Endometriosis Foundation of America
Endometriosis 2013 / Robotic Retroperitoneal Anatomy
Roseanne Kho, MD
Think of this as anatomy on steroids and then do it robotically. The goal of my talk in the next ten minutes is not to tell you that the robot is superior to laparoscopy because it is not. All it is the robot provides us with is another tool in which we could do things as minimally invasively as possible. I do not need to show you anymore of these slides it is quite clear as to why it is important, very important in endometriosis surgery to know your anatomy really well.
Dr. Ted Lee talked about how for him he feels confident. You have heard about many different tips and tricks as to how it is one can feel comfortable and confident during surgery. For me, I am confident when I go into a difficult surgery when I know my anatomy well. It is my GPS, my tool in which I can navigate myself around the retroperitoneal into the abdominal cavity, the pelvic cavity.
If I can just break down the difficult parts of this surgery, let's just deconstruct anatomy here, what I would like to provide you with are the following tools. Think about how you could get into the retroperitoneal. Where should you be identifying the ureter? How do you isolate the infundibulopelvic ligament? Why is it important to know the pararectal and paravesical spaces where it is three different tips to get to know the uterine artery so that it could be easy for you to know how to isolate the blood supply to the central uterus in order to excise all the disease of endometriosis.
The other path that I think is quite critical is to isolate and mobilize the ureter. If you go into a difficult surgery, if you have all the tips and tricks in order to perform these different tasks, I think that your task...as a surgeon is much, much easier.
Let's just go over some things here. I know I have ten minutes so I have to figure out which are the most important things to think about in terms of performing this procedure. I would like to provide you with some of the tools that I have come upon trying to get to know how to do this. Let's just quickly go through this in the next minute or so and talk about the pararectal and paravesical spaces. I start with the open approach because this is how we learn the procedure. There is the posterior cul-de-sac. The best place to enter into the retroperitoneum is at the pelvic brim because the old fashioned way where we would still be cutting the round ligament first we no longer do that in laparoscopy or robotics. This is how we enter into the retroperitoneum. We are right at the pelvic brim. We have the external iliac right there. We are medial to the psoas muscle. The space that is in between the external iliac and the ureter is the pararectal space. You open up this space right here as we go up caudally we will find the superior vesical, going up to the obliterated umbilical. Again, this is the pararectal space found by the external iliac and the ureter medially. You then go up with the superior vesical being medial, external iliac lateral and...paravesical space. What has that done for you? That we have isolated your parametrium where you will find your uterine artery going right across, right there. Let's stop right here and go on to the next video.
Just talking about why it is important to be able to isolate your ureter, and again, you start right here at the pelvic brim. We have retracted the infundibulopelvic medially. You open up the space - that is the ureter right there. You create the window immediately superior to it. Something to think about - if you do this all the time with your easy procedures then it becomes easier when you have a difficult case in front of you. This is our routine in terms of adenectomy removing the ovaries tomorrow I will be talking about ovarian remnant syndrome and will emphasize to you why it is important to be able to ligate the ovarian vessels high so that you do not leave behind any ovarian tissue.
Going on to the next video, how do we isolate the uterine artery? Here we are right here. We have isolated the superior vesical going up to the abdominal wall, we have opened up the paravesical space right here. If you follow the superior vesical down to its insertion to the internal iliac you would then find the uterine artery coming right across. So again, let's just review this video right here. You have got the paravesical space. Right here is the pararectal space that is bordered by the ureter medially. Laterally you have got the external iliac. You have isolated the parametrium right here. Here is the superior vesical going up to the abdominal wall. If you trace that back you will find the uterine artery crossing over exactly as that as these videos show.
What is the third way you can find the uterine artery? When you follow the ureter down you will come upon the bridge above the water phenomenon. So, depending upon the type of disease you have, you have to have these three different techniques that you can isolate the uterine artery. I think this video here would show it to you. Let's just keep playing right here. Again, superior vesical, there is the uterine artery coming right across right there and there is the ureter where you will find the uterine artery coming right on top of it.
Let's go on now to why it is important to know these spaces. Here we are; we have a woman who wants to achieve pregnancy. We are keeping her tubes and ovaries. We start right at the pelvic brim to find the ureter because it is the most superficial area where you will find the ureter. We will go ahead and make an excision in the peritoneum with quick touches of the monopolar spatula right here. You can see she has disease...all along the...sidewall; isolate the ureter, mobilize it, lateralize it. Once we have identified that important structure it is easy then for us to go ahead and go about excising the rest of the lesions right here.
One of the things that we often hear as we go around teaching robotics is that it is difficult to feel the endometriosis. I would say that as you do more robotic procedures you become extremely well versed to looking at using visual cues to know where normal tissue ends and fibrotic endometriotic lesions begin. Fibrotic lesions would not look filmy and pink and healthy like normal tissue does. As you can see here you get to feel with your eyes with robotic. Here we have isolated a ureter. We are seeing immediately below it with the ovary lateral to the ureter and feel very comfortable with this excision.
I just wanted to show you the spaces again; here we are, so we are starting another way of approaching this procedure similar to Dr. Ted Lee's case. Here we have a large ovarian endometrioma. We start right at the pelvic brim, we have identified the ureter, identified the ovarian vessels and external iliac staying lateral. Here we are coming upon - which vessel is this? It is going up to the abdominal wall - superior vesical absolutely - here we are we have opened the pararectal space, the paravesical space. We have identified the ureter. We are staying immediately superior to it, right at 12:00 o'clock. A quick touch of the monopolar instrument we would then mobilize it, lateralize it and feel very comfortable excising all this tissue immediately medial to it. Similar to Dr. Ted Lee you can go ahead and isolate the ureter and divide it as it inserts into the internal iliac or, as in this case, we are going to be coming upon it here. So, we are following the ureter down. We know we are going to come upon the uterine artery right here. We can easily isolate it right there and we can come down with the vessel...once we have isolated it and go about the rest of the procedure.
Just one last video to share with you; this is another case, again, similar. Where do we isolate the ureter? Right at the pelvic brim often for it is not involved with disease because the most superficial is crossing over the common iliac. We are creating that window. The IP is right here. We just stay immediately superior to the ureter right at 12:00 o'clock - quick touches of the monopolar instrument push the ureter down or lateral coming upon the uterine artery immediately superior to it. Isolate it and be able to go on with the rest of the case.
If there is any one slide that I would want to emphasize, and any specific steps that I think are important to master a surgeon doing endometriosis, it would be these: Know how to isolate your pararectal/paravesical spaces, how to isolate your main blood supply to the ovaries and the uterus with isolating the ureter, and then learn how to mobilize the ureter, follow its track all the way down as you are doing the procedure, all the way down to the uterosacral ligament.
Thank you so much for your attention.