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Fertility and Sterility Jun 2021To present 10 consecutive, standardized, and reproducible surgical steps allowing complete excision of deep endometriosis nodules infiltrating the parametrium and sacral...
OBJECTIVE
To present 10 consecutive, standardized, and reproducible surgical steps allowing complete excision of deep endometriosis nodules infiltrating the parametrium and sacral roots.
DESIGN
Surgical video presenting the 10 surgical steps. Local institutional review board approval was not required for this video article, because the video describes a technique and the patient cannot be identified whatsoever.
SETTING
Endometriosis Center.
PATIENTS
Patients undergoing excision of deep endometriosis nodules of the parametrium and sacral roots.
INTERVENTION
The excision of deep endometriosis infiltrating the parametrium down to the sacral roots may be performed following 10 steps: complete ureterolysis and removal of ureteral stenosis; opening of the pararectal space in contact with the rectum in a sagittal plane; dissection caudally toward the rectovaginal space, section of the rectovaginal nodule in two separate blocks infiltrating the rectum and vagina, respectively, all the way down to the levator ani muscles; dissection of the presacral space and identification of the superior hypogastric plexus and hypogastric nerve; transverse incision of the peritoneum at the level of the promotorium, extended laterally above the origin of the hypogastric vessels; anterograde dissection of the hypogastric artery and identification of the hypogastric vein; anterograde dissection of the hypogastric vein and opening of Okabayashi space, followed by identification and, when required, ligation of hypogastric vein tributaries; dissection is extended behind the venous network with identification of the pyriform muscles and sacral roots S2, S3, and S4; anterograde dissection of the nerve network and inferior hypogastric plexus, up to the posterior limits of the deep endometriosis nodule; and excision of the deep endometriosis nodule from the posterior limit to the inferior limit in contact with the sacral roots, which should be released or shaved, then to the lateral limit in contact with the pyriform muscle and lateral pelvic wall. Additional steps may be required to remove adjacent infiltration of the vagina, rectum, bladder, or ureters. The movie does not reflect a similar approach in cases of isolated nodules of the sciatic nerves involving a specific lateral dissection plane between the external iliac vessels and the iliopsoas muscle.
MAIN OUTCOME MEASURES
Description of 10 successive surgical steps.
RESULTS
The 10-step procedure already has been employed in 70 women with deep endometriosis of the parametria involving sacral roots, in whom sensory or motor complaints were not completely relieved by continuous amenorrhea provided by contraceptive pill intake or gonadotropin-releasing hormone analogs. Baseline complaints included somatic pain (85.7%), severe bladder dysfunction (10%), or hydronephrosis (24.3%). Main localizations concerned sacral roots (95.7%), sciatic nerves (7.1%), mid/low rectum (87.1%), and bladder (21.4%). Operative time was 224 ± 94 minutes. Among postoperative complications, we recorded rectovaginal fistulae (14.3%), urinary tract fistulae (4.3%), and bladder dysfunction at 3 weeks (22.9%) and 12 months (5.7%) after the surgery.
CONCLUSIONS
Laparoscopic excision of deep endometriosis nodules of the parametria involving the sacral roots is a challenging procedure, requiring good anatomic and surgical skills. Teaching such a complex procedure is a delicate task. By following 10 sequential steps, the surgeon may reduce the risk of hemorrhage originating from the hypogastric venous network, preserve as much as possible autonomic nerves and organ function, and successfully excise deep endometriosis nodules. However, transection of the internal iliac artery and vein should not be systematic, as it may adversely affect the vascular supply of the pelvis. Transection of small pelvic splanchnic nerves should be performed only if they actually are included in fibrous nodules, as it may be followed by sexual, bladder, and rectal dysfunction or perineal sensory effects. Although the 10 steps attempt to standardize the surgical approach in a challenging localization of deep endometriosis, they are not mandatory and their use should be individualized.
Topics: Dissection; Endometriosis; Female; Humans; Laparoscopy; Lumbosacral Plexus; Peritoneum; Sacrococcygeal Region; Spinal Nerve Roots; Treatment Outcome
PubMed: 33766459
DOI: 10.1016/j.fertnstert.2021.02.014 -
Fertility and Sterility Oct 2016The mesothelium was traditionally thought to be a simple tissue with the sole function of providing a slippery, nonadhesive, and protective surface to allow easy... (Review)
Review
The mesothelium was traditionally thought to be a simple tissue with the sole function of providing a slippery, nonadhesive, and protective surface to allow easy movement of organs within their body cavities. However, our knowledge of mesothelial cell physiology is rapidly expanding, and the mesothelium is now recognized as a dynamic cellular membrane with many other important functions. When injured, mesothelial cells initiate a cascade of processes leading either to complete regeneration of the mesothelium or the development of pathologies such as adhesions. Normal mesothelial healing is unique in that, unlike with other epithelial-like surfaces, healing appears diffusely across the denuded surface, whereas for epithelium healing occurs solely at the wound edges. This is because of a free-floating population of mesothelial cells which attach to the injured serosa. Taking advantage of this phenomenon, intraperitoneal injections of mesothelial cells have been assessed for their ability to prevent adhesion formation. This review discusses some of the functions of mesothelial cells regarding maintenance of serosal integrity and outlines the mechanisms involved in mesothelial healing. In addition, the pathogenesis of adhesion formation is discussed with particular attention to the potential role of mesothelial cells in both preventing and inducing their development.
Topics: Animals; Epithelial Cells; Epithelium; Female; Homeostasis; Humans; Male; Peritoneum; Risk Factors; Signal Transduction; Surgical Procedures, Operative; Tissue Adhesions; Treatment Outcome; Wound Healing
PubMed: 27692285
DOI: 10.1016/j.fertnstert.2016.09.005 -
Journal of Medical Imaging and... Oct 2018
Review
Topics: Douglas' Pouch; Female; Humans; Magnetic Resonance Imaging; Male; Peritoneum; Rectum
PubMed: 30309141
DOI: 10.1111/1754-9485.49_12784 -
British Journal of Hospital Medicine... Jan 2008
Review
Topics: Adult; Analgesics; Anti-Bacterial Agents; Child; Female; Humans; Intubation, Gastrointestinal; Male; Peritoneum; Peritonitis; Prognosis
PubMed: 18293728
DOI: 10.12968/hmed.2008.69.Sup1.28050 -
Colorectal Disease : the Official... Sep 2020
Topics: Female; Hernia, Inguinal; Herniorrhaphy; Humans; Internal Hernia; Laparoscopy; Peritoneum
PubMed: 32180330
DOI: 10.1111/codi.15039 -
Pediatric Radiology Jul 2017The normal peritoneal structures, including the mesenteries and the omenta, are only a few cell layers thick and are visible on imaging based upon the tissues (e.g.,... (Review)
Review
The normal peritoneal structures, including the mesenteries and the omenta, are only a few cell layers thick and are visible on imaging based upon the tissues (e.g., fat) and structures (e.g., blood vessels and lymph nodes) contained within them. These structures become more visible and change in appearance when involved by pathological processes. In this pictorial essay, we discuss the normal anatomy of the various abdominopelvic peritoneal structures and illustrate numerous developmental and acquired diagnoses that involve these structures in the pediatric and young adult population.
Topics: Child; Humans; Mesentery; Omentum; Peritoneum
PubMed: 28646385
DOI: 10.1007/s00247-017-3864-3 -
Kidney & Blood Pressure Research 2018Fibrosis and angiogenesis are the most common processes that result in progressive peritoneal tissue remodeling and, eventually, peritoneal membrane dysfunction. The... (Review)
Review
Fibrosis and angiogenesis are the most common processes that result in progressive peritoneal tissue remodeling and, eventually, peritoneal membrane dysfunction. The role of exosomes, which contributes to intercellular communication, in these processes has been neglected. Various biomolecules, including DNA, mRNA, proteins, lipids, and particular certain miRNAs, can be transferred by exosomes to local, neighboring and distal cells. Upon stimulation by cytokines or other microenvironment stimuli, donor cells release a mass of exosomes to peritoneal mesothelial cells, further affecting fibrosis and angiogenesis. This important exosomes-mediated intracellular communication is thought to regulate peritoneal membrane function. Understanding the molecular mechanisms of these processes, targeting changes in exosomes and regulating exosomal miRNAs will advance therapeutic methods for protecting peritoneal membrane function.
Topics: Cell Communication; Exosomes; Fibrosis; Humans; Membranes; Neovascularization, Pathologic; Peritoneum
PubMed: 29940564
DOI: 10.1159/000490821 -
The American Surgeon Nov 2021Carl Florian Toldt was an Austrian anatomist who made meaningful contributions worldwide and defined what is one of the most important surgical landmarks in abdominal...
Carl Florian Toldt was an Austrian anatomist who made meaningful contributions worldwide and defined what is one of the most important surgical landmarks in abdominal surgery. Through his research studies, the embryologic dissection plane known as the "White Line of Toldt" represents an important anatomical landmark that helps to mobilize either the ascending or descending colon. His career spanned over 45 years, beginning in Verona and continuing to Prague and Vienna. He was an author of several innovative books and scientific articles regarding micro- and macroscopic anatomy. In addition, he received numerous recognitions and prizes for his work, making him an essential figure in the medical scientific community. Even a street in Vienna, Karl-Toldt-Weg, is named in his honor. The purpose of this historical article is to celebrate and honor Toldt 100 years following his death, remembering his scientific contributions to the medical and surgical fields and giving thanks for his numerous accomplishments. This article brings light to the man behind the eponym.
Topics: Anatomy; Austria-Hungary; Colon; Dissection; Histology; History, 19th Century; History, 20th Century; Humans; Italy; Mesocolon; Peritoneum; Retroperitoneal Space
PubMed: 33720793
DOI: 10.1177/0003134821991979 -
Contributions To Nephrology 1979
Review
Topics: Blood Physiological Phenomena; Capillaries; Capillary Permeability; Diffusion; Humans; Nitroprusside; Peritoneal Dialysis; Peritoneum; Regional Blood Flow; Solutions; Vasodilator Agents
PubMed: 385246
DOI: 10.1159/000402979 -
Cancer Treatment and Research 2007
Review
Topics: Ascites; Capillaries; Carcinoma; Humans; Peritoneal Neoplasms; Peritoneum; Regional Blood Flow
PubMed: 17633049
DOI: 10.1007/978-0-387-48993-3_6