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Surgical Core Curriculum - Gyn Onc Amreen Husain, M.D.

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Presentation on theme: "Surgical Core Curriculum - Gyn Onc Amreen Husain, M.D."— Presentation transcript:

1 Surgical Core Curriculum - Gyn Onc Amreen Husain, M.D.

2 Abdominal Wall Determine best incision for planned surgery Several layers depending on the orientation of incision Course of vessels in abdominal wall. Potential need for preservation of epigastric vessels Potential placement of stoma

3 Abdomen Landmarks to note –Costal margins –Xiphoid process –Umbilicus –Anterior superior iliac spines –Inguinal creases –Pubis

4 Layers of abdominal wall Skin Superficial fascia External and internal obliques Transversus abdominis muscles, Aponeurosis and fascia Rectus muscles and sheaths Preperitoneal fat Parietal peritoneum

5 Rectus muscle Blood supply derived from sup epigastric artery (branch of int mammary or thoracic artery) and inf epigastric artery (branch of external iliac artery. Nerve supply from anterior rami of thoracic nerves from T6-T12 which enter posteriorly then divide ant, medial and lateral. Denervation occurs if muslce is divided longitudinally or freed laterally

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11 The Pelvis Surrounded by bony structures: –Sacrum, ischium, ilium and pubic bones Floor is composed of muscles: –Piriformis, coccygeus and levator ani

12 The Pelvis Divided into an anterior and posterior component by the transversely oriented broad ligament in the center of which is the uterus Broad ligament has two layers : anterior and posterior leaves, round ligament runs anterolateral in the broad ligament to the pelvic wall

13 The Pelvis Ovaries attached to posterior leaf of the broad ligament by meso-ovarium, to the uterus by the ovarian ligament and to the pelvic wall by the infidibulo-pelvic ligament which contains the ovarian vessels and lymphatics Adnexal triangle an important landmark – bounded ant by round ligament, post by IP ligament and laterally by peritoneal reflection over psoas. Allows easy access to the retroperitoneum

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15 Surgical Anatomy of the Pelvis Pelvic organs include the uterus, cervix and vagina, ovaries and Fallopian tubes, bladder, pelvic ureters, rectum and portion of the sigmoid Eight tissue planes which are avascular two dimensional potential spaces until developed by the surgeon Three pairs of fibrovascular ligaments

16 Avascular Tissue Planes Paired Spaces: –Paravesical/paravaginal spaces –Pararectal spaces Unpaired spaces: –Prevesical (retropubic) space of Retzius –Vesicovginal space –Rectovaginal space –Presacral (retrorectal) space

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18 Fibrovascular ligaments Cardinal ligaments –Constitute the thickened posterior most portion of broad ligament –Arises from endopelvic fascia of the lateral cervix and extends to pelvic sidewall where it inserts into the endopelvic fascia –Posterior portion contains a major component of the autonomic nerve supply to the bladder and rectum –Contains the uterine, vaginal, inferior vesical and middle rectal arteries and veins as well as lymphatics –Ureter penetrates upper portion just below uterine artery 1-2 cm lateral to the isthmus of the uterus

19 Fibrovascular ligaments Uterosacral ligaments with rectal pillars –Posterolateral thickenings which originate from posterolateral aspect of the cervix and run to anterolateral aspect of the rectum –they straddle the posterior cul-de-sac –Rectal pillars are longitudinal fibrovasuclar bundle btwn vagina and rectum, run the length of the vagina

20 Fibrovascular ligaments Bladder pillars –Paired longitudinal fibrovascular bundles that run the length of the vagina anteriorly and form the lateral limits of the vesicovaginal space –Upper end connects to the lower half of the cervix forming the vesico-uterine ligament

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22 The Ureter Crossing Retroperitoneal during its entire passage from the kidney to the bladder. Enters the pelvis by crossing over the vessels at or just proximal to the bifurcation of the common iliac artery On the left it passes under the proximal sigmoid colon and on the right passes under the cecum and terminal ileum

23 The Ureter As the ureter enters the pelvis it becomes attached to the lateral pelvic wall peritoneum and continues till it reaches the level of the uterosacral ligament and the posterior leaf of the broad ligament Ureter then contiunues through the cardinal ligament to the bladder going under the uterine artery

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26 Arteries and Veins Ovarian vessels –Ovarian arteries arise from the abdominal aorta 2-3 cm below the renal arteries –Ovarian vein on the right enters the vena cava below the right renal vein; the ovarian vein on the left enters the renal vein lateral to the vena cava

27 Arteries and Veins Common iliac vessels –Common iliac artery begins at the lower end of L4 and follows the pelvic brim laterally terminating over the sacroiliac joint by dividing into the external iliac and hypogastric (internal) iliac arteries –Ureter crosses both common iliac arteries near their bifurcation –Common iliac veins lie posterior to the artery, the left common iliac vein passes under the proximal part of the right common iliac artery

28 Arteries and Veins External iliac vessels –External iliac vein arises at lumbosacral joint and ends by passing under the inguinal ligament to become the femoral artery –Main branches are the deep circumflex and inferior epigastric vessels –External iliac veins are positioned inferiomedial to the arteries

29 Arteries and Veins Hypogastric Arteries –Posterior and Anterior divisions at 4 cm from its origin –Anterior Trunk : Six primary branches in order Common branch giving rise to the uterine, umbilical, superior vesical and sometimes vagina Obturator, Inferior vesical, middle Rectal, internal pudendal and inferior gluteal –Posterior Trunk Four branches none of which supply pelvic viscera Iliolumbar, superior and inferior lateral sacral, superior gluteal

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33 The Groin Femoral Triangle –Bounded superiorly by the inguinal ligament, laterally by the medial border of the sartorius muscle and medially by the adductor longus muscle –Structures passing via the subinguinal space from the pelvis to the leg from lateral to medial are the lateral femoral cutaneous nerve, iliopsoas muscle, femoral nerve, then the femoral artery, femoral vein, femoral canal w/ lymphatics and femoral branch of the genitofemoral nerve

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35 The Small Intestine Jejunum and Ileum combined average 22 ft in length of which the jejunum accounts for 40%. Jejunum and ileum differ in that the jejunum is thicker, has thicker mucosal folds, the mesenteric fat extends onto the wall of the ileum but not the jejunum, the vasa recta are shorter in the ileum

36 The Small Intestine Arterial Supply –Entire blood supply derived from the superior mesenteric artery (SMA) a ventral midline branch of the aorta. –SMA enters the base of the mesentery as it emerges from between the duodenum and pancreas –Branches are : Common inferior pancreaticoduodenal a., the middle and right colic a., ileocolic a., series of jejunal and ileal branches which anastomose with each other forming arcades.

37 The Large Intestine 4-6ft in length from ileocecal junction to the anus. Divisible into the cecum and appendix; the ascending, transverse, descending and sigmoid colon; Rectum and anus Ascending and descending colon are retroperitoneal while transverse and sigmoid colons have distinct mesenteries

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39 The Large Intestine Arterial Supply –Derived from superior and inferior mesenteric arteries –Marginal artery of Drummond is a scalloped continuous vessel formed by anastomosing arcades of the ileo-colic, right, middle, left colic and sigmoidal arteries –Inferior mesenteric artery (IMA) arises from the aorta at L# about 3-4 cm from bifurcation, Branches to the left colic artery, sigmoidal arteries (2-4), becomes the superior rectal artery in the pelvis

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41 Ureteral Injuries Incidence is 0.1% - 1.5% in pelvic surgeryIncidence is 0.1% - 1.5% in pelvic surgery 75% during gynecologic surgery75% during gynecologic surgery ¾ during abd surgery¾ during abd surgery ¼ during laparoscopic surgery¼ during laparoscopic surgery Most common causes of litigations against gyn surgeonsMost common causes of litigations against gyn surgeons

42 Anatomy of the Ureter RetroperitonealRetroperitoneal 25-30cm in length : divided into abdominal and pelvic segments by the pelvic brim25-30cm in length : divided into abdominal and pelvic segments by the pelvic brim Three layers :Three layers : -mucosa lined with transitional epithelium -muscularis made up of interweaving smooth muscle fibers -Adventitia containing intercommunicating network of blood vessels

43 Embryology Close proximity to reproductive organs due to proximity of mesonephric ducts and mullerian systemClose proximity to reproductive organs due to proximity of mesonephric ducts and mullerian system Congenital anomalies occur concomitantly % of the timeCongenital anomalies occur concomitantly % of the time Most common is ureteral duplication – 1% of womenMost common is ureteral duplication – 1% of women

44 Blood supply Segmental with much anastomisingSegmental with much anastomising Cephalad – supplied by branches of renal and ovarian arteriesCephalad – supplied by branches of renal and ovarian arteries Middle – form aortic and common iliac branchesMiddle – form aortic and common iliac branches Pelvic – from hypogastric, rectal and vaginal arteriesPelvic – from hypogastric, rectal and vaginal arteries

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46 Path of the ureter Abdominal ureter : runs along anterior surface of the psoas muscle and posterior to the ovarian vesselsAbdominal ureter : runs along anterior surface of the psoas muscle and posterior to the ovarian vessels Crosses pelvic brim anterior to common iliac at its bifurcationCrosses pelvic brim anterior to common iliac at its bifurcation

47 Path of the Ureter Pelvic ureter: travels along the pelvic sidewall lateral to the sacrum and anterior to the hypogastric. Veers medial as it passes beneath the uterine artery approx 1.5cm lateral to the internal os then passes into the tunnel of the cardinal ligament and travels medially and anteriorly over the vaginal fornix to enter the bladder.Pelvic ureter: travels along the pelvic sidewall lateral to the sacrum and anterior to the hypogastric. Veers medial as it passes beneath the uterine artery approx 1.5cm lateral to the internal os then passes into the tunnel of the cardinal ligament and travels medially and anteriorly over the vaginal fornix to enter the bladder. Travels 2cm within bladder wall before exitingTravels 2cm within bladder wall before exiting

48 Location of ureteral injuries Cardinal ligaments where uterine artery and ureter cross or at the ureteral tunnelCardinal ligaments where uterine artery and ureter cross or at the ureteral tunnel Infundibulopelvic ligamentInfundibulopelvic ligament Lateral pelvic sidewall along the uterosacral ligamentsLateral pelvic sidewall along the uterosacral ligaments Intramural portion of ureterIntramural portion of ureter

49 Types of injuries Crushing from a clampCrushing from a clamp LigationLigation TransectionTransection Angulation with secondary obstructionAngulation with secondary obstruction Ischemia due to thermal injuryIschemia due to thermal injury ResectionResection

50 Prevention Identification and visualizationIdentification and visualization After dividing round ligament enter broad ligament along psoas muscle and dissect retroperitoneal space, ureter is attached to the medial leaf of the broad ligamentAfter dividing round ligament enter broad ligament along psoas muscle and dissect retroperitoneal space, ureter is attached to the medial leaf of the broad ligament No benefit to preop IVP or stentingNo benefit to preop IVP or stenting Can also be palpated (with experience!!)Can also be palpated (with experience!!) Can also be identified as it crosses iliacCan also be identified as it crosses iliac

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52 Basic steps - TAH Routine identification before clamping IPRoutine identification before clamping IP Mobilize bladder from vaginal cuff for at least 1cmMobilize bladder from vaginal cuff for at least 1cm Clamp uterine artery at the internal os and at right angles to the uterusClamp uterine artery at the internal os and at right angles to the uterus Clamp inside prior pedicles once the uterine artery has been clampedClamp inside prior pedicles once the uterine artery has been clamped

53 Basic steps - TVH Develop vesico-vaginal space with retraction of the bladder anteriorlyDevelop vesico-vaginal space with retraction of the bladder anteriorly Palpation of the ureterPalpation of the ureter Small pedicle bites medial to where ureter is palpatedSmall pedicle bites medial to where ureter is palpated

54 Recognition of uerteral injury 70% not identified until post –op70% not identified until post –op Morbidity due to :Morbidity due to : Necrosis w/ extravasationNecrosis w/ extravasation Fistula formationFistula formation Stenosis w/ hydronephrosis and renal lossStenosis w/ hydronephrosis and renal loss Uremia and death with bilat obstruction (rare)Uremia and death with bilat obstruction (rare)

55 Signs and Symptoms Flank painFlank pain FeverFever Persistent IleusPersistent Ileus Ascites or retroperitoneal fluid collectionAscites or retroperitoneal fluid collection Rise by 0.8 in CreatinineRise by 0.8 in Creatinine Fistula formation 8-10 days post-opFistula formation 8-10 days post-op Usually subtle – high index of suspicionUsually subtle – high index of suspicion U/S normal in 20% - CT-IVP is standard testU/S normal in 20% - CT-IVP is standard test

56 Management of ureteral injury Antegrade or retrograde stent placementAntegrade or retrograde stent placement If stent placement unsuccessful decide between immediate repair vs PCN and delayed repairIf stent placement unsuccessful decide between immediate repair vs PCN and delayed repair < 72hrs – immediate repair< 72hrs – immediate repair >2wks – PCN and repair in 6-8 wks, obtain IVP prior to repair as spontaneous healing can occur in upto 80%>2wks – PCN and repair in 6-8 wks, obtain IVP prior to repair as spontaneous healing can occur in upto 80%

57 Principles of Repair Atraumatic handlingAtraumatic handling Healthy mucosa-to-mucosa approximationHealthy mucosa-to-mucosa approximation Minimal mobilization and dissectionMinimal mobilization and dissection Tension freeTension free Stent placementStent placement Epithelial healing in 2 weeksEpithelial healing in 2 weeks Normal peristalsis in 4 weeksNormal peristalsis in 4 weeks

58 Ureteroneocystotomy Ureteral injuries 5-6cm from bladderUreteral injuries 5-6cm from bladder Non-tunneled reimplantation into bladderNon-tunneled reimplantation into bladder Mobilize proximal ureterMobilize proximal ureter Mobilize bladderMobilize bladder Perform cystotomy in tranverse fashionPerform cystotomy in tranverse fashion

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60 Additional length Psoas hitch – bladder stretched to reach Psoas and attached to the musclePsoas hitch – bladder stretched to reach Psoas and attached to the muscle Boari flap – segment of bladder made into a tunnelBoari flap – segment of bladder made into a tunnel

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62 Ureterouretorostomy Injuries above the pelvic brimInjuries above the pelvic brim Freshen edgesFreshen edges Cheatle incision on either endCheatle incision on either end Reapproxiamte with 5-6 stitches usingReapproxiamte with 5-6 stitches using 4-0 Vicryl, place all stitches then tie StentStent

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65 Other Techniques TransureterouretrostomyTransureterouretrostomy Transposition of segment of ileumTransposition of segment of ileum Mobilization of kidneyMobilization of kidney

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67 Laparoscopy and ureteral injuries Incidence about 0.5%Incidence about 0.5% Usually due to electrocautery and eqaully divided between mono and bipolarUsually due to electrocautery and eqaully divided between mono and bipolar Also commonly due to stapling device when used on uterine arteries or IP as width of device is 1.2cmAlso commonly due to stapling device when used on uterine arteries or IP as width of device is 1.2cm Particular care when anatomy is distortedParticular care when anatomy is distorted

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69 Cystotomy and Repair Most common urinary tract injury during hysterectomyMost common urinary tract injury during hysterectomy Avoid by sharply dissecting bladder of cervix and anterior vaginaAvoid by sharply dissecting bladder of cervix and anterior vagina Trigone is only part that is fixed and not easily distensible, adjacent to upper vagina in the anterior vgainal fornuixTrigone is only part that is fixed and not easily distensible, adjacent to upper vagina in the anterior vgainal fornuix Injury near vaginal cuff or cervix is always close to or at trigoneInjury near vaginal cuff or cervix is always close to or at trigone

70 Repair of bladder dome injury Identify entire length and ends of defectIdentify entire length and ends of defect Use 3-0 or 4-0 Vicryl as 3weeks required for complete healing and chromic only maintains strength for 4-5daysUse 3-0 or 4-0 Vicryl as 3weeks required for complete healing and chromic only maintains strength for 4-5days Running suture through mucosa and muscularis, important to invert and reapproximate mucosaRunning suture through mucosa and muscularis, important to invert and reapproximate mucosa 2 nd layer of imbricating interrupteds2 nd layer of imbricating interrupteds Can be closed in any directionCan be closed in any direction Drain for 5-7 days in healthy tissueDrain for 5-7 days in healthy tissue

71 Repair of trigone injury Visulize ureteral orificesVisulize ureteral orifices Keep in mind ureters travel within bladder wall 2cm laterally, can be palpatedKeep in mind ureters travel within bladder wall 2cm laterally, can be palpated Two layer closure, maintain suture lines in direction away from ureters and trigoneTwo layer closure, maintain suture lines in direction away from ureters and trigone Retrograde filling and Cystoscopy at endRetrograde filling and Cystoscopy at end Drain for min10-14 daysDrain for min10-14 days

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