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Marc Possover - One of the best experts on this subject based on the ideXlab platform.

  • Laparoscopic Dissection and Anatomy of Sacral Nerve Roots and Pelvic Splanchnic Nerves
    Journal of Minimally Invasive Gynecology, 2014
    Co-Authors: ângela Zanatta, Mateus M. Rosin, Ricardo L. Machado, Leonardo Cava, Marc Possover
    Abstract:

    Study Objective: To demonstrate the technique of laparoscopic dissection for identification of sacral nerve roots and Pelvic Splanchnic Nerves. Design: Case report (Canadian Task Force classification III). Setting: Private practice hospital in São Paulo, Brazil. Patient: A 31-year-old woman with suspected iatrogenic and/or compression of sacral nerve roots. She reported debilitating Pelvic, gluteal, and perineal unilateral left-sided pain (score 8 on a pain scale of 0-10), and had primary infertility with 1 previous failed attempt at invitro fertilization. Surgical history included laparoscopic excision of endometriosis 10months before the procedure and left oophoroplasty during adolescence because of a benign neoplasm. Interventions: Standard 4-puncture laparoscopy was performed. The peritoneum of the left Pelvic sidewall was resected to preclude eventual residual endometriosis. This also enabled identification of uterine vessels including the deep uterine vein, which is the limit between the pars vascularis superiorly and the pars nervosa inferiorly in the uterine broad ligament. Surgery was using the laparoscopic neuro-navigation (LANN) technique, previously described by one of us (M. P.). For identification of the sacral roots, dissection was begun medial to the ureter and lateral to the uterosacral ligament. The Okabayashi pararectal space was entered as deep as possible via blunt dissection in avascular spaces. Hemostasis was performed using 5-mm bipolar forceps, and harmonic energy was not used. The hypogastric fascia was entered from medial to lateral, and the piriformis muscle was identified. The sacral nerve root S1 was identified lying over it. Dissection then proceeded caudally, and sacral roots S2 and S3 were sequentially identified. Small and delicate fibers forming the Pelvic Splanchnic Nerves were isolated emerging from sacral roots S2 and S3. Other nerve fibers were identified caudally, probably representing Pelvic Splanchnic Nerves emerging from S4. Measurements and Main Results: The surgical operative time was 70minutes, and bleeding was minimal. No suspected compression or iatrogenic injury was identified. The patient was discharged on the day after the procedure. At 8-month follow-up, she had partial resolution of pain (score 5, pain scale 0-10), and another failed attempt at invitro fertilization was attributed to unsatisfactory quality of the embryos. There were no symptoms or dysfunctions attributable to manipulation of the Nerves. Conclusion: Laparoscopy is a useful tool for identification of sacral roots and Pelvic Splanchnic Nerves in suspected diseases. Its application in the field of neuropelveology can be expanded with proper knowledge and training.

  • Anatomy of the Sacral Roots and the Pelvic Splanchnic Nerves in Women Using the LANN Technique.
    Surgical laparoscopy endoscopy & percutaneous techniques, 2007
    Co-Authors: Marc Possover, Vito Chiantera, Jan Baekelandt
    Abstract:

    AimsTo report on our anatomic and electrophysiologic findings about the sacral nerve roots and the Pelvic Splanchnic Nerves during laparoscopic Pelvic surgery.MethodsThe Pelvic Splanchnic Nerves and the sacral nerve roots were dissected in 336 consecutive patients undergoing laparoscopy for Pelvic p

  • The LANN technique to reduce postoperative functional morbidity in laparoscopic radical Pelvic surgery.
    Journal of the American College of Surgeons, 2005
    Co-Authors: Marc Possover, Jens Quakernack, Vito Chiantera
    Abstract:

    Background We investigated the feasibility and advantages of introducing Laparoscopic Neuro-Navigation (LANN) into the field of laparoscopic gynecologic radical Pelvic surgery. Study design In a prospective pilot study, 261 consecutive patients underwent laparoscopic radical Pelvic surgery for cervical cancer or deep infiltrating endometriosis of the parametria. During the procedure, dissection and electrostimulation, and consequently, sparing of the Pelvic parasympathetic Nerves by transection of the parametria, were performed. Postoperative bladder dysfunction was documented. Results Laparoscopic dissection and electrostimulation of the Pelvic Splanchnic Nerves were feasible in all patients without any complications, and the rate of postoperative bladder dysfunction was considerably reduced, to less than 1% of the patients. Conclusions The parasympathetic nerve-sparing method using the Laparoscopic Neuro-Navigation technique in laparoscopic radical Pelvic gynecologic surgery is a feasible and reproducible technique that preserves postoperative bladder function.

  • Laparoscopically assisted vaginal resection of rectovaginal endometriosis
    Obstetrics and gynecology, 2000
    Co-Authors: Marc Possover, Herbert Diebolder, Karin Plaul, Achim Schneider
    Abstract:

    Abstract Background: We wanted to establish a technique of laparoscopically assisted radical vaginal surgery for deep endometriosis of the rectovaginal septum with extensive rectal involvement. Technique: The procedure is started by vaginally excising the involved area which is left on the rectum, followed by bilateral dissection of the pararectal and retrorectal spaces. Para- and retrosigmoido-rectal spaces are developed laparoscopically along the coccygeosacral bone and medially to the Pelvic Splanchnic Nerves toward the para- and retrorectal openings that were made transvaginally. Rectal transection is done with a laparoscopic stapling device caudal to the endometriotic lesion. Using a suprapubic minilaparotomy, the bowel is transected cranial to the lesion and reintroduced into the abdomen, and a transanal circular stapler anastomosis is done. Experience: Thirty-four women had this procedure. The mean distance of the anastomosis was 4 cm above the anus. None required ileostomy or colostomy and no major complications were noted. Conclusion: The combination of laparoscopic and vaginal approaches is useful for removing extensive endometriotic infiltration of the rectosigmoid; bladder and rectal function and fertility can be preserved.

Lu Yin - One of the best experts on this subject based on the ideXlab platform.

  • The Anatomy of Lateral Ligament of the Rectum and Its Role in Total Mesorectal Excision
    World journal of surgery, 2010
    Co-Authors: Mou-bin Lin, Weiguo Chen, Liang Huang, Lu Yin
    Abstract:

    Background Lateral ligament of the rectum has suffered many diverse descriptions in its existence and composition. This study was undertaken to define the anatomy, nature, content of the lateral ligament of the rectum, and its role in total mesorectal excision. Methods Cadaver dissections were performed on 32 formalin-preserved cadavers. Results Bilateral lateral ligament appeared in all 32 cadavers as a bundle of dense connective tissue traversing between rectum and visceral fascia instead of Pelvic sidewall. No substantial tissue strand except Pelvic Splanchnic Nerves was found between visceral fascia and parietal fascia at the same level. The middle rectal artery was observed in only 18 of 64 Pelvic-halves (28.1%). The constant component of the lateral ligament of the rectum was the rectal branches from the Pelvic plexus, whereas the middle rectal artery was almost invisible in lateral ligament of the rectum. Conclusions During total mesorectal excision, it is impossible to reveal the lateral ligament of the rectum in the correct plane between visceral and parietal fascia. The entire rectum may be mobilized without the need for ligating the middle rectal artery. The clinical significance of lateral ligament is that, during lateral dissection, if the dense lateral ligament was identified, then the surgical plane was medial to the visceral fascia and incorrect surgical plane thus entered.

  • Understanding the planes of total mesorectal excision through surgical anatomy of Pelvic fascia
    Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery, 2008
    Co-Authors: Mou-bin Lin, Weiguo Chen, Lu Yin, Zhi-ming Jin, Wen-long Ding, Zhenggang Zhu
    Abstract:

    Objective To study the relationship of mesorectum with fasciae and Nerves in the Pelvic cavity and to specify the proper planes of dissection in total mesorectal excision. Methods Twenty- four pelvises (12 males and 12 females) harvested from cadavers were studied by dissection. Results There were three planes surrounding the rectum as the visceral fascia, vesicohypogastric fascia and parietal fascia. The Pelvic plexus and its branches situated between the visceral fascia and the vesicohypogastric fascia. Pelvic Splanchnic Nerves and hypogastric Nerves were observed between the visceral fascia and the parietal fascia. Conclusions The posterior plane of total mesorectal excision lies between the visceral fascia and the parietal fascia. The lateral dissection should be conducted in a plane between the visceral fascia and the vesicohypogastric fascia. The proper planes for posterior and lateral resection can be identified by the hypogastric nerve and the Pelvic plexus respectively. Key words: Rectum;  Pelvic;  Applied anatomy;  Total mesorectal excision;  Fascia

Achim Schneider - One of the best experts on this subject based on the ideXlab platform.

  • Slow-transit constipation after radical hysterectomy type III.
    Surgical endoscopy, 2002
    Co-Authors: M Possover, Achim Schneider
    Abstract:

    This study investigated ways to reduce the rate of slow-transit constipation after radical hysterectomy type III. A prospective study was conducted involving 59 consecutive patients with cervical cancer stage IB1-IIIA at high risk for parametrial or lymph node involvement who were treated between May 1996 and March 1999 by laparoscopically assisted radical vaginal hysterectomy type III. During laparoscopic transection of the cardinal ligament, particular attention was focused on conservation of the Pelvic Splanchnic Nerves. After vaginal removal of the uterus, a vaginal sacrocolporectopexy was performed transvaginally. Nerve preservation and pexy of the rectum allowed a significant reduction of postoperative constipation, as compared with classic radical hysterectomy without conservation of the Splanchnic Pelvic Nerves and without sacrocolporectopexy. Refinements in the preparation of the parasympathetic Nerves during radical Pelvic surgery and refixation of the terminal rectum helps to prevent postoperative constipation.

  • Laparoscopically assisted vaginal resection of rectovaginal endometriosis
    Obstetrics and gynecology, 2000
    Co-Authors: Marc Possover, Herbert Diebolder, Karin Plaul, Achim Schneider
    Abstract:

    Abstract Background: We wanted to establish a technique of laparoscopically assisted radical vaginal surgery for deep endometriosis of the rectovaginal septum with extensive rectal involvement. Technique: The procedure is started by vaginally excising the involved area which is left on the rectum, followed by bilateral dissection of the pararectal and retrorectal spaces. Para- and retrosigmoido-rectal spaces are developed laparoscopically along the coccygeosacral bone and medially to the Pelvic Splanchnic Nerves toward the para- and retrorectal openings that were made transvaginally. Rectal transection is done with a laparoscopic stapling device caudal to the endometriotic lesion. Using a suprapubic minilaparotomy, the bowel is transected cranial to the lesion and reintroduced into the abdomen, and a transanal circular stapler anastomosis is done. Experience: Thirty-four women had this procedure. The mean distance of the anastomosis was 4 cm above the anus. None required ileostomy or colostomy and no major complications were noted. Conclusion: The combination of laparoscopic and vaginal approaches is useful for removing extensive endometriotic infiltration of the rectosigmoid; bladder and rectal function and fertility can be preserved.

Mou-bin Lin - One of the best experts on this subject based on the ideXlab platform.

  • The Anatomy of Lateral Ligament of the Rectum and Its Role in Total Mesorectal Excision
    World journal of surgery, 2010
    Co-Authors: Mou-bin Lin, Weiguo Chen, Liang Huang, Lu Yin
    Abstract:

    Background Lateral ligament of the rectum has suffered many diverse descriptions in its existence and composition. This study was undertaken to define the anatomy, nature, content of the lateral ligament of the rectum, and its role in total mesorectal excision. Methods Cadaver dissections were performed on 32 formalin-preserved cadavers. Results Bilateral lateral ligament appeared in all 32 cadavers as a bundle of dense connective tissue traversing between rectum and visceral fascia instead of Pelvic sidewall. No substantial tissue strand except Pelvic Splanchnic Nerves was found between visceral fascia and parietal fascia at the same level. The middle rectal artery was observed in only 18 of 64 Pelvic-halves (28.1%). The constant component of the lateral ligament of the rectum was the rectal branches from the Pelvic plexus, whereas the middle rectal artery was almost invisible in lateral ligament of the rectum. Conclusions During total mesorectal excision, it is impossible to reveal the lateral ligament of the rectum in the correct plane between visceral and parietal fascia. The entire rectum may be mobilized without the need for ligating the middle rectal artery. The clinical significance of lateral ligament is that, during lateral dissection, if the dense lateral ligament was identified, then the surgical plane was medial to the visceral fascia and incorrect surgical plane thus entered.

  • Understanding the planes of total mesorectal excision through surgical anatomy of Pelvic fascia
    Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery, 2008
    Co-Authors: Mou-bin Lin, Weiguo Chen, Lu Yin, Zhi-ming Jin, Wen-long Ding, Zhenggang Zhu
    Abstract:

    Objective To study the relationship of mesorectum with fasciae and Nerves in the Pelvic cavity and to specify the proper planes of dissection in total mesorectal excision. Methods Twenty- four pelvises (12 males and 12 females) harvested from cadavers were studied by dissection. Results There were three planes surrounding the rectum as the visceral fascia, vesicohypogastric fascia and parietal fascia. The Pelvic plexus and its branches situated between the visceral fascia and the vesicohypogastric fascia. Pelvic Splanchnic Nerves and hypogastric Nerves were observed between the visceral fascia and the parietal fascia. Conclusions The posterior plane of total mesorectal excision lies between the visceral fascia and the parietal fascia. The lateral dissection should be conducted in a plane between the visceral fascia and the vesicohypogastric fascia. The proper planes for posterior and lateral resection can be identified by the hypogastric nerve and the Pelvic plexus respectively. Key words: Rectum;  Pelvic;  Applied anatomy;  Total mesorectal excision;  Fascia

Werner Kneist - One of the best experts on this subject based on the ideXlab platform.

  • Surgeons' assessment of internal anal sphincter nerve supply during TaTME - inbetween expectations and reality.
    Minimally invasive therapy & allied technologies : MITAT : official journal of the Society for Minimally Invasive Therapy, 2016
    Co-Authors: Werner Kneist, Daniel W. Kauff, Laura Isabel Hanke, Hauke Lang
    Abstract:

    AbstractBackground: Intraoperative identification of nerve fibers heading from the inferior rectal plexus (IRP) to the internal anal sphincter (IAS) is challenging. The transanal total mesorectal excision (TaTME) is said to better preserve Pelvic autonomic Nerves. The aim of this study was to investigate the nerve identification rates during TaTME by transanal visual and electrophysiological assessment.Material and methods: A total of 52 patients underwent TaTME for malignant conditions. The IRP with its posterior branches to the IAS and the Pelvic Splanchnic Nerves (PSN) were visually assessed in 20 patients (v-TaTME). Electrophysiological nerve identification was performed in 32 patients using electric stimulation under processed electromyography of IAS (e-TaTME).Results: The indication profile for TaTME was comparable between the v-TaTME and the e-TaTME group. The identification of IRP was more meaningful under electrophysiological assessment than under visual assessment for the left Pelvic side (81% v...

  • Evaluation of two-dimensional intraoperative neuromonitoring for predicting urinary and anorectal function after rectal cancer surgery
    International Journal of Colorectal Disease, 2013
    Co-Authors: Daniel W. Kauff, Karin Somerlik, K. P. Koch, K. P. Hoffmann, H. Lang, Werner Kneist
    Abstract:

    Purpose The aim of this study was to compare the results of two-dimensional intraoperative neuromonitoring (IONM) with the postoperative urinary and anorectal function of rectal cancer patients. Methods A consecutive series of 35 patients undergoing low anterior resection were investigated prospectively. IONM was performed with electric stimulations of the Pelvic Splanchnic Nerves under simultaneous manometry of the bladder and electromyography (EMG) of the internal anal sphincter (IAS). Urinary and anorectal function were evaluated preoperatively and at follow-up by standardized questionnaires, digital rectal examination scoring system, and long-term catheterization rate. Results The rate of postoperative newly developed bladder dysfunction was 17 %. IONM with bladder manometry had a sensitivity of 100 %, specificity of 96 %, positive predictive value of 83 %, negative predictive value of 100 %, and overall accuracy of 97 %, respectively. The proportion of patients with severely impaired anorectal function at follow-up was 8 %. The sensitivity, specificity, and positive and negative predictive values for IONM with EMG of the IAS were, respectively, 100, 96, 67, and 100 % with an accuracy of 96 %. The degree of agreement for IONM with EMG of the IAS was good for anorectal function ( к  = 0.780) and poor for urinary function ( к  = 0.119). IONM with bladder manometry yielded a very good degree of agreement for urinary function ( к  = 0.891) and a fair agreement for anorectal function ( к  = 0.336). Conclusions The two-dimensional IONM method is suitable for verification of bladder and IAS innervation. Accurate prediction of urinary and anorectal function necessitates both bladder manometry and EMG of the IAS.

  • Total Mesorectal Excision—Does the Choice of Dissection Technique have an Impact on Pelvic Autonomic Nerve Preservation?
    Journal of Gastrointestinal Surgery, 2012
    Co-Authors: Daniel W. Kauff, Klaus P. Koch, Hauke Lang, Oliver Kempski, Sabine Huppert, Klaus P. Hoffmann, Werner Kneist
    Abstract:

    Background The aim of this experimental study was to assess the quality of Pelvic autonomic nerve preservation of different dissection techniques. Material and Methods Twelve pigs underwent low anterior rectal resection (LARR) with scissors, ultracision, monopolar diathermy, and waterjet, each in three animals. Assessment of Pelvic autonomic nerve preservation was carried out by stimulation of the Pelvic Splanchnic Nerves under electromyography of the internal anal sphincter (IAS). Neurostimulation was performed bilaterally after posterior dissection, after complete mesorectal dissection, and after rectal resection. Results Stimulation resulted in significantly increased amplitudes of the time-based electromyographic signal of the IAS, confirming nerve preservation. The stimulation results after complete mesorectal dissection showed comparable median amplitude increases for dissection with scissors (10.34 μV (interquartile range [IQR], 5.58; 14.74)) and ultracision (9.79 μV (IQR, 7.63; 11.6)). Lower amplitude increases were observed for monopolar diathermy (4.47 μV (IQR, 2.52; 10.46)) and waterjet (0.61 μV (IQR, 0.07; 2.11)) ( p  = 0.038). All animals undergoing dissection with scissors, ultracision, and monopolar diathermy had bilateral positive results. Of three animals undergoing LARR with waterjet, one had bilateral positive results. Two had unilateral negative results, indicating incomplete nerve preservation. Conclusion Scissors, ultracision, and monopolar diathermy might have comparable nerve-sparing potentials and differed from waterjet.

  • Selective Pelvic Autonomic Nerve Stimulation with Simultaneous Intraoperative Monitoring of Internal Anal Sphincter and Bladder Innervation
    European surgical research. Europaische chirurgische Forschung. Recherches chirurgicales europeennes, 2011
    Co-Authors: Werner Kneist, Daniel W. Kauff, Axel Heimann, Klaus P. Koch, Irene Schmidtmann, Klaus-peter Hoffmann, Hauke Lang
    Abstract:

    Pelvic autonomic nerve preservation avoids postoperative functional disturbances. The aim of this feasibility study was to develop a neuromonitoring system with simultaneous intraoperative verification of internal anal sphincter (IAS) activity and intravesical pressure. 14 pigs underwent low anterior rectal resection. During intermittent bipolar electric stimulation of the inferior hypogastric plexus (IHP) and the Pelvic Splanchnic Nerves (PSN), electromyographic signals of the IAS and manometry of the urinary bladder were observed simultaneously. Stimulation of IHP and PSN as well as simultaneous intraoperative monitoring could be realized with an adapted neuromonitoring device. Neurostimulation resulted in either bladder or IAS activation or concerted activation of both. Intravesical pressure increase as well as amplitude increase of the IAS neuromonitoring signal did not differ significantly between stimulation of IHP and PSN [6.0 cm H(2)O (interquartile range [IQR] 3.5-9.0) vs. 6.0 cm H(2)O (IQR 3.0-10.0) and 12.1 μV (IQR 3.0-36.7) vs. 40.1 μV (IQR 9.0-64.3)] (p > 0.05). Pelvic autonomic nerve stimulation with simultaneous intraoperative monitoring of IAS and bladder innervation is feasible. The method may enable neuromonitoring with increasing selectivity for Pelvic autonomic nerve preservation. Copyright © 2011 S. Karger AG, Basel.

  • Intraoperative Pelvic nerve stimulation performed under continuous electromyography of the internal anal sphincter
    International Journal of Colorectal Disease, 2010
    Co-Authors: Werner Kneist, Daniel W. Kauff, Roman K. Rahimi Nedjat, Andreas D. Rink, Axel Heimann, Karin Somerlik, Klaus P. Koch, Thomas Doerge, Hauke Lang
    Abstract:

    Purpose The aim of this animal study was to investigate the effect of intraoperative Pelvic nerve stimulation on internal anal sphincter electromyographic signals in order to evaluate its possible use for neuromonitoring during nerve-sparing Pelvic surgery. Methods Eight pigs underwent low anterior rectal resection. The intersphincteric space was exposed, and the internal (IAS) and external anal sphincter (EAS) were identified. Electromyography of both sphincters was performed with bipolar needle electrodes. Intermittent bipolar electric stimulation of the inferior hypogastric plexus and the Pelvic Splanchnic Nerves was carried out bilaterally. The recorded signals were analyzed in its frequency spectrum. Results In all animals, electromyographic recordings of IAS and EAS were successful. Intraoperative nerve stimulation resulted in a sudden amplitude increase in the time-based electromyographic signals of IAS (1.0 (0.5–9.0) μV vs. 4.0 (1.0–113.0) μV) and EAS ( p