Anatomy
The schematic diagrams below show the location of structures in the pelvis. The uterus, tubes and ovaries are located in the mid pelvis. The uterus is the “filling” of the sandwich, and is associated with the bladder on top, and the rectum below. It is easy to see how close structures are to each other in this diagram, and how the pelvis is almost like a funnel with limited space. The spine confines the funnel posteriorly (bottom), with the pubic bone confining it anteriorly (top). Note the location of the ureters, the tubes that drain urine from the kidney to the bladder, and how they course very close to the uterus and cervix. Also note the location of the uterine artery, and the extensive blood supply to the uterus from the uterine artery and other vessels as they feed the uterus.
Retroperitoneal Dissection
Retroperitoneal dissection, or RPD for short, is an extremely powerful technique that has been used for decades in open surgery. CGS doctors learned this technique in their fellowship training, in which retroperitoneal procedures were used extensively for laparoscopy. RPD is not performed by OBGYN’s, and is rarely used even by traditional fellowship trained laparoscopic surgeons. It offers many advantages over standard laparoscopy, the most important being complete identification and visualization of the anatomy. With RPD, the surgeon is less likely to injure structures during the course of surgery because they are identified clearly. Standard laparoscopy and robotic surgery do not clearly identify the ureter, the large vessels, the pelvic nerves, and the full extent of the bladder, possibly leading to injury. Because RPD techniques allow the surgeon to fully identify and locate all the pelvic structures the risk of injury and complications is greatly decreased.
- The Ureter
A common site of injury and complication with standard laparoscopy is damage to the ureter, the tube that carries urine to the bladder. This is because the ureter tracks down on either side of the pelvis, and can be injured at multiple levels such as removal of the ovary, the uterus, or the cervix. Injuries can be a direct transection, or cut of the ureter, or more commonly a thermal injury, or burn, to the ureter leading to a fistula. Fistulas are connections between the ureter and the vagina, leading to vaginal leakage of urine. Repair of fistulas is a long process, requiring multiple additional procedures. RPD allows the surgeon to fully identify the ureter throughout its course, thereby greatly decreasing the risk of injury. CGS data indicates that ureteral injury occurs in less than 0.1% of their patients, far less than with standard approaches. Further, with RPD, an injury to the ureter can be immediately identified and repaired during the surgery, thereby preventing the need for additional surgery. Another advantage with RPD is the ability to perform ureterolysis, a technique that gently displaces the ureter from structures it may be adhered to. Ureterolysis decreases the rise of ureteral injury, and ensures the procedure will be completed laparoscopically. - The Uterine Artery
The uterine artery is the main cause for bleeding with standard laparoscopy during hysterectomy and other procedures. Standard approaches cauterize, or “burn” the uterine artery at the side of the cervix, which in many cases is ineffective in controlling bleeding for hysterectomy and other procedures. With RPD approaches, the uterine artery is “ligated”, or transected, at its origin, which controls blood loss dramatically. The results with uterine artery ligation are amazing. Procedures can be performed with very little blood loss, and can be performed faster, safer, and with far fewer complications. During surgery, continuous bleeding from an artery can cause problems with visualization, leading to problems with identifying anatomy resulting in complications. Heavy blood loss can lead to the need for transfusion, long term hospital stay, and even ICU admission. Ligation of the artery in the retroperitoneal space is so effective that the safety of the procedures performed using ARLS is actually better than with open surgery. Ligation allows a well trained ARLS surgeon to perform procedures such as hysterectomy and myomectomy that otherwise would not be possible with standard laparoscopic approaches faster and safer. Overall, uterine artery ligation through retroperitoneal techniques can be considered the most important development in Advanced Retroperitoneal Laparoscopic Surgery. - Bladder
The bladder in the pelvis lies above the uterus. After cesarean section, the bladder will in many cases scar down to the uterus due to adhesions. RPD approaches allow the surgeon to fully identify the bladder, and lateral bladder dissection can be accomplished easily and safely to remove the bladder off the uterus. Knowing where the bladder is through RPD, and knowing how to safely release the bladder from the uterus and other structures decreases injury to the bladder and complications. This avoids additional surgery, and possibly long term problems with bladder function. - Iliac Vessels
On either side of the pelvis, the iliac vessels provide blood supply to the pelvis and the lower extremities (legs). These vessels are large, and injury can occur in more complicated cases where the anatomy is not clear. RPD approaches allow for full visualization of the pelvic vessels, thereby greatly avoiding injury. It is extremely rare that the large vessels are injured with RPD techniques, which greatly increases the safety of the procedures. Injury to these vessels requires immediate open surgery, and can lead to massive blood loss and even death in rare cases.
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