in the Trendelenburg position, with the loops of bowel improved peroperative preservation of functional structures fallen back above the promontory and uterine anteversion. in the pelvis, notably the vasculo-nervous elements, with External uterine cannulation is a crucial element for important clinical consequences.. This chapter deals with mobilisation of the uterus. In addition to exposure the various surgical views of the pelvis, placing the accent on the various sides of the uterus, it will also provide easier access retroperitoneum where this approach appears to have the to the vesico-uterine and recto-uterine (Douglas) pouches, most significant advantages. With the aim of using standard with their subjacent septums, and access to the lateral anatomo-surgical terms, as far as possible we have used the retroperitoneal spaces level with the broad ligaments. Nomina Anatomica international anatomical terminology adapted to French by the French College of professors of anatomy. For those interested in further information, we can thoroughly recommend the reference anatomical work [1] or recent international publications on the subject [5]. PERITONEAL OPERATING FIELD AND PELVIC CAVITY Anterior abdominal wall When inserting the lateral operating trocars, great care must be taken to identify the inferior epigastric vessels. The classic safety triangle insertion with trocars placed supra-pubically and inside these vessels is no longer used 2.1 today for ergonomic reasons. Inferior epigastric vessels. Left side (1: round ligament; 2: umbilical artery; 3: inferior epigastric Identifying the inferior epigastric vessels vessels; 4: lateral edge of the rectus abdominis muscle). If it is difficult to view them transperitoneally, for example in obese patients, then the lateral edge of the rectus abdominis muscle is used as a landmark when inserting the lateral trocars. Inserting the trocar outside this limit avoids any damage to these vessels, since they run along the posterior surface of this muscle above the pelvis. For a pelvic approach, the lateral trocars are nowadays 2.2 2.4 Right ovarian fossa and ureter. General view of the pelvis. (1: suspensory ligament of the ovary; 2: parietal then (1: uterus; 2: round ligament; 3: tube; 4: proper ovarian retroligamentary ureter; 3: internal iliac artery; 4: umbilical ligament; 5: ovary; 6: utero-sacral ligaments; 7: recto- artery; 5: uterine vessels; 6: vaginal artery; 7: uterosacral uterine pouch; 8: sigmoid colon). ligament ). The lateral endoscopic view of the pelvic cavity (figure 2.3) allows the uterine adnexa, tube and ovary to be seen in greater detail, along with the broad ligament whose anterior peritoneal leaf is lifted in the middle by the round ligament running between the uterine horn and deep inguinal ring. We can also see where the suspensory ligament of the ovary (lumbo-ovarian ligament) emerges, crossing over the line of the external iliac vessels. Inwards from this pedicle, the endoscopic forceps is indicating the parietal and retroligamentary portion of the right ureter in the ovarian fossa. In thin patients, it is sometimes possible to see through the peritoneum of this fossa the first collateral branches of the anterior trunk of the internal iliac artery (hypogastric artery) , to which the ureter lies laterally; this anterior 2.3 trunk consists of: the umbilical, uterine and vaginal Right lateral view of the pelvis. arteries (figure 2.4). Note that on the left side it is often (1. round ligament; 2: suspensory ligament of the ovary; 3: more difficult to view the ureter at this level, along with external iliac vessels; 4: ureter). the point where the suspensory ligament of the ovary emerges, due to the presence of the sigmoid colon and rectum. For these structures to be approached it is thus often necessary to detach the recto-sigmoid junction level with the external iliac vessels. A more detailed description of the pelvic ureter will be given in a specific paragraph (see page 30). Promontory Lying at the upper limit of the pelvis, the promontory is most often approached to the right of the sigmoid. Consequently laparoscopic exposure of the promontory along with the sacral concavity can be made easier in certain Anatomical variations procedures (see chapter 11, page 179) by transparietal fixation of the perisigmoid and perirectal fatty tissue in the When working in the female pelvis, the possibility of such left hypochondrium. variations must be borne in mind, notably with respect to Figure 2.5 illustrates the sub-peritoneal anatomical the vascularisation where they occur relatively frequently. structures to be seen in this area. On the midline, the median sacral vessels are located level with the common PELVIC RETROPERITONEUM prevertebral ligament. They are generally preserved during laparoscopic promonto-fixation, where in our practice the The connective tissue space between the pelvic peritoneum prosthesis is fixed to the right side of the ligament. Laterally and abdominal walls is of prime importance from the to the right: we can see the homolateral primitive iliac functional point of view, due to the anatomical structures artery, then the iliac bifurcation and the ureter crossing it contains. It is crossed by the ureter, the vessels, lymphatic the origin of the external iliac artery. Since the iliac venous system and autonomic nervous system to and from the junction is located lower and slightly lateral relative to the pelvic viscera. It is a real challenge for surgical treatment bifurcation of the aorta, it is the left primitive iliac vein that for cancer and deep endometriosis, not forgetting prolapse. represents the upper limit of this region. Its functional organisation is provided by dense connective structures, the visceral «ligaments» and visceral and parietal fascias, leaving areas of looser connective tissue in contact with the viscera and abdominal walls which can be cleaved surgically, i.e. spaces and septums. The method for dealing with these spaces, which are virtual in terms of their physiological condition, forms the very basis of surgical dissection. Concerning the septums and spaces, the following are found in succession (figure 2.6): - on the midline, the vesico-uterine, vesico-vaginal, recto- vaginal septums and the retropubic (Cave of Retzius), rectorectal and presacral spaces; - laterally, two matching and symmetrical spaces: the Promontory. paravesical and pararectal fossae. (1: median sacral vessels; 2: right primitive iliac artery; 3: external iliac artery; 4: ureter; 5: left primitive iliac vein). These various spaces communicate with each other at their ends. Left common iliac vein and promontory Outside the rectorectal and presacral space, they are described here from the endoscopic point of view. Its closeness and certain anatomical variations mean it Concerning the visceral «ligaments», the following are also is essential to identify this vascular structure accurately described: when approaching and dissecting the promontory. - sagittally the vesico-uterine ligaments (formerly termed It is a potentially dangerous vein during dissection of the the internal pillars of the bladder) and uterosacral promontory because it is so close, and because it is not ligaments; always easy to locate. This is due in part to the pressure of - laterally, the parametrium, paracervix, lateral ligament of the pneumoperitoneum which tends to flatten its peritoneal the bladder (formerly the external pillars of the bladder), relief, more particularly in obese patients, in which case and the lateral ligament of the rectum. its blue colour will help to show it up. In addition certain anatomical variations such a s a venous junction lower The lateral ligaments carry the terminal branches of the down and/or sacralisation of the promontory link it even anterior trunk of the internal iliac artery. Concerning closer to the promontory and increase the care needed the sagittal ligaments, these contain autonomic nervous when dissecting it. system nerves along part of their course. They are of great importance surgically. As already mentioned, these are not ligaments in the strictly anatomical sense, but areas where the connective tissues are more dense, exchanging fibres with each other and prolonged by the fascias at their ends. The result is that these structures are intricately mingled which means they can give rise to confusion, not only for the surgeon but also for any description of the surgical techniques. This situation applies for the lateral «ligaments» (figures 2.7 and 2.8). In contact with the lateral abdominal wall (figure 2. 9), the parametrium, paracervix and lateral ligament of the bladder form a perfectly continuous insertion and it is not possible to tell them apart. The same applies at the bladder (figure 2.10) for the vesico-uterine ligament, parametrium (anterior expansion) and lateral ligament of the bladder. The impression the surgeon has is that there is a single structure running transversally through the lateral pelvis, giving rise to various names such as the cardinal ligament (parametrium-paracervix), which continue to be used and add to the confusion because of their imprecision. This is why it now seems to be most appropriate to use the international anatomical terminology for this subject, with the aim of harmonising the vocabulary of surgical anatomy [1]. The ureter remains the essential landmark when distinguishing between these structures. For the sake of clarity, it should be remembered that the parametrium carries the uterine artery and is located above the ureter, while the paracervix carries the vaginal artery or arteries and is located below the ureter, as is the lateral ligament of the bladder which carries the superior vesical artery. In this context, the discernment provided by laparoscopy can cope perfectly with the anatomical detail and complexity of these structures. Diagram of the pelvic visceral ligaments. Upper view. (a: retropubic space; b: paravesical space; c: pararectal space; d: retrorectal space; e: presacral space; 1: parietal pelvic fascia; 2: lateral vesical ligament; 3: vesico-uterine ligament; 4: paracervix; 5: parametrium; 6: uterosacral ligament; 7:. recto-uterine pouch; 8: medial umbilical ligament; 9: umbilicovesical fascia; 10: obturator artery; 11: superior vesical artery; 12: vesicovaginal artery; 13: uterine artery; 14: vaginal artery; 15: middle rectal artery; 16: posterior vaginal fornix; 17: ureter). Special points concerning retroperitoneal dissection by thus invaluable for the surgeon, revealing the plane that laparoscopy needs to be followed to enlarge the space and helping the dissection to progress. This advantage also gives To start with, the «dissecting» effect of the peritoneum in laparoscopic surgical dissection an «intuitive» element. this space should be underlined. It can be seen right from When opening certain spaces, it is possible in fact to do the peritoneal incision phase when the C02 infiltrates without the usual anatomical landmarks and follow the beneath the peritoneum held under traction, and detaches gas once the superficial layer of connective tissue has been it. Subsequently as the various pelvic spaces are approached, breached. the gas always travels along the cleavage planes. This effect can be seen thanks to the creation of «bubbles» caused by the gas expanding the connective tissues which originally filled these virtual spaces. In practice, these «bubbles» are Bubbles and pneumoperitoneum limits of the spaces concerned by the operation. This is why the surgeon should have a haemostatic instrument such as These «bubbles» are formed when the pneumoperitoneum a bipolar forceps in one of his hands almost constantly, and dilates the retroperitoneal attachment surfaces. By their all the more so since the technological progress made with existence, cleavage planes for spaces that were originally these instruments provides them with new functions in virtual become visible on the screen. So they indicate the terms of grasping and dissection. direction to follow to open and dissect these spaces. In case Finally, for ergonomic reasons which must be constantly of difficulty in accessing a space, the operating field should borne in mind by all laparoscopic surgeons, it may be be scrutinised in order to find them. These little bubbles are necessary to improve exposure by transparietal tissue thus of real help to the laparoscopist by allowing dissection fixation. Various organs can be fixed quite simply, to be more «intuitive». using needles and suture: the perisigmoid fatty tissues when approaching the promontory, the ovaries in In addition, divergent traction using the operator’s two case of endometriosis of the rectovaginal septum, the instruments is frequently used to help progress in the mesentery during lumbo-aortic lymphadenectomy, or dissection of these spaces. again the bladder during dissection of the ureter and the They reproduce the opening and closing movements of parametrium. traditional surgical scissors, although of greater amplitude due to the greater leverage afforded by the fixed points Spaces, septums and median ligaments provided by the trocars. So these movements be must limited by any resistance felt, because otherwise there will Vesico-uterine and vesico-vaginal septums be tissue damage and bleeding. These separate in perfect continuity the supravaginal part of the posterior surface of the bladder followed by the anterior vagina from the bladder trigone. They finish at the bottom in the dense connection between urethra and vagina. Their lateral limits are formed by the vesico- uterine ligaments. Access is gained via the vesico-uterine pouch (figure 2.11) after using the manipulator to push the uterus towards the promontory. The peritoneum is incised at about 10 mm below the vesico-uterine peritoneal fold. The first assistant uses grasping forceps to draw the prevesical peritoneum and underlying bladder vertically. Provided there is no scar from prior caesarean section, the first cut of the scissors (placed perpendicular) allows the vesico-uterine septum to be opened, arriving opposite the pericervical fascia. Then the surgeon’s two instruments, in contact with the fascia, push the bladder along the midline in order to carry out vesico-vaginal dissection (figure 2.12). 2.7 Lateral space and « ligaments». Operative view. (1: vesico-uterine ligament; 2: paracervix; 3: lateral ligament of the bladder; 4: parametrium; 5: obturator nerve; 6: ureter). A reminder of the principle of strict and meticulous haemostasis is appropriate here, with the aim of ensuring good anatomical vision throughout dissection to the deepest 2.8 Right visceral «ligaments». (a: lateral cervico-uterine artery at the ureter-uterine crossover point: b: multiple cervico-vaginal arteries; l: bladder; 2: sectioned vesico-uterine ligament; 3: vaginal fornix; 4: paracervix; 5: uterine isthmus; 6: parametrium; 7: ureter; 8: vaginal arteries; 9: expansion of the parametrium (anterior parametrium); 10: lateral ligament of the bladder and superior vesical artery; 11: cervico-vaginal artery; 12: uterine artery). 2.9 2.11 Left paracervix after partial exeresis and exposure of the recto-uterine pouch; 8: vaginal vessels. The dotted line represents the line for peritoneal incision (1: umbilical artery reclined medially; 2: vaginal vessels; to access the vesico-uterine and vesico-vaginal septums. 3: paracervix; 4: lateral ligament of the bladder; 5: internal obturator muscle; 6: obturator vein; 7: obturator nerve; 8: pararectal fossa). 2.12 Vesico-uterine and vesico-vaginal septums (1: vagina; 2: bladder; 3: vesico-uterine ligaments) . 2.10 Right intraligamentary ureter covered by the parametrium The lateral resistance related with the vesico-uterine and vesico-uterine ligament. ligaments is distinctly perceptible via the instruments (1: retroligamentary ureter; 2: parametrium with uterine during this procedure. During dissection, the vesico- artery; 3: vesico-uterine ligament; 4: anterior expansion of uterine ligaments are sectioned level with their anterolateral the parametrium; 5: bladder; 6: vagina). cervico-vaginal insertions in order to remain well away from the ureters that run through their posterolateral portions. How far the vesico-vaginal dissection needs to go depends on the operative indication. While 30 to 40 mm is adequate for simple total laparoscopic hysterectomy, dissection will need to go lower close to the trigone and include dissection of the ureters for hysterectomy with conservation of a vaginal cuff, and for cystocele repair with fixation of a prosthesis in the reclined portion of the vesico-vaginal errors is to dissect too close to the peritoneum without septum (figure 2.12). going above this fascia, with a consequential risk of bladder injury. Rectovaginal septum This separates the posterior vagina from the rectum and is accessed via the recto-uterine pouch between the vaginal insertions of the uterosacral ligaments. Here too there are two levels for dissection depending on the type of indication: - during excision surgery (deep endometriosis, total hysterectomy), it is necessary to dissect the vagina from the rectum and uterosacral ligaments; - during reparative surgery (promontofixation), dissection can be taken laterally as far as the levator ani muscles with respect to their pubo-rectal and pubo-coccygeal portions. In this indication the aim is to fix the rectovaginal strap of the prosthesis to these muscles in order to correct or prevent rectocele. 2.13 Peritoneal incision in the recto-uterine pouch to access the With the uterus anteverted, the first assistant draws the recto-vaginal septum. anterior surface of the rectum backwards and the peritoneal (1: rectum; 2: rectovaginal septum; 3: vaginal insertions of incision is made above it (figure 2.13). We can then identify the uterosacral ligaments} the posterior surface of the vagina and continue separating it from the rectum along the midline {figure 2.14). In case of any doubt about the exact position of the vagina, there must be no hesitation to make it visible by a vaginal touch in the posterior fornix. In order to reach the pubo-rectal and pubo-coccygeal portions of the levator ani (figure 2.15), we need to move laterally while still remaining in contact with the posterior vagina. The bundles of muscles running parasagittally are identifiable in most cases (figure 2.15) and if not it is the feeling of reaching a fixed plane perceived via the laparoscopic instruments which will allow them to be detected. Retropubic cave of Retzius This space is filled with fatty tissue and is located between the pubis, to the front, and the bladder to the rear. We 2.14 access it through the anterior abdominal wall. The Rectovaginal septum peritoneal incision is started on the midline (median (1: vagina; 2: rectum; 3: utero-sacral ligaments) umbilical fold) between the bulge of the symphysis and the midline operating trocar (figure 2.16). It is continued in each direction as far as the umbilical arteries (median umbilical fold). In order to enter the space, we have to cross the umbilicovesical fascia (figure 2.17), below which run the two umbilical arteries to the front of the bladder. It shows as a greyish membrane which is thinner here that at the origin of the umbilical arteries. One of the possible