Dissection of Retroperitoneal Anatomy

Is knowledge about retroperitoneal anatomy the Achilles' heel of gynecologic surgeons? No matter the specialty, the core skills for any surgeon include knowledge of the applicable anatomy and the ability to safely expose that anatomy. These basic skills are necessary for surgeons to reveal anatomy without having an effect on either the structure or the function of the organs involved.

In a series of presentations at the 43rd AAGL Global Congress on Minimally Invasive Gynecological Surgery in November 2014, Jaime B. Long, MD, Chief of Urogynecology at Reading Health System in West Reading, PA, discussed several techniques aimed to bridge the knowledge gap and instruct gynecologic surgeons in proper surgical techniques.

The three objectives of Long's presentation were to teach the attendees to:

1. Use dissection techniques to expose anatomy safely.

2. Understand the purpose of dissection maneuvers.

3. Expertly reveal structural anatomy.

In her talk, Long points out that good technique can empower a surgeon faced with a complex scenario, cut down on complications, and result in faster surgeries. Without technical skill, surgeons can't expect favorable outcomes for their patients. Students who understand and apply good techniques during their procedures should be able to progress into competent surgeons.

The 6 techniques included in Long's presentation include millimeter by millimeter, grasp and tent, push and spread, traction-counter-traction, gentle wiping/teasing, hydrodissection, and skeletonizing. The "millimeter by millimeter" approach allows for the correct orientation and direction of dissection, ongoing evaluation of instruments and techniques, safe exploration of the anatomy, and limiting the potential of injury.

With the "grasp and tent" procedure, surgeons can move the peritoneum or other tissues away from the vital organs before making an incision. Visualization is improved because the tissue contained in the grasp is thinned. In "push and spread," which might also sometimes be called "poke and open," tissue is thinned out even more, releasing scarring.

"Traction-counter-traction" can be done with assistance from a surgical team member and is used to gently pull tissues. The field of dissection is better visualized because this technique thins visceral connection tissues. "Gentle wiping/teasing" is applied slowly, millimeter by millimeter. This technique thins tissues, clears blood, and can help reveal tissue planes. Long advises against using blunt or quick strokes, which could lead to damage.

Hydrodissection, the process of injecting sterile fluid to tent and thin out connective tissues can open potential spaces and is helpful in vaginal dissection. In laparoscopy, CO₂ gas might also be used instead of fluid to dissect open spaces. To separate adhesions, clean connective tissue, or for broad ligament dissection, skeletonizing is used. This technique is done by gently brushing the tissue with an open pair of scissors or a fine cutting instrument.

Long also suggests that students start with easy dissections and progress to difficult ones; remain flexible; act quickly on warning signs of bleeding; perform techniques the same way each time they're used; and make use of lighting, retraction, and hemostasis to better visualize the surgical field.

References:

Source: Jaime B. Long, MD. Didactic (Live Cadaveric Demo): Fulfill Your Destiny as a MIG Surgeon, You Must. The Way of the Jedi Master, Surgical Anatomy, It Is. The Art and Practice of Expert Surgical Dissection. 43rd AAGL Global Congress on Minimally Invasive Gynecology. ANAT-702.