MCC 2011 - Slide 3
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The document describes seven key anatomical structures related to colorectal surgery: 1) Inferior mesenteric plexus, 2) Superior hypogastric plexus, 3) Hypogastric nerves, 4) Inferior hypogastric plexus, 5) Pelvic splanchnic nerves, 6) Urogenital bundle at the level of the seminal vesicles, and 7) Urogenital bundle at the level of the prostate. Care must be taken during surgery to identify and preserve these structures to avoid nerve damage.
MCC 2011 - Slide 3
- 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. Department of Surgery, University Medical Center Groningen Ureter Hypogastric Nerve Splanchnic nerves Inferior Hypogastric Plexus Havenga 1 2 3 4 5 6 7
- 3. 1 Inferior mesenteric plexus
- 4. 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
- 5. 2 Superior hypogastric plexus
- 6. 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
- 7. Superior hypogastric plexus Willem Hans Steup
- 9. Hypogastric nerves Cees Maas / De Ruiter
- 10. 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
- 11. 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
- 15. Hypogastricus Nerves 1 cm from midline at promontorium Runs parallel to ureter (medial) Sympathetic nerve Ejaculation Bladder neck innervation
- 16. 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
- 17. Hypogastric nerves Department of Surgery, University Medical Center Groningen
- 18. 4 Inferior hypogastric plexus
- 19. Inferior hypogastric plexus Department of Surgery, University Medical Center Groningen
- 20. 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
- 21. 5 Pelvic Splanchnic nerves
- 22. Pelvic Splanchnic Nerves Department of Surgery, University Medical Center Groningen
- 23. Rectosacral fascia divided Parasympathetic Nerves shine through
- 24. Another angle Levator Ani Muscle Piriformis Muscle Sacral Foramen ± 3 cm. laterally Parasympathetic nerves covered by parietal fascia
- 25. Parasympathetic Nerves Branches of Medial Rectal Vessels Medial part of mesorectum removed Cranially to the nerve Covered by Parietal fascia
- 26. S. 4 S. 3 Parasympathetic nerves Detrusor Erection Vaginal lubrication
- 27. Medial Rectalis Vein Cranially to nerves Parasympathetic branch towards rectum
- 28. 6 Urogenital bundle, level of seminal vesicles
- 29. Urogenital bundle level seminal vesicles Department of Surgery, University Medical Center Groningen
- 30. Urogenital bundle level seminal vesicles Department of Surgery, University Medical Center Groningen P=prostate R=rectum SV=seminal vesicle DVF=green Nerves=red
- 31. Urogenital bundle level seminal vesicles Department of Surgery, University Medical Center Groningen P=prostate R=rectum SV=seminal vesicle DVF=green Nerves=red
- 32. Urogenital bundle level seminal vesicles Careful dissection lateral if in front of Denonvilliers’ fascia Department of Surgery, University Medical Center Groningen
- 33. 7 Urogenital bundle, level of prostate (laterodorsal)
- 34. 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
- 35. 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
- 36. 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
- 37. Nervus levator ani From S3,S4 Superior surface pelvic floor Underneath pelvic parietal fascia Department of Surgery, University Medical Center Groningen
- 38. 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
- 39. 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