Laparoscopic dissection of the pararectal space.

Pelvic adhesions affecting the uterine adnexa or cul-de-sacs are a common finding in gynaecological surgery. We present a referred patient with a history of laparoscopic hysterectomy and right salpingo-oophorectomy and an unresected left ovarian mass causing ovarian retention syndrome. The left ovarian complex was hidden in the left pararectal space. The laparoscopic technique for dealing with such a rare case is explained.

INTRODUCTION

Pelvic adhesions are a common finding in gynaecological surgery. They tend to occur in women with inflammatory pelvic disease, endometriosis or prior pelvic / abdominal surgery. These adhesions often affect the uterine adnexa resulting in tubo-ovarian complexes that adhere to the pelvic sidewall.[1] Less commonly, the posterior or anterior cul-de-sacs may be obliterated posing a therapeutic challenge to the surgeon, especially a surgeon who performs minimal invasive surgery.[23] Rarely the ovary becomes hidden in the pararectal space. These cases require that the surgeon performing minimal invasive surgery have high laparoscopic skills. We present such a case and explain the steps to deal with such pathology.

CASE REPORT

A 34-year-old, gravida 2 para 2 patient was referred to us because of ovarian retention syndrome, with persistent pelvic pain. She had a history of two ovarian cystectomies and more recently she underwent laparoscopic hysterectomy with right salpino-oophorectomy. During that operation, the referring surgeon could not remove the left tubo-ovarian complex because it was buried in the left pararectal space. The ultrasound showed an enlarged left ovary, with a multilocular septated mass, the greatest diameter of which was 7 cm, and a CT of the pelvis confirmed these findings, with no evidence of free fluid or adenopathy. The patient's CA-125 was negative. She was counselled on her options and due to the author's experience with minimal invasive surgery, operative laparoscopy was selected. During surgery the patient was found to have the sigmoid colon adherent to the left pelvic sidewall overlying the adnexal mass and covering it completely. Using harmonic scalpel dissection, traction and countertraction, the sigmoid colon was separated from the pelvic sidewall, exposing the pelvic brim. The ureter was dissected out beginning at the level of the pelvic brim. The dissection was continued until the large cystic mass was noted. The patient had a large cystic mass scarred into the left pelvic sidewall, with the ureter overlying the mass, and the uterosacral ligament medial to the mass which had dissected itself down into the pararectal space on the left side. The uterine vessels were re-discovered and re-coagulated, because dissection caused them to bleed. The cardinal web or tunnel was unroofed to the bladder allowing anterolateral retraction of the ureter away from the area of dissection. Continued harmonic and blunt dissection was performed, freeing the mass from the area of the ureter and cardinal ligament. The mass was bluntly dissected free along the margin of the uterosacral ligament as well as out of the pararectal space, freeing it completely [Figure 1]. The adnexal tissue was removed en block utilizing an endopouch inserted through a slightly enlarged incision at the left lower quadrant puncture site. The pathology showed benign hydrosalpinx with extensive tubo-ovarian adhesions and mild inflammatory changes.

Figure 1

Laparoscopic image showing the dissected pararectal space and the freed mass

COMMENTARY

The approach to the dissection of the pararectal space when there is distorted anatomy is not an easy task. In such cases, it is wiser to begin the dissection in an area of normal anatomy, usually at the pelvic brim. This allows exposure of the ureter and visualisation of the bifurcation of the iliac vessels. The infundibulopelvic ligament (IP) can then be taken to allow de-vascularisation of the diseased adexa and the IP can be used for traction to expose the area of dissection. The ureter is then dissected free from the mass to the level of the cardinal ligament. With the ureter and hypogastric vessels and the retroperitoneal margin of the rectum identified, the mass can then be dissected free from the pelvic sidewall and its adherence in the pararectal space without injury to the surrounding vital structures. When the masses are endometriotic, varying amounts of the uterosacral ligament may also need to be resected en bloc with the adherent mass. Identification of the potential spaces of the pelvis, and opening them to assist in difficult dissections, is the transference of traditional gynaecological dissection principles used in open gynae-oncological surgery to the laparoscopic approach, which allows almost all benign gynaecological surgeries to be performed via the laparoscopic approach [Figure 1].