1. Retroperitoneal surgeryBy
Dr. Khattab Omar, MD
Prof. & Head of Obstetrics and Gynaecology Department Faculty of Medicine, Al-Azhar University, Damietta

2. Introduction
Retroperitoneal space of the true pelvis differs from retro-peritoneal areas elsewhere in the abdomen by the presence of the sub-peritoneal areolar (cellular) connective tissue.

3. We can recognize about 6 retroperitoneal spaces.

4. Cardinal lig

5. The subperitoneal area of the pelvis is partitioned into potential spaces by the various organs & their re-spective fascial coverings, and by the selective thick-enings of the endopelvic fascia into ligaments and septa.

6. Vesical fascia
Cut edge of the peritoneum
Vesicovaginal lig. & space

7. Indications for development of retroperitoneal surgical approaches
1- Malignancy & Lymphadenectomy.
2- Endometriosis.
3- Chronic PID.
4- Tubo-ovarian abscess.
5- Large or interligamentous myoma
6- Complications in post-hysterect. reserved ovaries.
7- Hypogastric artery ligation.
8-Vaginally-inaccessible urinary fistula
9- Colpopexy.
10- Laparoscopic hysterectomy.

8. 1- The paravesical space:
It is limited
laterally by the obturator internus and levator ani Ms,
medially by the bladder pillars,
inferiorly by the endopelvic fascia,
superiorly by the lateral umbilical ligament,
and posteriorly by the uterine artery.

9. This space can be developed by dissecting between the external iliac vessels and the anterior division of the internal iliac artery (precisely, the superior vesical artery) lateral to the bladder.

11. Steps
First, expose the external iliac vessels anteriorly near their entrance into the femoral canal by dividing the round ligament near the deep inguinal ring. Note where the circumflex iliac vein crosses the external iliac artery. The anterior division of the internal iliac artery lies just medial.

12. Cut round ligament
going through the deep inguinal ring

13. Laparoscopically
The space can be developed laparoscopically, but in different steps.

14. Developing the space lateral to the obliterated umbilical artery
Developing the space lateral to the obliterated umbilical artery. Note direction of the pull exerted through the dissecting forceps (arrow)

15. Developing the space medial to the obliterated umbilical artery
Developing the space medial to the obliterated umbilical artery. Note direction of the pull exerted through the dissecting forceps (arrow)

16. Surgical importance
On the lateral side of the para-vesical space lies the obturator fossa containing blood vessels, nerve and lymph nodes. Blunt dissection following the in-ward pelvic slope can be continu-ed to the pelvic diaphragm.

17. GSI can be attributed to disruption of muscle and fascia of the proximal urethra  bladder neck hyper-mobility (midline defect). The pubo-cervical fascia acts as a suspending hammock for the bladder and urethra.
The pravaginal fascia too plays an important role (paravaginal defect is the most common injury occurring >75%-80% of the time).
Impaired support of the anterior vaginal wall is associated with stress incontinence and prolapse of the anterior vaginal wall.

18. All bladder neck surgeries carry a risk of postoperative detrusor instability and long-term voiding difficulties.
All such techniques rely on creation of a "compensatory abnormality“.
Ritchardson advised repair of the paravaginal defect that was so anatomic that it almost never resulted in either short- or long-term urinary retention, and the patients remained continent over the time.

19. Right paravaginal defect (the vagina's antero-lateral sulcus is avulsed away from the white line). The obturator foramen is 1.5-2cm above the white line. The defect is absent in the left side.

23. 2- The pararectal space:
Boundaries:
Laterally by the levator ani,
medially by the rectal pillars, and
posteriorly above the ischial spine by the anterolateral aspect of the sacrum.
Anteriorly and superiorly
peripheral part of the cardinal ligament and the uterine artery divide the paravesical & the pararectal spaces.

25. Steps
To best develop the pararectal space, dissect between the first portion of the anterior division of the internal iliac artery laterally and the ureter medially. The uterosacral ligament and the ureter are located very near to each other between the rectovaginal and pararectal spaces. Remain close to the rectum to avoid the internal iliac vein and its side wall tributaries. Bleeding from these veins might kill the patient.

27. Laparoscopically
Developing the pararectal space laparoscopically; dissecting behind the uterine artery.

28. Laparoscopically
The uterine artery and the round ligament are divided and the incision is extended along the anterior broad ligament and bladder peritoneum.

29. The infundibulopelvic ligament has been divided and the ureter is displaced laterally to extend the peritoneal incision from the broad ligament to just below the uterosacral ligaments. The peritoneum is separated from the uterosacral ligaments, and the peritoneal incision is continued along the posterior cul-de-sac.

30. The uterosacral ligaments are coagulated and divided (inset).

31. 3- The vesicovaginal space:
Incise the vesicouterine peritoneal fold transversely. Push the bladder down bluntly or by sharp dissection. Moist gauze packing usually controls any encountered slow venous bleeding.
A common error is to dissect too close to the cervix and fail to get into the proper plane.

32. Developing this space gives access to the vesicouterine ligament which contains the ureter as it passes to the bladder.
Developing this space gives access to vesicovaginal fistula & cervical fibriod.

33. 4- The rectovaginal space (plane)
It extends from the Douglas pouch to the perineal body. It is bounded anteriorly by the rectovaginal septum (firmly adherent to the vagina), and posteriorly by the anterior rectal wall. Rectocele often results from a defect or avulsion of the septum from the perineal body.

34. How to develop?
Incise the peritoneum between the insertion of the 2 uterosacral lig.
Bluntly dissect the vagina from the rectum by sweeping the palm along the posterior vaginal wall.
For adherent areas, sharp dissection against the vagina is used.

35. -Rectocele often results from a defect or avulsion of the septum from the perineal body. -Enterocele -congenital type- results from maldevelop-ment of the rectovaginal septum.

36. The vesicovaginal and rectovaginal spaces may be considerably altered
The vesicovaginal and rectovaginal spaces may be considerably altered. In such instances, developing the paravesical and the pararectal spaces first is very helpful.

37. 5- The presacral space:
This space can be developed by gently incising the overlying parietal peritoneum.
The sigmoid colon is shifted to the left.
Inside this space, encased in fat, is the sympathetic nerve plexus (the presacral nerve) in addition to the middle sacral artery and vein.

38. Sacral colpopexy
Frog-leg position. The handle of a retractor is placed into the vagina The small intestines are packed superiorly and the sigmoid colon is retracted aside using a sponge forceps.

39. The apex of the vagina is grasped in the midline and the serosal covering is denuded while the vaginal retractor is pushed up. Then, the scissors are used to undermine the serosa.

40. The peritoneum covering S2-3 is grasped and incised
The peritoneum covering S2-3 is grasped and incised. The scissors are used to undermine and incise the peritoneum progressively until the vaginal apex is reached.

41. Denudation of the vaginal apex against handle of the vaginal retractor
Denudation of the vaginal apex against handle of the vaginal retractor. The sigmoid colon is retracted aside using sponge forceps.

42. A peanut sponge is used to carefully expose the middle sacral ligament all the while searching for the middle sacral artery and veins so as not to traumatise them. The glistening white ligament is exposed for 2 cm. A merselene tape is passed from the vaginal vault retroperitoneally to appear just medial to the sigmoid mesocolon. A right similar loop is taken and both are fixed in the mid piece of the sacrum

43. 6- The prevesical space.
Actually this is an extra-peritoneal, rather than, a retroperitoneal space.
It can be developed by gently dissecting the areolar tissue immediately posterior to the symphysis pubis.

44. Entering the retroperitoneum

45. - A preoperative IVU is recommended.
- In most cases, the round ligament may be divided and the peritoneum lateral to the infundibulopelvic ligament incised without difficulty.
- With large masses or when the anatomy is severely distorted, a paracolic or lateral psoas approach is required.

46. The round ligament approach

47. Placing a retractor near to the round ligament provides upward traction on it.
The ligament is then picked up & transfixed.
The broad lig. should be incised sharply in its lateral portion overlying the psoas Ms.
The peritoneum can then be incised cephalad lateral and parallel to the ovarian vessels.
This is followed by sharp & blunt dissection.
The initial dissection should be bounded by the posterior leaflet of the broad ligament & the ureter medially (the ureter attaches to the broad lig. peritoneum) and the iliac vessels and the pelvic side wall laterally.

48. The paracolic approach

49. It is useful when the pelvic anatomy is severely distorted and the round lig not easily identified, or if the pelvis is occupied with a mass.

50. The paracolic peritoneum is elevated and incised.
The incision begins over the psoas muscle lateral to the ureter and ovarian vessels.

51. This is followed by combined sharp and blunt dissection to mobilize medially the coecum or sigmoid colon, or to visual-ize the ureters. Dissection is continued down into the pelvis using the ureter as the landmark (ureteric cath-eter ± inserted) around which both the ovarian and the iliac vessels may be identified.

52. Post Lt Rt
Anter
The incision begins over the psoas muscle lateral to the ureter and ovarian vessels.

53. The retroperitoneal space may also be entered over or lateral to the psoas muscle.
Begin and stay medial to the iliac vessels.

55. Opening the pelvic sidewall triangles:
The uterus is deviated to one side to de-lineate the triangle in the opposite wall.
The base of the triangle is the round lig., the lateral border is the external iliac a., the medial border is the infundibulopelvic lig, and the apex is where the infundibul- opelvic ligament crosses the common iliac artery.

57. The peritoneum in the middle of the triangle is incised and the broad lig is opened by bluntly separating the extraperitoneal areolar tissue.
Even tiny vessels should be coagulated.
The incision is extended to the round ligament which is not divided at this time and then to the apex of the triangle lateral to the infundibulopelvic ligament.

60. The paravesical space is opened and the infundibulopelvic ligament is pulled medially.

62. Conclusion
Retroperitoneal approaches might be the magic key to navigate through the darkness of frozen or severely distorted pelvis.
Retroperitoneal navigation should be con-ducted very cautiously to avoid injury to important structures, particularly veins.

63. Thanks prof morad k hasanein