Laparoscopic Anatomy of the Pelvic Floor

208 Pages·2020·23.508 MB·English

by  Jean- Bernard Dubuisson, Jean Dubuisson, Juan Puigventos

Jean-Bernard Dubuisson
Jean Dubuisson
Juan Puigventos
Laparoscopic Anatomy
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123
Laparoscopic Anatomy of the Pelvic Floor
Jean-B ernard Dubuisson • Jean Dubuisson
Juan Puigventos
Laparoscopic Anatomy of the
Pelvic Floor
Jean-Bernard Dubuisson Jean Dubuisson
Department of Obstetrics and Gynecology Gynecological Surgery Unit
University Hospitals of Geneva University Hospitals of Geneva
Institut Médico-Chirurgical de Champel Geneva
Geneva Switzerland
Switzerland
Juan Puigventos
Bern
Switzerland
ISBN 978-3-030-35497-8 ISBN 978-3-030-35498-5 (eBook)
https://doi.org/10.1007/978-3-030-35498-5
© Springer Nature Switzerland AG 2020
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Preface
Why This Atlas?
The Atlas is the outcome of 25 years of laparoscopic photos and reflexions on the anatomy and
the reconstructive surgery of the pelvic floor in women. During these years, thanks to the clear
vision obtained by laparoscopy, we were interested in the diversity of pelvic floor defects and,
as a consequence, in the new possibilities of treating genital prolapses.
The Diagnosis of Pelvic Floor Defects Is Clinical
It is obvious that the diagnosis of the pathologies of the pelvic floor is essentially clinical and
stays the same that the one that would have realized the famous Samuel Pozzi more than one
century ago. However, the urodynamics, the ultrasonography and the MRI, prescribed in cer-
tain cases, allow to precise at best the tissue damages and to make the most adapted
treatment.
Always a Place for Vaginal Access to Do Reconstructive Pelvic Surgery
The pathologies of the pelvic floor and in particular the genital prolapses benefited for a long
time from the vaginal reconstructive surgery. This one remains effective, well tolerated and of
rather easy teaching, thanks to the companionship. During these last years, in vaginal surgery,
we saw technical improvements probably related to a better knowledge of the anatomy and
also to the progress of the anaesthesia.
Now, a Great Place for Laparoscopy Using Meshes
For many decades, surgeons took more care of the patients affected by these pathologies and
tried to improve the longevity of the pelvic reconstruction and their quality of life. Since the
1990s, the greatest progress to treat pelvic organ prolapse has been the possibility of treating
with the laparoscopic access. The main technical improvement was the association with lapa-
roscopy and implementation of meshes. Today the laparoscopic surgery with meshes offers
excellent results and remarkable coverage of the patients, for their quality of life.
Which Laparoscopic Technique?
The sacrocolpopexy by laparoscopy is now considered the gold standard to treat pelvic organ
prolapse. In this technique, the difficulty may be the access of the promontory. This is evident
for the young surgeons with a limited experience in pelvic floor reconstructive surgery. Among
v
vi Preface
the resident gynaecologists and the collaborators who worked with us, some were shy and
anxious to have to do the dissection of the promontory during the realization of a laparoscopic
sacrocolpopexy. The main reason was the risk of injury of vessels, bowel and ureter. In our
team, we have a preference for our technique of laparoscopic lateral suspension using meshes.
Almost all preferred to do a lateral suspension because of less operative time and risks. We are
convinced that it is a good technique for treating mainly the cystocele and the procidentia of
the uterus (colposuspension or isthmo-colposuspension). It has many advantages: safety, sim-
plicity, efficiency and profits for the quality of life of the patients. All these points are devel-
oped in the sixth part.
This Atlas? A Hymn to Laparoscopy and Laparoscopists
These few lines of introduction explain why we had the idea of publishing this Atlas focused
on laparoscopy of the pelvic floor. This book explains the main anatomical structures of the
pelvic floor to be known, and shows the different pathologies, with the vision of a laparosco-
pist. The Atlas also gives the precise and exhaustive description of the technique of sacrocol-
popexy and of lateral suspension. For this last technique, the main studies were realized with
the great collaboration of Nikolaus Veit-Rubin.
Geneva, Switzerland Jean-Bernard Dubuisson
Geneva, Switzerland Jean Dubuisson
Bern, Switzerland Juan Puigventos
Acknowledgements
With my true affection to my family, my wife Catherine, Pierre, Paul, Jean, our sons, who have
supported and encouraged me in my endeavours for many years. And a special thought to Jean
who followed me in the long difficult course of gynaecologic surgery.
J.B. Dubuisson
A special word of friendship and deep gratitude to Dr. Nicklaus Veit-Rubin who helped us
so much for 10 years for many studies concerning the laparoscopic lateral suspension to treat
genital prolapse.
With the most faithful feelings for those who supported us and believed in the technique of
laparoscopic lateral suspension of Dubuisson: Pr. Aubert Agostini, Dr. Silvia Berning, Pr. Sassi
Boughizane, Dr. Jean Bouquet de Jolinière, Dr. Tina Cadenbach-Blome, Dr. Ladina Christoffel,
Dr. Christian Deetjen, Dr. Francesca Delprà, Pr. Anis Feki, Dr. Verena Geissbühler, Dr.
Massimo Gianoni, Dr. Martine Henri, Dr. Jörg Humburg, Dr. Stevan Jovanovic, Dr. Sandrine
Jacob, Dr. Isabelle Kaelin-Gambirasio, Dr. Armando Librino, Dr. Liliana Mereu, Dr. Giacomo
Serboli, Dr. Stefan Mohr, Dr. Nabil Moulay, Dr. Mohamed Osman, Dr. Friedrich Pauli, Pr.
Tomaso Simoncini, Pr. Saverio Tateo, Dr. Claire Tourette, Pr. Arnaud Wattiez and Pr. Maciej
Wilczak.
J.B. Dubuisson, J. Dubuisson, J. Puigventos
vii
Contents
Part I T raditional Anatomy of the Pelvic Floor
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1 Muscles, Fascias and Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2 The Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.1 Two Categories of Pelvic Muscles Are Individualized . . . . . . . . . . . . . . . . . . . . 8
2.2 Lateral Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.3 Pelvic Floor Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.3.1 Obturator Internus Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.3.2 Levator Ani (L.A.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.3.3 L.A. Iliococcygeus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.3.4 Coccygeus Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.3.5 Piriformis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.4 The Superior View of the Pelvic Floor Muscles . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.5 The Lateral View of the Pelvic Floor Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3 The Fascias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.1 Endopelvic Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.2 Visceral Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
4 The Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.1 The Pelvic Ligaments Seen by Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.1.1 Round Ligament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.1.2 Uterosacral Ligament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.1.3 The Anatomical Landmarks of the Two Uterosacral Ligaments . . . . . . . 22
4.2 Visceral Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.2.1 The Visceral Ligaments for Pelvis Support . . . . . . . . . . . . . . . . . . . . . . 22
4.2.2 Ventro-Dorsal Axis (Also Called ‘Lame sacro-recto-génito-
pubienne’ Described by Farabeuf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.2.3 Medio-Lateral Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
5 The Attachment Sites for the Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
5.1 The Landmarks of the Pelvic Floor for the Surgeon . . . . . . . . . . . . . . . . . . . . . . 26
5.2 The Four Risks of the Attachment Site Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
5.3 The Risks of the Promontory for the Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
5.4 The Presacral Anatomy Below the Promontory . . . . . . . . . . . . . . . . . . . . . . . . . . 30
ix
x Contents
Part II L aparoscopic Normal Anatomy of the Pelvic Floor Seen
By Transperitoneal Vision
6 Ventrolateral Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
6.1 Umbilical Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
6.2 Inferior Epigastric Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
6.3 Paravesical Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
7 Lateral Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
7.1 The Ureter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
7.2 Laparoscopic Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
8 Landmarks of the Ureter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
8.1 Ureter in the Promontory Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
8.2 Lateral Anatomy Below the Adnexa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
8.3 The Ureter Below the Adnexa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
9 Dorsal and Lateral Anatomy of the Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
9.1 Two Hypogastric Nerves, Right and Left . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
9.2 The Inferior Hypogastric Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
10 Promontory Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
10.1 The Cranial Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
10.2 Middle Sacral Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
10.3 Sigmoid Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
10.4 Left Common Iliac Vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
10.5 The Vision in Female Cadaver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Part III Laparoscopic Normal Retroperitoneal Anatomy of the Pelvic
Floor Seen After Peritoneal Incision
11 Prevesical Space, Cooper’s Ligament, Paravesical Space, Arcus
Tendineus Fascia Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
11.1 The Prevesical Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
11.1.1 A ccess to the Prevesical Space, After Filling the Bladder . . . . . . . . . . . 66
11.1.2 D issection of the Retzius Space in Avascular Loose Tissue . . . . . . . . . 66
11.1.3 The ‘Champagne’ Bubbles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
11.1.4 P rogressive Dissection of the Prevesical Space . . . . . . . . . . . . . . . . . . 68
11.1.5 F ocus on Cooper’s Ligament, Technique of Exposition,
Left Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
11.1.6 F ocus on Cooper’s Ligament, Technique of Suture, Left Side . . . . . . . 70
11.2 The Prevesical Space (Continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
11.2.1 Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
11.2.2 C omplete Dissection of the Prevesical Space . . . . . . . . . . . . . . . . . . . . 72
11.2.3 P anoramic View of Dissection Between the Umbilico-Vesical
Fascia and Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
11.3 The Paravesical Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
11.3.1 F ocus on ATFP, Between Pubis and Ischial Spine (Right Side) . . . . . . . 74
11.3.2 F ocus on Obturator Pedicle, Between Pubis and Ischial
Spine, at the Entry in the Obturator Canal, Left Side . . . . . . . . . . . . . . 76
11.3.3 F ocus on Obturator Pedicle (Right Side, and Left Side) . . . . . . . . . . . . 78
11.3.4 Focus on Corona Mortis Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
11.3.5 R elationship Between the Obturator Nerve and the Corona
Mortis Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
11.4 The Panoramic View of the Pre- and Paravesical Space . . . . . . . . . . . . . . . . . . 82
11.4.1 Prevesical Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Contents xi
12 The Vesicovaginal Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
12.1 Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
12.2 Access to the Vesicovaginal Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
12.3 The Loose Connective Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
12.4 Section of the Bladder Pillars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
12.5 The Cleavage Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
12.6 The Panoramic Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
12.7 Vesicovaginal Space (Continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
12.7.1 Bladder Pillars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
12.7.2 Lateral to the Vesicovaginal Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
12.8 Deep Vesico-Cervico-Vaginal Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
12.8.1 Lateral to the Vesicovaginal Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
12.8.2 Visualization During Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
12.8.3 Visualization with Magnification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
13 The Dorsolateral Dissection of the Uterine Artery . . . . . . . . . . . . . . . . . . . . . . . . .101
13.1 The Dorsal Approach to Preventive Occlusion . . . . . . . . . . . . . . . . . . . . . . . . .102
13.2 The Technique of Dorsal Approach of the Uterine Artery for
Preventive Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
13.3 Visualization of the Uterine Artery and of the Ureter . . . . . . . . . . . . . . . . . . . .104
13.4 The Titanium Clip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104
14 The Rectovaginal Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
14.1 The Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
14.2 Vaginal Venous Plexuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
15 The Pararectal Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111
15.1 Laparoscopic Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112
15.2 The Middle Rectal Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112
15.3 Deep Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114
15.4 Lateral Rectal Dissection in Cadaver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114
15.5 Situation of the Medial Pararectal Space of Okabayashi . . . . . . . . . . . . . . . . . .114
15.6 Situation of Lateral Pararectal Space of Latzko . . . . . . . . . . . . . . . . . . . . . . . . .114
15.7 Pelvic Lymphadenectomy: The Main Benchmarks . . . . . . . . . . . . . . . . . . . . . .116
15.8 The Pudendal Nerve, Laparoscopic Approach . . . . . . . . . . . . . . . . . . . . . . . . . .116
15.8.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116
15.9 Laparoscopic Dissection of the Right Pudendal Nerve . . . . . . . . . . . . . . . . . . .116
15.9.1 T he View of the Pudendal Nerve by Laparoscopy . . . . . . . . . . . . . . . . .116
15.9.2 V iew of the Ischial Spine Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116
15.9.3 V isualization of the Sacrospinous Ligament . . . . . . . . . . . . . . . . . . . . .118
15.9.4 Pudendal Nerve Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118
15.9.5 The Pudendal Nerve Dissected Appears White . . . . . . . . . . . . . . . . . . .120
15.10 Laparoscopic Dissection of the Left Pudendal Nerve (Continued) . . . . . . . . . .120
15.10.1 D issection of the Pudendal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
15.10.2 P rogressive Vision of the Pudendal Nerve . . . . . . . . . . . . . . . . . . . . . . .122
Part IV L aparoscopic Anatomy of the Pelvic Floor in Case of Genital Prolapse
Seen By Clinical Examination and Transperitoneal Vision
16 Cystocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127
16.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128
16.2 External Aspect of Exteriorized Lateral Cystocele, Associated with Procidentia
(Uterine Descent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128
16.3 External Aspect of Large Cystocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130
16.4 Complete Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130