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MCC 2011 - Slide 3
 

MCC 2011 - Slide 3

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    MCC 2011 - Slide 3 MCC 2011 - Slide 3 Presentation Transcript

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