Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France; Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark.
Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France.
Fertil Steril. 2021 Jun;115(6):1586-1588. doi: 10.1016/j.fertnstert.2021.02.014. Epub 2021 Mar 23.
To present 10 consecutive, standardized, and reproducible surgical steps allowing complete excision of deep endometriosis nodules infiltrating the parametrium and sacral roots.
Surgical video presenting the 10 surgical steps. Local institutional review board approval was not required for this video article, because the video describes a technique and the patient cannot be identified whatsoever.
Endometriosis Center.
Patients undergoing excision of deep endometriosis nodules of the parametrium and sacral roots.
The excision of deep endometriosis infiltrating the parametrium down to the sacral roots may be performed following 10 steps: complete ureterolysis and removal of ureteral stenosis; opening of the pararectal space in contact with the rectum in a sagittal plane; dissection caudally toward the rectovaginal space, section of the rectovaginal nodule in two separate blocks infiltrating the rectum and vagina, respectively, all the way down to the levator ani muscles; dissection of the presacral space and identification of the superior hypogastric plexus and hypogastric nerve; transverse incision of the peritoneum at the level of the promotorium, extended laterally above the origin of the hypogastric vessels; anterograde dissection of the hypogastric artery and identification of the hypogastric vein; anterograde dissection of the hypogastric vein and opening of Okabayashi space, followed by identification and, when required, ligation of hypogastric vein tributaries; dissection is extended behind the venous network with identification of the pyriform muscles and sacral roots S2, S3, and S4; anterograde dissection of the nerve network and inferior hypogastric plexus, up to the posterior limits of the deep endometriosis nodule; and excision of the deep endometriosis nodule from the posterior limit to the inferior limit in contact with the sacral roots, which should be released or shaved, then to the lateral limit in contact with the pyriform muscle and lateral pelvic wall. Additional steps may be required to remove adjacent infiltration of the vagina, rectum, bladder, or ureters. The movie does not reflect a similar approach in cases of isolated nodules of the sciatic nerves involving a specific lateral dissection plane between the external iliac vessels and the iliopsoas muscle.
Description of 10 successive surgical steps.
The 10-step procedure already has been employed in 70 women with deep endometriosis of the parametria involving sacral roots, in whom sensory or motor complaints were not completely relieved by continuous amenorrhea provided by contraceptive pill intake or gonadotropin-releasing hormone analogs. Baseline complaints included somatic pain (85.7%), severe bladder dysfunction (10%), or hydronephrosis (24.3%). Main localizations concerned sacral roots (95.7%), sciatic nerves (7.1%), mid/low rectum (87.1%), and bladder (21.4%). Operative time was 224 ± 94 minutes. Among postoperative complications, we recorded rectovaginal fistulae (14.3%), urinary tract fistulae (4.3%), and bladder dysfunction at 3 weeks (22.9%) and 12 months (5.7%) after the surgery.
Laparoscopic excision of deep endometriosis nodules of the parametria involving the sacral roots is a challenging procedure, requiring good anatomic and surgical skills. Teaching such a complex procedure is a delicate task. By following 10 sequential steps, the surgeon may reduce the risk of hemorrhage originating from the hypogastric venous network, preserve as much as possible autonomic nerves and organ function, and successfully excise deep endometriosis nodules. However, transection of the internal iliac artery and vein should not be systematic, as it may adversely affect the vascular supply of the pelvis. Transection of small pelvic splanchnic nerves should be performed only if they actually are included in fibrous nodules, as it may be followed by sexual, bladder, and rectal dysfunction or perineal sensory effects. Although the 10 steps attempt to standardize the surgical approach in a challenging localization of deep endometriosis, they are not mandatory and their use should be individualized.
介绍 10 个连续、标准化且可重复的手术步骤，以完全切除累及子宫旁和骶神经根的深部子宫内膜异位症结节。
手术视频展示了 10 个手术步骤。由于该视频仅描述了一种技术，且无法识别患者身份，因此无需获得当地机构审查委员会的批准。
子宫内膜异位症中心。
接受子宫旁和骶神经根深部子宫内膜异位症结节切除术的患者。
可以按照以下 10 个步骤切除累及骶神经根的深部子宫内膜异位症结节：完全松解输尿管并切除输尿管狭窄；在矢状面与直肠接触的部位打开直肠旁间隙；向直肠阴道间隙方向向尾侧解剖，分别切开两个独立的直肠阴道结节，直至肛提肌；解剖骶前间隙并识别上腹下丛和下腹神经；在耻骨联合水平切开腹膜，向外侧延伸至下腹血管的起始部；向头侧解剖下腹动脉并识别下腹静脉；向头侧解剖下腹静脉并打开冈田间隙，随后识别并在需要时结扎下腹静脉属支；在静脉网后面进行解剖，识别梨状肌和骶神经根 S2、S3 和 S4；向头侧解剖神经丛和下腹下丛，直至深部子宫内膜异位症结节的后缘；从后缘到接触骶神经根的下缘切除深部子宫内膜异位症结节，应松解或刮除骶神经根，然后到接触梨状肌和骨盆侧壁的外侧缘。可能需要进一步切除阴道、直肠、膀胱或输尿管的相邻浸润。对于涉及髂外血管和腰大肌之间特定外侧解剖平面的坐骨神经孤立性结节，该方法并不适用于类似的情况。
描述 10 个连续的手术步骤。
该 10 步手术已应用于 70 例累及骶神经根的深部子宫内膜异位症患者，这些患者的感觉或运动性投诉在通过避孕药或促性腺激素释放激素类似物连续闭经的情况下并未完全缓解。基线投诉包括躯体疼痛（85.7%）、严重膀胱功能障碍（10%）或肾积水（24.3%）。主要定位涉及骶神经根（95.7%）、坐骨神经（7.1%）、中/低位直肠（87.1%）和膀胱（21.4%）。手术时间为 224±94 分钟。术后并发症包括直肠阴道瘘（14.3%）、尿路瘘（4.3%）以及术后 3 周（22.9%）和 12 个月（5.7%）膀胱功能障碍。
腹腔镜切除累及骶神经根的子宫旁深部子宫内膜异位症结节是一项具有挑战性的手术，需要良好的解剖和手术技能。教授如此复杂的手术是一项精细的任务。通过遵循 10 个连续的步骤，外科医生可以降低源自腹下静脉丛的出血风险，尽可能保留自主神经和器官功能，并成功切除深部子宫内膜异位症结节。然而，不应系统性地横断髂内动脉和静脉，因为这可能会对骨盆的血管供应产生不利影响。只有当小骨盆内脏神经确实包含在纤维性结节中时，才应进行横断，因为这可能会导致性功能、膀胱和直肠功能障碍或会阴感觉效应。尽管这 10 个步骤试图在深部子宫内膜异位症的具有挑战性的定位中标准化手术方法，但它们不是强制性的，应根据具体情况进行个体化应用。
