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Ezekiel Turner
Ezekiel Turner

Atlas Of Pelvic Anatomy And Gynecologic Surgery, 4e

Pubic vein: This is a vascular connection between the external iliac/inferior epigastric and obturator vein, and hemorrhage of this vein is called corona mortis. It is on the posterior part of pubic bone over the obturator fossa (Figure 8). This area is dissected during pelvic lymphadenectomy in gynecologic oncology practice, and the surgeon should be careful to prevent hemorrhage from this venous connection(5).

Atlas of Pelvic Anatomy and Gynecologic Surgery, 4e

The value of preoperative ureteric stent placement in cases with noted bladder involvement is unclear and is left to a case-by-case evaluation 24. Collaboration with a urologic surgeon or a gynecologic oncologist is advisable in cases with suspected urologic involvement. The role of preoperative placement of catheters or balloons into pelvic arteries for potential interventional radiologic occlusion also is controversial 60 61 62. Iliac artery occlusion has been reported to decrease blood loss in some 63 64 but not all case series 60 65. A small randomized controlled trial also showed no benefit 66. Because serious complications such as arterial damage, occlusion, and infection may occur 67, routine use is not recommended.

In most cases when hysterectomy is necessary, a total hysterectomy is required because lower uterine segment or cervical bleeding frequently precludes a supracervical hysterectomy 55. Regardless, extensive vascular engorgement with challenging anatomy is the rule, and having the most experienced pelvic surgeons involved from the outset is recommended. Careful dissection in the retroperitoneal space with attention to devascularization of the uterine corpus in proximity to the placenta often is required given the overwhelming vascularity and friability of involved tissues. Further technical specifics are beyond the scope of this document. These procedures are preferably performed at a level III or IV center with considerable expertise with placenta accreta spectrum.

Given the extensive surgery, placenta accreta spectrum patients require intensive hemodynamic monitoring in the early postoperative period. This often is best provided in an intensive care unit setting to ensure hemodynamic and hemorrhagic stabilization. Close and frequent communication between the operative team and the immediate postoperative team is strongly encouraged. Postoperative placenta accreta spectrum patients are at particular risk of ongoing abdominopelvic bleeding, fluid overload from resuscitation, and other postoperative complications given the nature of the surgery, degree of blood loss, potential for multiorgan damage, and the need for supportive efforts.

Combining detailed descriptions of pelvic anatomy with easy-to-follow instructions for gynecologic procedures, Atlas of Pelvic Anatomy and Gynecologic Surgery, 5th Edition, is a comprehensive, up-to-date atlas that reflects current practices in this fast-changing field. Pelvic anatomy and surgical operations are depicted through full-color anatomic drawings, correlative surgical artwork with step-by-step photographs, and computer-assisted hybrid photo illustrations. Complete coverage of both conventional and endoscopic surgeries helps you master the full spectrum of surgical procedures.

  • processing.... Drugs & Diseases > Obstetrics & Gynecology Uterine Prolapse Treatment & Management Updated: Mar 05, 2020 Author: George Lazarou, MD, FACOG, FACS; Chief Editor: Kris Strohbehn, MD more...

  • Share Email Print Feedback Close Facebook Twitter LinkedIn WhatsApp webmd.ads2.defineAd(id: 'ads-pos-421-sfp',pos: 421); Sections Uterine Prolapse Sections Uterine Prolapse Overview Background

  • History of the Procedure Problem Epidemiology Etiology Presentation Indications Relevant Anatomy Contraindications Show All Workup Imaging Studies

  • Other Tests Diagnostic Procedures Show All Treatment Medical Therapy

Surgical Therapy Preoperative Details Intraoperative Details Postoperative Details Follow-up Complications Outcome and Prognosis Future and Controversies Conclusions Show All Media Gallery References Treatment Medical Therapy Patients with mild uterine prolapse do not require therapy because they are usually asymptomatic. However, when symptoms occur, many patients initially opt for conservative treatment. Patients who are poor surgical candidates or are strongly disinclined to surgery can be offered pessaries for symptom relief. Topical estrogen is an important adjunct in the conservative management of patients with UP. When operative repair for prolapse of the uterus is chosen, a clear surgical plan must be formulated. The pelvic surgeon should consider surgical risks, coital activity, and normal vaginal anatomy. The correct operation must be tailored to the individual patient (see Indications).

The challenge to the pelvic surgeon is to recreate normal anatomy while maintaining normal function. Experienced gynecologic surgeons can reevaluate the anatomy intraoperatively, noting the strength and consistency of the various support structures (eg, uterosacral ligaments). If these structures are found to be weak, it may be necessary to use other, stronger reattachment sites, such as the sacrospinous ligament or the presacral fascia, for the correction of the defect. In addition, make every attempt to prevent a recurrence of POP. For example, when performing a retropubic urethropexy for UI, a concomitant culdoplasty may avoid the formation of an enterocele in the future.

No evidence indicates that hysterectomy has any effect on long-term success of sacropexy. Furthermore, the efficacy of incontinence surgery, with complete pelvic floor reconstruction, is not affected by whether a hysterectomy is performed. [54] The authors advocate deferring surgical treatment of UP for patients who desire future childbearing until completion of childbearing. Hysteropexy for those patients who elect to retain their uteri has been reported, but the data is limited. [55, 56]

With a trend toward minimally invasive endoscopic surgery, procedures have been developed to accomplish repair of pelvic defects via laparoscopic approaches. Although results in short-term subjective reports are excellent, long-term randomized controlled trials are lacking. The attractive advantages of laparoscopic vault suspension are shorter hospitalizations, better cosmetic results, less morbidity, and shorter postoperative recovery periods.

The classical surgical anatomy of the female pelvis is limited by its gynecological oncological focus on the parametrium and burdened by its modeling based on personal techniques of different surgeons. However, surgical treatment of pelvic diseases, spreading beyond the anatomical area of origin, requires extra-regional procedures and a thorough pelvic anatomical knowledge. This study evaluated the feasibility of a comprehensive and simplified model of pelvic retroperitoneal compartmentalization, based on anatomical rather than surgical anatomical structures. Such a model aims at providing an easier, holistic approach useful for clinical, surgical and educational purposes. Six fresh-frozen female pelves were macroscopically and systematically dissected. Three superficial structures, i.e., the obliterated umbilical artery, the ureter and the sacrouterine ligament, were identified as the landmarks of 3 deeper fascial-ligamentous structures, i.e., the umbilicovesical fascia, the urogenital-hypogastric fascia and the sacropubic ligament. The retroperitoneal areolar tissue was then gently teased away, exposing the compartments delimited by these deep fascial structures. Four compartments were identified as a result of the intrapelvic development of the umbilicovesical fascia along the obliterated umbilical artery, the urogenital-hypogastric fascia along the mesoureter and the sacropubic ligaments. The retroperitoneal compartments were named: parietal, laterally to the umbilicovesical fascia; vascular, between the two fasciae; neural, medially to the urogenital-hypogastric fascia and visceral between the sacropubic ligaments. The study provides the scientific rational for a model of pelvic retroperitoneal anatomy based on identifiable anatomical structures and suitable for surgical planning and training.

Female pelvic surgical anatomy evolution went hand-in-hand with progress firstly in cervical cancer surgery and later to rectal cancer surgery (Latzko and Schiffmann 1919; Okabayashi 1921; Heald 1988). Classical surgical anatomy emphasizes the pivotal role of the internal iliac artery and its branches via exposure of a retroperitoneal puzzle of avascular spaces, surrounding a controversial surgical anatomical structure, like the lateral parametrium (Galczynski et al. 2017; Puntambekar and Manchanda 2018; Höckel and Fritsch 2006).

However, eradication of the endometriosis, urogynecological reconstructive and oncological exenterative surgery, may require dissection planes far from the gynecological parametrial heart of the pelvis and a holistic, wider anatomical knowledge so as to decrease iatrogenic complications (Ceccaroni et al. 2012; Cosma et al. 2017).

We aimed at overcoming the disjointed organ-specific surgical anatomy and providing a comprehensive pelvic perspective, to aid the pelvic surgeon in planning and optimizing surgical strategies and young surgical trainees in their learning process.

Our proposed comprehensive and simplified model of pelvic retroperitoneal compartmentalization, based on anatomical rather than surgical anatomical structures, aims at providing all pelvic surgeons with easily detectable landmarks for the treatment of both oncologic and non-oncologic pelvic diseases. Those landmarks (the OUA, the ureter and the SUL) are like the tip of an iceberg, with its deep portion being represented by: the UGHF, supporting the uronervous component of the pelvis; the UVF, supporting the vascular component; the SPL, supporting the axis of the viscera. The parietal, vascular, neural and visceral compartments were identified as a result of the intrapelvic development of these structures. The lateral parametrium in our model is downsized to give it the same importance as the other anatomical structures within the vascular compartment. Fritsch et al. (2012) went so far as questioning the very existence of the lateral parametrium, as they were unable to identify any ligamentous structure running transversely from the cervix to the pelvic wall and stated that it seemed to be an artifact of surgical and cadaveric dissection, rather than a true anatomical structure. However, classical surgical anatomy of the female pelvis is focused on this surgical anatomical structure, without which, the whole model would collapse.


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