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6 - INTRAPERITONEAL AND RETROPERITONEAL ANATOMY
- Camran Nezhat, Stanford University School of Medicine, California, Farr Nezhat, Mount Sinai School of Medicine, New York, Ceana Nezhat
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- Book:
- Nezhat's Operative Gynecologic Laparoscopy and Hysteroscopy
- Published online:
- 23 December 2009
- Print publication:
- 07 July 2008, pp 70-82
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- Chapter
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Summary
Sound surgical technique, whether during laparotomy or laparoscopy, is based on accurate anatomic knowledge. Laparoscopic surgeons must adapt to the altered appearance of anatomy due to the effects of pneumoperitoneum, Trendelenburg positioning, and traction from a uterine manipulator. There are inherent limitations of laparoscopy related to the fixed visual axis, loss of depth of field, and magnification. Furthermore, laparoscopes with different angles of view make orientation more challenging.
Because a three-dimensional field is projected to video monitors as a two-dimensional image, it is imperative for the endoscopic surgeon to understand that the anatomic structures appearing superior on the monitor are actually anterior and those inferior are posterior.
In this chapter, we describe some important anatomic relations that are critical during laparoscopic procedures.
SUPERFICIAL INTRAPERITONEAL ANATOMY (LANDMARKS TO RETROPERITONEAL STRUCTURES)
Superficial intraperitoneal landmarks within the pelvis alert the operator to key anatomic structures in the retroperitoneal space (Figure 6.1A—C).
The umbilicus is located at the level of L3—L4, although the location varies with the patient's weight, the presence of abdominal panniculus, and the position of the patient on the operating table (supine vs. Trendelenburg). The abdominal aorta bifurcates at L4–L5 in 80% of cases. [1]
The parietal peritoneum over the anterior abdominal wall is raised at five sites, representing the five umbilical folds.
16 - GYNECOLOGIC MALIGNANCY
- Camran Nezhat, Stanford University School of Medicine, California, Farr Nezhat, Mount Sinai School of Medicine, New York, Ceana Nezhat
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- Book:
- Nezhat's Operative Gynecologic Laparoscopy and Hysteroscopy
- Published online:
- 23 December 2009
- Print publication:
- 07 July 2008, pp 435-498
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- Chapter
- Export citation
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Summary
Laparoscopy has been used for second-look assessments in ovarian cancer since first described in 1973 by Bagley et al. However, it was new developments in equipment and instrumentation, such as videolaparoscopy, high pressure insufflators, and energy sources, in the late 1980s to early 1990s — combined with the work of some of the pioneers of laparoscopic surgery — that made the use of operative laparoscopy in gynecologic oncology feasible. Dargent and Salvat, Querleu et al., and Nezhat et al. first established the safety and practicability of laparoscopic retroperitoneal and intraperitoneal lymphadenectomy and radical hysterectomy. An increasing number of surgeons have since used advanced operative techniques for evaluation and surgical management of gynecologic cancers.
Laparoscopy has the benefit of image magnification to aid in identification of metastatic or recurrent disease, especially in areas such as the upper abdomen, liver and diaphragm surfaces, posterior cul-de-sac, bowel, and mesenteric surfaces. In addition, challenging retroperitoneal spaces of the pelvis, such as the paravesical, pararectal, vesicovaginal, and especially the rectovaginal space, can be accessed laparoscopically. Additional benefits of laparoscopy in gynecologic oncology surgery include limited bleeding from small vessels due to the pressure established by pneumoperitoneum, elimination of large abdominal incisions, shortened hospital stay, and rapid recovery.