Ten Tips and Tricks for Posterior Cul De Sac Dissection

Abstract

Study Objective

Endometriosis and other etiologies of pelvic adhesive disease can distort anatomy, increasing the risk of injury to the rectum and other pelvic structures. Knowledge of pelvic anatomy and precise technique are essential when traveling from safe anatomic landmarks toward areas of disease in the posterior cul-de-sac. The objectives of this video are to: 1.Review the anatomy of the rectovaginal space and pelvic retroperitoneum. 2.Describe tips and tricks for posterior cul-de-sac dissection while avoiding rectal injury

Design

educational video

Setting

operating room, laparoscopic or robotic-assisted surgery

Patients or Participants

patients with endometriosis or pelvic adhesive disease

Interventions

minimally invasive gynecologic surgery: adhesiolysis, rectovaginal dissection and excision of endometriosis

Measurements and Primary Results

This video includes 10 key points to perform safe dissection of the rectovaginal space. These include tips to optimize (1) exposure and (2) identification of key anatomic landmarks in the rectovaginal and pararectal spaces. Recommendations for (3) choosing dissection instruments, (4) approaches for safely performing adhesiolysis and interrogating tissue as well as (5) specific dissection techniques are then reviewed. Focus is then directed to dissection of the rectum by (6) utilizing and navigating perirectal fat planes and (7) delineating the rectum from vagina. Finally, tips for (8) maintaining visualization and controlling bleeding, (9) optimally performing lesion excision after restoring anatomy, and (10) evaluating, testing, and repairing superficial rectal injury are reviewed.

Conclusion

Precise surgical technique is needed in combination with knowledge of pelvic anatomy to approach dissection of an obliterated rectovaginal space. These tips can help safely perform complex dissections.