Presented by:
Emma Goddard
Affiliations:
Memorial University of Newfoundland
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What are the Avascular Pelvic Spaces?
The avascular pelvic spaces are naturally occurring tissue planes within the pelvis that contain relatively few major blood vessels. Identifying and developing these spaces is an important part of complex gynecologic surgery because they provide surgical pathways to important organs, blood vessels, nerves, and supporting structures while helping surgeons navigate the pelvis safely. Here’s what it involves:
- Retroperitoneal Entry: The retroperitoneum is carefully opened to expose anatomical landmarks and begin developing the pelvic spaces.
- Pararectal Spaces: These spaces are developed alongside the rectum and help define relationships between the rectum, ureters, pelvic vessels, and surrounding tissues.
- Paravesical Spaces: Located beside the bladder, these spaces provide access to the pelvic sidewall and help identify nearby vascular and urinary structures.
- Rectovaginal Space: The plane between the rectum and vagina is developed to separate these structures during posterior pelvic dissection.
- Vesicovaginal Space: This space between the bladder and vagina can be developed to safely mobilize the bladder during pelvic surgery.
- Prevesical Space: Located anterior to the bladder, this space provides access to structures within the anterior pelvis.
- Identification of Neurovascular Structures: As these spaces are developed, nearby ureters, blood vessels, nerves, and pelvic organs can be more clearly identified and protected.
- Restoration of Distorted Anatomy: In conditions such as advanced endometriosis or cancer, developing recognizable pelvic spaces can help surgeons re-establish anatomical orientation when normal tissue planes have been altered.
Understanding these spaces provides surgeons with a three-dimensional roadmap of the pelvis and can facilitate safer dissection during procedures ranging from endometriosis excision to radical hysterectomy.
What are the Risks of Dissection of the Avascular Pelvic Spaces?
Although these spaces are described as avascular, they are surrounded by important blood vessels, nerves, urinary structures, and pelvic organs. Their boundaries may also be significantly distorted by endometriosis, cancer, previous surgery, or adhesions.
- Vascular Injury and Bleeding: Dissection outside the correct tissue plane can injure nearby pelvic vessels and cause significant bleeding.
- Ureteral Injury: The ureters are closely related to several retroperitoneal spaces and can be damaged if they are not clearly identified during dissection.
- Bladder Injury: Development of the paravesical, vesicovaginal, or prevesical spaces can potentially result in bladder injury.
- Bowel or Rectal Injury: Dissection of the pararectal or rectovaginal spaces can injure the rectum or surrounding bowel, particularly when normal planes are distorted.
- Nerve Injury: Pelvic autonomic nerves lie close to these spaces, and injury can potentially affect bladder, bowel, or sexual function.
- Injury in Distorted Anatomy: Endometriosis, malignancy, adhesions, and previous surgery can eliminate or alter normal tissue planes, making safe identification of the spaces more difficult.
- Infection or Hematoma: Bleeding or tissue disruption within the retroperitoneum can occasionally result in hematoma or postoperative infection.
- General Surgical Risks: Depending on the underlying operation, additional risks can include blood clots, anesthesia-related complications, postoperative adhesions, and conversion to open surgery.
Precise knowledge of pelvic anatomy, identification of fixed landmarks, and careful development of the correct tissue planes help surgeons use these spaces while minimizing injury to surrounding structures.