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Laparoscopic Presacral Neurectomy: Anatomic Approach

Ted T.M. Lee, MD; Linda C. Yang, MD

With the application of laparoscopy, an old procedure gets a second wind and resumes its rightful place in the surgical armamentarium for patients with endometriosis who do not desire hysterectomy.

More than 100 years have passed since presacral neurectomy was first described in 1899.1,2 Traditionally, presacral neurectomy has been a pelvic denervation procedure performed to treat intractable pelvic pain and dysmenorrhea when hysterectomy was undesired. The popularity of this procedure likely reached its peak in the 1960s.3 The need for pelvic denervation declined sharply in the ensuing decades as many women achieved significant symptomatic relief from oral contraceptives and NSAIDs.

Despite these advancements, however, approximately 20% to 25% of patients with dysmenorrhea and pelvic pain do not respond to conservative medical therapy.4,5 When the option of hysterectomy is not compatible with the patient’s desire for childbearing, presacral neurectomy remains a reasonable option for women whose symptoms are refractory to medical management. Recent randomized, controlled trials have shown presacral neurectomy to be an effective adjuvant procedure for pelvic pain associated with endometriosis.6-8 With the advent of minimally invasive techniques, presacral neurectomy can be performed safely and efficiently via the laparoscopic approach.

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SET-UP AND INSTRUMENTATION

After induction of anesthesia, the patient is placed in a modified dorsal lithotomy position. The arms are tucked with protective padding to allow the surgeon to operate from a more ergonomic position above the patient’s umbilicus. A uterine manipulator should be placed routinely to facilitate comprehensive evaluation of the pelvis for the presence of endometriosis or other pathology, particularly in patients with pelvic pain.

Trocar placement for laparoscopic presacral neurectomy can differ among institutions. At the authors’ institution, a 12-mm visual trocar is placed at the umbilicus using an open laparoscopy technique. Two 5-mm trocars are placed laterally at McBurney’s point in the right lower quadrant, and at the equivalent of McBurney’s point in the left lower quadrant. Placement of the 5-mm midline occurs approximately halfway between the umbilicus and pubic symphysis, providing the surgeon with optimal access to the sacral promontory region

A combination of different types of energy sources can be used—eg, bipolar (with or without cutting capabilities), monopolar, harmonic scalpel, ultra-sonic—depending on the surgeon’s preference and comfort level. The authors utilize a bipolar, Maryland-tip dissector and monopolar scissors. An atraumatic grasping forceps is also recommended to accomplish elevation of the presacral nerve off the periosteum.

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TECHNIQUE

The skills required to perform laparoscopic presacral neurectomy are similar to those used in lap-aroscopic pelvic and paraaortic lymphadenectomy. A thorough understanding of the presacral vascular anatomy is mandatory. In thin patients, vascular anatomy can be readily observed under the peritoneum. In patients with higher body mass indices, however, major vasculature can be obscured under variable amounts of adipose tissue. The spatial relationship between various anatomic landmarks is especially important when performing laparoscopic presacral neurectomy in obese patients.

After the patient is in steep Trendelenburg position, the sacral promontory is identified by either direct observation or palpation. A vertical peritoneal incision is made between the sacral promontory and the bifurcation of the aorta, ensuring that the peritoneum is elevated to avoid injury to the underlying vasculature.

The left edge of the peritoneal incision is elevated, and the peritoneal edge is retracted laterally. The first cord-like structure parallel to the left peritoneal edge is the rectal branch of the inferior mesenteric artery—perhaps the most important anatomic landmark for presacral neurectomy. As the artery crosses over both the left common iliac vein and artery, it serves as the left border of dissection (Figure 1); additional dissection lateral to this border is not necessary. Occasionally, the left ureter can be seen beneath and lateral to the inferior mesenteric artery. When the left edge of the peritoneal incision is reflected laterally, the inferior mesenteric artery remains attached to the peritoneum (Figure 2). Dissection between this artery and the peritoneum usually results in bleeding, which will obscure subsequent dissection. Rather, by developing the avascular space between the inferior mesenteric artery and left common iliac vein, the border of the left common iliac vein can be defined in relation to the sacrum (Figures 3, 4). The left common iliac vein is essentially a midline structure, such that the key dissections on the left side are now complete.

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FIGURE 1. Left border of presacral neurectomy dissection. IMA = inferior mesenteric artery; Left CIA = left common iliac artery. Image courtesy of Ted Lee, MD.

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FIGURE 2. Relationship of inferior mesenteric artery and surrounding structures with retraction of peritoneal edge. IMA = inferior mesenteric artery; URE = ureter; LEFT CIA = left common iliac artery; LEFT CIV = left common iliac vein; PSN = presacral nerve. Image courtesy of Ted Lee, MD.

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FIGURE 3. Entry into avascular space (arrow) between inferior mesenteric artery and left common iliac vein. MA = inferior mesenteric artery; LEFT CIV = left common iliac vein. Image courtesy of Ted Lee, MD.

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FIGURE 4. Dissection of neurofibrous tissue (arrow) of the presacral plexus. IMA = inferior mesenteric artery; LEFT CIV = left common iliac vein). Image courtesy of Ted Lee, MD.

The presacral nerve, or superior hypogastric plexus, typically exists as a plexus of nerve fibers. It is a single trunk in 20% of anatomic dissections. The presacral nerve plexus lies to the left of the midline in approximately 75% of patients, and is observed as a midline structure in 25%; it is not typically found to the right of the midline.9

The dissection on the right side is relatively easier. The right common iliac artery and ureter are two useful anatomic landmarks. The right ureter crosses over the right common iliac artery near its bifurcation. Dissection should remain medial to the right ureter and to the bifurcation of the right common iliac artery. The right common iliac artery is easily skeletonized by elevating and incising the fibroadipose tissue over the vessel (Figure 5). The dissection is continued over the right lateral sacral promontory.

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FIGURE 5. Right border of presacral neurectomy dissection. PSN = presacral nerve; RIGHT CIA = right common iliac artery. Image courtesy of Ted Lee, MD.

Using a firm atraumatic grasping forceps, the neurofibrous tissue of the presacral plexus is elevated off the periosteum of the sacral promontory inferior to the border of the left common iliac vein. The Maryland dissecting forceps is used to apply bipolar energy to the neurofibrous tissue between the grasping forceps and the periosteum of the sacral promontory. With continued elevation of the neurofibrous tissue off the sacral promontory, the desiccated neurofibrous tissue of the presacral plexus is transected with laparoscopic scissors. This helps to avoid bleeding from the middle sacral vessels, which remain attached to the periosteum of the sacral promontory. However, bleeding from these vessels can usually be controlled with bipolar dissecting forceps.

Next, the natural plane between the presacral plexus and periosteum of the sacral promontory is entered. This plane continues cephalad between the presacral plexus and the left common iliac vein. Hydrodissection can be used at this point if desired. Using the open-and-spread technique, a window is created laterally on the left side between the presacral plexus and the left common iliac vein. The remaining caudal attachment of the presacral plexus on the left is transected after desiccation with bipolar forceps. The severed end of the presacral nerve is then reflected cephalad to expose the left common iliac vein underneath (Figure 6). The remaining attachment between the presacral plexus and the right common iliac artery can be separated using monopolar scissors.

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FIGURE 6. Presacral nerve reflected cephalad to expose the left common iliac vein. LEFT CIV = left common iliac vein; PSN = presacral nerve. Image courtesy of Ted Lee, MD.

Finally, the free end of the presacral plexus is elevated toward the anterior abdominal wall. After desiccation with bipolar forceps, the presacral nerve is transected below the bifurcation of the aorta. Consistent resection of a 2- to 3-cm segment of the superior hypogastric plexus with histologic confirmation can be achieved using the same techniques.

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CONCLUSION

A clear understanding of the presacral anatomy facilitates safe and effective execution of laparoscopic presacral neurectomy. Using this technique, the gynecologic surgeon can enhance the surgical care of patients with refractory endometriosis who experience debilitating pain.

Ted T.M. Lee, MD, is Director of Minimally Invasive Gynecologic Surgery, and Linda C. Yang, MD, is Fellow in Minimally Invasive Gynecologic Surgery; both in the Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA.

References

1. Jouboulay M. Le traitement de la n³vralgie pelvienne par la paralysie du sympathique sacre. Lyon Med. 1899;90:102-108.
2. Ruggi C. La simpatectomia abdominale utero- ovarica come mezzo di cura di alcune lesioni interne degli organi genitali della donna. Bologna, Italy: Zanichelli; 1899.
3. Black W Jr. Use of presacral sympathectomy in the treatment of dysmenorrhea. Am J Obstet Gynecol. 1964;89:16-22.
4. Dawood MY. Dysmenorrhea. Pain Analges. 1985;1:20.
5. Henzl MR. Dysmenorrhea: achievements and challenges. Sex Med Today. 1985;9:8-12.
6. Candiani GB, Fedele L, Vercellini P, Bianchi S, Di Nola G. Presacral neurectomy for the treatment of pelvic pain associated with endometriosis: a controlled study. Am J Obstet Gynecol. 1992;167(1): 100-103.
7. Zullo F, Palomba S, Zupi E, et al. Effectiveness of presacral neurectomy in women with severe dysmenorrhea caused by endometriosis who were treated with laparoscopic conservative surgery: a 1-year prospective randomized double-blind controlled trial. Am J Obstet Gynecol. 2003;189(1):5-10.
8. Zullo F, Palomba S, Zupt E, et al. Long-term effectiveness of presacral neurectomy for the treatment of severe dysmenorrhea due to endometriosis. J Am Assoc Gynecol Laparosc. 2004; 11(1):23-28.
9. Curtis AH, Anson BJ, Ashley FL, Jones T. The anatomy of the pelvic autonomic nerves in relation to gynecology. Surg Gynecol Obstet. 1942;73:743-750.

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