Roberto Clarizia

Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery

BackgroundEfforts to improve approaches to the so called “parametrium” with minimally invasive and less dangerous techniques have led to a better study of the anatomic location and composition of that region. Nevertheless, many misconceptions and confusions about the anatomy of the posterior parametrium and its structures still remain. This study aimed to review anatomic and surgical data and to identify several clear landmarks and surgical steps for a nerve-sparing approach to posterior parametrectomy in the course of radical pelvic surgery with or without rectal resection.MethodsThe literature and anatomic dissections of fresh, embalmed, and formalin-fixed female pelvis cadavers were reviewed. The authors’ laparotomic and laparoscopic case series also was reviewed for deep-infiltrating endometriosis as well as uterine, ovarian, and rectal cancer.ResultsThe anatomic entity commonly termed the “posterior parametrium” can be identified as the conjunction of three important anatomic structures (ligaments): the cranial structure (uterosacral ligaments), the caudad structure (rectovaginal ligaments), and the laterocaudad structure (lateral rectal ligaments). Identification of these structures (containing autonomic innervations for pelvic viscera) may allow an accurate nerve-sparing surgical approach in many radical pelvic operations.ConclusionsThe incidences of urinary, rectal, and sexual morbidity after radical pelvic surgical procedures for oncologic diseases (rectal/ovarian cancer, advanced endometrial/cervical cancer, posterior pelvic recurrences) and deep severe endometriosis can be reduced by better knowing and dissecting the right embryo-anatomic planes of the so-called “posterior parametrium.”

Strategies for Management of Colorectal Endometriosis

Abstract Endometriosis has clearly three distinct clinical presentations and deep endometriosis, especially compromising the rectosigmoid is probably the most concerning one for both patients and surgeons. Currently, with the available tools, it is mandatory to have a precise diagnostic of this type of disease prior to indication of treatment. Strategies to manage this form of endometriosis will take into account several involved aspects, such as age of the patient, reproductive desire or infertility, clinical symptoms, as well as the extension and localization of the disease. Treatment could vary from more conservative to more radical depending on those aspects. As we pointed out in this article, the key to manage colorectal endometriosis is to start with a good diagnosis. Knowing exactly what is the extension and localization of the disease and knowing the patients wishes as well as the clinical complaints, surgeons are able to define the best option for each patient. Critical points should always be discussed; for example, patients chosen to have clinical treatment should be aware of important issues regarding the follow‐up, while patients undergoing surgery must be advised about all surgical possibilities and related complications.

Role and technique of nerve-sparing surgery in deep endometriosis

Background Nerve-sparing (NS) surgery reduces bowel, bladder and sexual dysfunction without decreasing surgical efficacy. Objectives This study aimed to summarize the anatomical and surgical data of NS technique and to review the post-operative outcomes after NS surgery for deeply infiltrating endometriosis (DIE). Data Sources Data were collected from published research articles from MEDLINE and the Cochrane Library databases. Conclusions, implications of key findings The NS technique approach for DIE seems to be feasible and reproductive. In comparison to the conventional surgery (CS), it seems to demonstrate better preservation of pelvic visceral function and an improvement in quality of life with same recurrence rates. The concept of preservation of autonomic nerves during surgical treatment of DIE should become standard in reference center.

Anatomical Landmarks in Deep Endometriosis Surgery

Deep endometriosis (DE) represents a chronic inflammatory disease, affecting pelvic viscera and peritoneal and retroperitoneal structures and completely distorting their normal aspect and reciprocal relationships by a mechanism of progressive infiltration and retraction. One of the main objectives of its surgical treatment, together with reducing pelvic pain and improving fertility, is the restoration of normal pelvic anatomy. For this reason, surgeons must have a deep knowledge of pelvic anatomy, in order to reassess a grossly distorted surgical field. Thus, pelvic anatomical landmarks represent essential points of reference to start procedures such as mobilization of the pelvic viscera, wide peritoneal resections, or the identification of further anatomical structures to be preserved, such as parasympathetic and orthosympathetic pelvic neural fibers in nerve-sparing procedures.