2. Retroperitoneal surgery 4 By Dr. Khattab Omar, MD Prof. & Head of Obstetrics and Gynaecology Department Faculty of Medicine, Al-Azhar University, Damietta

3. 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.

4. We can recognize about 6 retroperitoneal spaces.

5. Cardinal lig

6. 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.

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

8. 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. Indications for development of retroperitoneal surgical approaches

9. The presacral space

10. This space can be developed by gently incising the overlying parietal peritoneum. The sigmoid colon is shifted to the left.

11. Surgical importance

12. Inside this space, encased in fat, is the sympathetic n. plexus (the pre- sacral nerve) in add ition to the middle sacral artery & vein

13. Sacral colpopexy

14. 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.

15. 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.

16. 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.

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

18. 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

20. Thanks prof morad k hasanein