MCC 2011 - Slide 3

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MCC 2011 - Slide 3

  1. 1. Cadaver Demonstration: Seven times at risk ESO-ESSO Masterclass in Colorectal Cancer Surgery February 13, 2011 Caiscais, Portugal Klaas Havenga University Medical Center Groningen
  2. 2. Department of Surgery, University Medical Center Groningen Ureter Hypogastric Nerve Splanchnic nerves Inferior Hypogastric Plexus Havenga 1 2 3 4 5 6 7
  3. 3. 1 Inferior mesenteric plexus
  4. 4. Inferior mesenteric plexus <ul><li>Ligation of the inferior mesenteric artery 1 centimeter from the aorta </li></ul>Department of Surgery, University Medical Center Groningen Caudal Proximal Inferior mesenteric artery Inferior Mesenteric Plexus
  5. 5. 2 Superior hypogastric plexus
  6. 6. Superior hypogastric plexus <ul><li>Careful lifting of the vascular pedicle of the rectum in the avascular plane </li></ul>Department of Surgery, University Medical Center Groningen Hohenberger 2007 Caudal Proximal hypogastric nerve common iliac artery mesorectal fascia incision
  7. 7. Superior hypogastric plexus Willem Hans Steup
  8. 8. 3 Hypogastric nerve
  9. 9. Hypogastric nerves Cees Maas / De Ruiter
  10. 10. Hypogastric nerves <ul><li>Black arrows: Fascia propria rectum </li></ul><ul><li>White arrows: Parietal presacral fascia </li></ul><ul><li>Black arrow head: Prehypogastric fascia </li></ul>Department of Surgery, University Medical Center Groningen Kinugasa Br J Surg 2007 <ul><li>PSN: pelvic splanchnic nerves </li></ul><ul><li>HGN: hypogastric nerve </li></ul><ul><li>SRA: superior rectal artery </li></ul><ul><li>SRV: superior rectal vene </li></ul>S1 S4
  11. 11. Hypogastric nerves <ul><li>NVB=neurovascular bundle </li></ul><ul><li>LA= levator ani </li></ul><ul><li>DVF=Denonvilliers’ fascia </li></ul><ul><li>FPR= fascia propria rectum </li></ul><ul><li>PX=pelvic plexus </li></ul><ul><li>PN=pudendal nerve </li></ul><ul><li>MR=mesorectal fascia </li></ul><ul><li>PSN=pelvic splanchnic nerve </li></ul><ul><li>PM=piriform muscle </li></ul><ul><li>HGN=hypogastric nerve </li></ul><ul><li>Pre-HGF=pre hypogastric fascia </li></ul><ul><li>PF=Parietal presacral fascia </li></ul>Department of Surgery, University Medical Center Groningen Kinugasa Br J Surg 2007
  12. 15. <ul><li>Hypogastricus Nerves </li></ul><ul><ul><li>1 cm from midline at promontorium </li></ul></ul><ul><ul><li>Runs parallel to ureter (medial) </li></ul></ul><ul><ul><li>Sympathetic nerve </li></ul></ul><ul><ul><ul><li>Ejaculation </li></ul></ul></ul><ul><ul><ul><li>Bladder neck innervation </li></ul></ul></ul>
  13. 16. <ul><li>Nervus Hypogastricus </li></ul><ul><ul><li>Runs between mesorectum and </li></ul></ul><ul><ul><li>visceral fascia </li></ul></ul><ul><li>Hypogastricus nerve </li></ul><ul><ul><li>During TME the Hypogastricus </li></ul></ul><ul><ul><li>Nerve remains attached to </li></ul></ul><ul><ul><li>pelvic wall </li></ul></ul><ul><ul><li>Sometimes a step in level of </li></ul></ul><ul><ul><li>dissection is necessary </li></ul></ul>
  14. 17. Hypogastric nerves Department of Surgery, University Medical Center Groningen
  15. 18. 4 Inferior hypogastric plexus
  16. 19. Inferior hypogastric plexus Department of Surgery, University Medical Center Groningen
  17. 20. Inferior hypogastric plexus <ul><li>Black arrows: Fascia propria rectum </li></ul><ul><li>Black arrow head: Prehypogastric fascia </li></ul><ul><li>White arrows: Parietal presacral fascia </li></ul><ul><li>PSN: pelvic planchnic nerves </li></ul><ul><li>HGN: hypogastric nerve </li></ul><ul><li>PX: pelvic plexus </li></ul><ul><li>MRV: middle rectal vein </li></ul><ul><li>IPV: internal pudendal vein </li></ul><ul><li>PN: pudendal nerve </li></ul><ul><li>IGA: inferior gluteal artery </li></ul><ul><li>lateral ligament </li></ul><ul><li>levator muscle </li></ul>Department of Surgery, University Medical Center Groningen Kinugasa Br J Surg 2007
  18. 21. 5 Pelvic Splanchnic nerves
  19. 22. Pelvic Splanchnic Nerves Department of Surgery, University Medical Center Groningen
  20. 23. Rectosacral fascia divided Parasympathetic Nerves shine through
  21. 24. Another angle Levator Ani Muscle Piriformis Muscle Sacral Foramen ± 3 cm. laterally Parasympathetic nerves covered by parietal fascia
  22. 25. Parasympathetic Nerves Branches of Medial Rectal Vessels Medial part of mesorectum removed Cranially to the nerve Covered by Parietal fascia
  23. 26. S. 4 S. 3 <ul><li>Parasympathetic nerves </li></ul><ul><ul><li>Detrusor </li></ul></ul><ul><ul><li>Erection </li></ul></ul><ul><ul><li>Vaginal lubrication </li></ul></ul>
  24. 27. Medial Rectalis Vein Cranially to nerves Parasympathetic branch towards rectum
  25. 28. 6 Urogenital bundle, level of seminal vesicles
  26. 29. Urogenital bundle level seminal vesicles Department of Surgery, University Medical Center Groningen
  27. 30. Urogenital bundle level seminal vesicles Department of Surgery, University Medical Center Groningen P=prostate R=rectum SV=seminal vesicle DVF=green Nerves=red
  28. 31. Urogenital bundle level seminal vesicles Department of Surgery, University Medical Center Groningen P=prostate R=rectum SV=seminal vesicle DVF=green Nerves=red
  29. 32. Urogenital bundle level seminal vesicles <ul><li>Careful dissection lateral if in front of Denonvilliers’ fascia </li></ul>Department of Surgery, University Medical Center Groningen
  30. 33. 7 Urogenital bundle, level of prostate (laterodorsal)
  31. 34. Urogenital bundle at level prostate= laterodorsal <ul><li>LPF= lateral pelvic fascia </li></ul><ul><li>EPF=endopelvic fascia </li></ul><ul><li>LAF=levator ani fascia </li></ul><ul><li>ADF=anterior lamina Denonvilliers’ fascia </li></ul><ul><li>PDF=posterior part Denonvilliers’ fascia </li></ul>Department of Surgery, University Medical Center Groningen
  32. 35. Urogenital bundle at level prostate= laterodorsal <ul><li>EPF= endopelvic fascia </li></ul><ul><li>DVC= dorsal vein complex </li></ul><ul><li>RHS=rhabdosphincter </li></ul><ul><li>DMR=dorsal median raphe </li></ul><ul><li>OSM=outer smooth muscle layer </li></ul><ul><li>FRHS= fascia rhabdosphincter </li></ul><ul><li>ISM=inner smooth muscle layer </li></ul>Department of Surgery, University Medical Center Groningen
  33. 36. Urogenital bundle at level prostate <ul><li>Specific anatomy </li></ul><ul><ul><li>Knee elbow position </li></ul></ul><ul><ul><li>Prostate </li></ul></ul><ul><ul><li>Rectum </li></ul></ul><ul><ul><li>Levator </li></ul></ul><ul><ul><li>Neurovascular bundle </li></ul></ul><ul><li>Technical aspects: cut the levators in the horizontal plane at the level of the prostate and not ventral </li></ul>Department of Surgery, University Medical Center Groningen
  34. 37. Nervus levator ani <ul><li>From S3,S4 </li></ul><ul><li>Superior surface pelvic floor </li></ul><ul><li>Underneath pelvic parietal fascia </li></ul>Department of Surgery, University Medical Center Groningen
  35. 38. Nerve damage possible at level of <ul><li>Inferior mesenteric plexus </li></ul><ul><li>Superior hypogastric plexus </li></ul><ul><li>Hypogastric nerves </li></ul><ul><li>Inferior hypogastric plexus </li></ul><ul><li>Pelvic splanchnic nerves </li></ul><ul><li>Urogenital bundle at level seminal vesicles </li></ul><ul><li>Urogenital bundle at level of prostate </li></ul><ul><li>Nervus levator ani ? </li></ul>Department of Surgery, University Medical Center Groningen
  36. 39. Take home <ul><li>Know your anatomy 3-D </li></ul><ul><li>Dissection close to rectal visceral fascia </li></ul><ul><li>In front of Denonvillier do not go lateral </li></ul><ul><li>At level prostate stay dorsal </li></ul>Department of Surgery, University Medical Center Groningen

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