Technique Retroperitoneal Dissection

Overview

Retroperitoneal Dissection or RP Dissection (RPD) is a powerful technique used at The Center for Innovative GYN Care. It allows the surgeon to safely perform advanced gynecological techniques like DualPortGYN, and complete minimally invasive procedures like hysterectomies for complex conditions that would have otherwise required open surgery. The retroperitoneal approach works as a mapping system for the pelvic cavity and can be effectively used for almost any GYN procedure.

 

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Retroperitoneal dissection, or RPD for short, is a very powerful technique in surgery. This approach allows the surgeon to see the anatomy of the retroperitoneal space, the hidden space on either side of the pelvis. A look inside the retroperitoneal space allows the surgeon to clearly see the vital structures that can be easily injured. When identified and protected at the beginning of surgery, procedures are completed more efficiently, and are safer.

RPD allows the surgeon to perform and complete surgeries that would have otherwise required an open surgical approach, preventing the pain, complications, and long-term recovery.

The retroperitoneal approach can be very effective for almost any GYN procedure. Unfortunately, very few minimally invasive surgeons truly understand the anatomy of the space, and most are not skilled enough to safely operate within the space.

RPD makes it possible to perform a safer procedure with minimal blood loss, smaller incisions, and faster recovery than standard laparoscopic, robotic, or open surgeries for fibroids, endometriosis, pelvic masses, prolapse, and cancer.

The following is a brief description of structures within the retroperitoneal space, and the procedures performed.

The Uterine Artery

The uterine artery is one of three blood supplies on each side of the uterus. The blood supply of the uterus is very complex, since there are “collateral” or shared supplies from the uterine arteries, the ovarian arteries, and the cervical and vaginal arteries that feed the uterus. On the side of the uterus, these blood supplies often come together at the neck of the uterus. It is at the neck of the uterus that almost all GYN surgeons and even surgical specialists try to block the blood flow to the uterus during some procedures, such as hysterectomy. Blocking this flow can be very difficult in patients with large fibroids or with extensive scar tissue from endometriosis or prior surgery. Many patients have uncontrolled bleeding at the neck of the uterus, requiring the surgeon to convert to open surgery. More concerning is injury to other structures near the uterine artery such as the ureter and bladder, leading to complications.

Uterus Blood Supply

Retroperitoneal uterine artery ligation (UAL), or bilateral uterine artery ligation (BUAL) refers to blockage of the uterine artery within the retroperitoneal space. When performed this way, the uterine artery is blocked directly off at its source, eliminating the problems with excessive bleeding and injury of other structures that can occur with blockage at the neck of the uterus. UAL can be easily and very safely performed by a skilled retroperitoneal laparoscopic surgeon, and allows the laparoscopic removal of almost any size uterus, or for complicated hysterectomy. UAL is also extremely effective for patients requiring myomectomy (removal of fibroids) to help prevent hysterectomy and heavy bleeding during and after myomectomy. Temporary blockage, bilateral uterine artery occlusion (BUAO) of the uterine artery is also commonly used by CIGC surgeons for those patients that want myomectomy for fertility reasons. Temporary blockage uses the application of removable clips or a tourniquet, which is used to control bleeding during the procedure. The clips or tourniquet is then removed after the surgery, allowing for full restoration of blood flow to the uterus.

The Ureter

The ureter is the tube that transports urine from the kidney to the bladder, and runs down the side of the pelvis in the retroperitoneal space. Injury to the ureter is one of the most common complications in GYN surgery. It occurs in many cases because the ureter is not completely seen. When not fully seen, or the location of the ureter is unknown, the surgeon can inadvertently “cut” the ureter, “ligate” the ureter by placing a clamp on it or suture across it, or “thermally injure” the ureter when electricity gets too close to the ureter.

Superior Vesical Artery

Superior Vesical Artery

Ureterolysis is a technique that identifies and isolates (dissects) the ureter within the retroperitoneal space to move the ureter out of harm’s way during surgery. This is a very effective and valuable technique in GYN surgery commonly used by CIGC surgeons. Surgeons with the ability to perform ureterolysis provide their patients with the benefits of successfully completing the surgery laparoscopically and minimizing the complications of ureteral injury.

Applications of Ureterolysis

ENDOMETRIOSIS

Patients with this disease can have implants in the ureter that can only be removed by performing ureterolysis. By moving the ureter away from the implant, the entire implant can be removed without injury to the ureter. For those patients with severe endometriosis requiring hysterectomy, ureterolysis is required to take down extensive scar tissue endometriosis can cause to the ureter.

HYSTERECTOMY

Patients with larger fibroids often require the ureter to be identified and moved away from the uterus in order to remove the uterus safely.

PROLAPSE PROCEDURES

Prolapse is the “drop down” or “falling out” of the pelvic organs such as the rectum, bladder, uterus, and ureters. This is a common condition that usually results from vaginal delivery. The location of the ureter can be changed due to prolapse, especially with prolapse of the bladder and uterus. Identification of the ureter and sometimes ureterolysis is helpful to avoid injury during these procedures.

CANCER SURGERY

Cancer-related procedures such as hysterectomy, node dissection, and removal of cancer implants often requires extensive ureterolysis to remove all implants and avoid injury to the ureter.

The Bladder

The bladder is the storage organ for urine from the kidneys. The ureters transport urine to the bladder. The bladder sits directly on top of the vagina and lower portion of the uterus. Certain procedures such as cesarean section require the surgeon to move the bladder off of the uterus, in order to safely deliver the baby. This movement of the bladder, also called dissection of the bladder, can result in scar tissue (adhesions) that develop between the bladder and the uterus. Severe endometriosis and patients with many prior surgeries can have scarring to the bladder as well.

Pelvic Adhesions

Pelvic Adhesions

 

Lateral Bladder Dissection (LBD) is a technique that allows the surgeon to move the bladder off of the uterus using a “side” or lateral approach that is extremely safe. LBD is accomplished through the retroperitoneal space, and is extremely effective in patients requiring hysterectomy after multiple cesarean section deliveries. Without this approach, standard bladder dissection approaches dramatically increase the risk of bladder injury.

The Vessels

The large vessels of the pelvis – the iliac vessels – course along the side of the pelvis to supply blood to the pelvic organs and the legs. The vessels are located within the retroperitoneal space. Access to the retroperitoneal space allows the surgeon to completely see all of the vessels during surgery, significantly decreasing injury. Being able to see these vessels is very important to avoid injury, which can occur with non-retroperitoneal approaches. Major injury to these vessels can be disastrous, with rapid, heavy blood loss that is difficult to control.