Surgical Anatomy

It is essential to understand the anatomy of the anterior wall and the pelvis to safely perform laparoscopy. There are several vessels and nerves that come into play with laparoscopic pelvic procedures. The first vessels at risk from trocar placement are the great vessels (aorta/vena cava) at the infraumbilical site. The umbilicus is at the L3-L4 level and, in women with thin to normal body habitus, the aortic bifurcation is at L4-L5. In obese women, the umbilicus is lower. In thin to normal-sized women, the infraum-bilical trocar is placed at a 45 degree angle inclined toward the pelvis, while in an obese female, the trocar can be placed closer to a 90 degree angle. The left common iliac vein crosses over the lateral half of the lower lumbar vertebrae and can be inferior to the umbilicus, making it susceptible to injury at trocar insertion or when exposing the sacral promontory. The common iliac vessels course 5 to 6 cm lateral from the midline before bifurcating into the internal and external common iliac vessels.

The inferior epigastric artery, arising from the distal portion of the external iliac artery, crosses the medial border of the inguinal ligament and runs along the inferior lateral edge of the rectus muscle to anastomose with the superior epigastric artery, a branch of the internal mammary artery (Fig. 1). Two inferior epigastric veins accompany the artery. The superficial epigastric artery arises from the femoral artery 1 cm below the inguinal ligament and passes through the femoral sheath to supply the superficial area of the abdominal wall, up to the umbilicus. If the patient is thin, this vessel can be transilluminated.

The obturator artery is one of the terminal branches of the internal iliac artery and is found on the lateral pelvic sidewall, leaving the pelvis via the obturator canal along with the obturator nerve (Fig. 2). It gives off a pubic branch, which anastomoses with

FIGURE 1 ■ Abdominal wall vascular and neural structures at risk during laparoscopy and normal trocar sites. (A) Superficial circumflex artery, (B) femoral artery, (C) superficial inferior epigastric artery, (D) external iliac artery, (E) inferior epigastric artery, (F) iIiohypogastric nerve, (G) ilioin-guinal nerve, (H) 10-mm trocar sites, (I) 5-mm trocar sites.

FIGURE 1 ■ Abdominal wall vascular and neural structures at risk during laparoscopy and normal trocar sites. (A) Superficial circumflex artery, (B) femoral artery, (C) superficial inferior epigastric artery, (D) external iliac artery, (E) inferior epigastric artery, (F) iIiohypogastric nerve, (G) ilioin-guinal nerve, (H) 10-mm trocar sites, (I) 5-mm trocar sites.

the pubic branch of the inferior epigastric artery to supply the posterior surface of the symphysis. In 25% of patients, an accessory obturator artery arises from the inferior epigastric artery. In approximately 4% of patients, both an obturator and an accessory obturator branch are present. Care must be taken with these vessels, because they complete an anastamotic circle of vessels between the internal and external iliac arteries, referred to as the circle of death in many surgical texts. Damage to any vessel in this circle can result in significant hemorrhage.

Neuropathies can occur from nerve damage or entrapment during laparoscopic surgery. Lateral trocar placement can damage the iliohypogastric and ilioinguinal nerve, leading to sharp pain in the suprapubic or groin area (18) (Fig. 1). Obturator nerve damage can occur during dissection of the space of Retzius or with paravaginal repairs, causing sensory loss to the medial thigh and difficulty in ambulating (19).

Dieting Dilemma and Skinny Solutions

Dieting Dilemma and Skinny Solutions

The captivating thing about diets is that you don't get what is researched or predicted or calculated but rather, you get precisely what you expect. If the diet resonates with you then it will likely work, if it doesn't resonate, it won't.

Get My Free Ebook


Post a comment