The video demonstrates a laparoscopic approach for excising a large, rare fibroid found within the Retzius space of the female pelvis.
The Retzius space, located between the bladder and pubic bone, contains several nerve bundles and venous plexuses, requiring careful dissection to avoid hemorrhage.
The patient, a healthy 36-year-old G1P1 with a growing abdominal mass, underwent laparoscopic myomectomy after receiving GnRH agonist treatment.
The laparoscopic procedure involved identifying key anatomical structures, securing the blood supply, and performing careful dissection to ensure safe removal of the fibroid.
The surgery was successful, with minimal blood loss, no post-operative complications, and the patient discharged on post-op day one; the excised fibroid was confirmed as a leiomyoma weighing 556 grams.
Laparoscopic myomectomy is a minimally invasive surgical procedure to remove uterine fibroids, which are non-cancerous growths in the uterus.
The procedure involves making small incisions in the abdomen and inserting a laparoscope (a thin tube with a light and camera) to visualize and remove the fibroids.
Laparoscopic myomectomy offers several advantages over traditional open surgery, including less scarring, reduced blood loss, shorter hospital stay, and quicker recovery time.
The surgery is typically performed under general anesthesia and may involve the use of specialized instruments such as ultrasonic scalpels or laser devices to cut and remove the fibroids.
Laparoscopic myomectomy is recommended for women who wish to preserve their fertility or avoid a hysterectomy, but the suitability of the procedure depends on factors such as the size, number, and location of the fibroids.
Potential risks and complications include bleeding, infection, damage to surrounding organs, and recurrence of fibroids, although these are generally less common compared to open surgery.
Video Transcript: Laparoscopic Myomectomy in the Retzius Space
This video will illustrate a laparoscopic approach for the excision of a large fibroid found within the Retzius space. The authors have no relevant disclosures. The objectives of this video include illustrating a laparoscopic approach for the excision of the rare fibroid found within the Retzius space. Showcasing relevant anatomy of the paravesical and Retzius space, as well as reviewing the retroperitoneal vascular anatomy of the female pelvis.
Overview of the Retzius Space
The Retzius space, or retropubic space, is the least studied anatomical space in the female pelvis. It is located between the bladder and the pubic bone, bound by the anterior abdominal wall. Its lateral borders are the arcus tendineus fascia pelvis and the ischial spines. Development of masses in this space are rare, with a very limited number of cases having been previously reported.
The Retzius space contains several nerve bundles and venous plexuses, as such, meticulous haemostatic dissection is crucial in order to avoid haemorrhage. An important structure to note, when dissecting in this region, is the corona mortis, otherwise known as the crown of death. It is a common anatomical variant which, if cut, will cause significant haemorrhage that will be challenging to temporise.
The patient was a healthy 36-year-old G1P1, with a growing abdominal mass, she was otherwise asymptomatic. She consented for laparoscopic myomectomy and underwent GnRH agonist treatment three months prior to surgery. Ultrasound showed a normal-appearing uterus, with a large, pedunculated, left-sided fibroid, measuring 11cm x 8cm x 8cm.
The MRI described the fibroid as measuring 12cm x 9cm x 9cm, displacing and compressing the bladder and uterus towards the right. A probable peduncle between the fibroid and uterus was noted, measuring 4cm x 4cm. A 5mm umbilical port was used for initial entry. Two left 5mm ports were placed under direct visualisation. A right-quadrant port was also placed, along with a 10mm suprapubic port, which was later converted to a 5cm Pfannenstiel incision for fibroid removal.
Upon entry into the abdominal cavity, a large mass was visualised in the Retzius space to the left of the bladder, with no connection to the uterus. Closer inspection of the left broad ligament confirmed the Retzius space location of the mass. Posteriorly, the mass extended to the left pelvic side wall, extending close to the ureter. The bladder was filled with CO2 to assess the proximity to the mass. Anatomic landmarks were identified along the anterior abdominal wall, including the left round ligament, left inferior epigastric vessels, left obliterated umbilical ligament.
Steps of the Laparoscopic Procedure
Right obliterated umbilical ligament, and median umbilical fold, or urachus. We entered the Retzius space medial to the left umbilical artery, and dissected down to the mass until the fibroid capsule was visualised. Before further dissection of the mass, we worked at securing its blood supply. Lateral to the left ureter, we began dissecting into the left pararectal space. We suspended the ovary to optimise exposure. Tugging on the obliterated umbilical ligament pointed out the location of the internal iliac artery.
From here we were able to identify key anatomical structures including the IP ligament, external iliac artery, internal iliac artery, and ureter. We continued dissecting on the medial aspect of the internal iliac artery, to find the origin of the uterine artery. The obturator nerve was seen lateral to the internal iliac. Once again, tugging of the obliterated umbilical ligament confirmed the location of the internal iliac artery.
We placed two endoclips on the internal iliac artery, proximal to the origin of the uterine artery, with the aim of occluding all potential blood supply to the fibroid, including the superior vesical artery. Once this was secured we continued with the myomectomy, using a combination of blunt and ultrasonic dissection. As the dissection progressed deeper into the retropubic space, we identified Cooper’s ligament and the origin of the inferior epigastric artery from the external iliac. The venous plexus of Santorini was coagulated meticulously.
We then reached the pubic symphysis. Once the majority of the fibroid was detached, we made a 5cm transverse suprapubic incision, placed a small-sized Alexis retractor, detached, and removed, the fibroid. We applied a haemostatic matrix on small venous bleeding, for excellent haemostasis. Once the fibroid was removed, we checked major retroperitoneal vessels to ensure haemostasis. We tugged on the obliterated umbilical ligament and could see the internal iliac artery and the uterine artery.
Once haemostasis was ensured, we closed the peritoneum through the suprapubic incision. On cystoscopy, the bladder, left ureter, and urethra, were intact. The estimated blood loss was 400ccs. The patient had no post-operative complications and was discharged home on post-op day one. The final specimen pathology was leiomyoma, with a specimen weight of 556g.
The key takeaways from this presentation are that leiomyomas within the Retzius space are rare and can be safely excised using a laparoscopic approach. Bladder insufflation, along with recognition of pelvic anatomical landmarks, optimises surgical navigation. Awareness of vascular structures present within the Retzius space is instrumental for safe dissection. We hope you have found this video informative, thank you for watching.