Keep Your Landmarks Close, and the Hypogastric Nerve Closer: An Approach to Nerve-sparing Endometriosis
Extensive resections for endometriosis can cause damage to the autonomic nervous system of the pelvis resulting in urinary, anorectal, and sexual dysfunction. This educational video seeks to describe the autonomic neuroanatomy of the pelvis, illustrate the predictable location of the hypogastric nerve in relation to other pelvic landmarks, and demonstrate a technique for identifying, dissecting, and ultimately sparing the hypogastric nerve and consequently, the inferior hypogastric plexus. With laparoscopic footage, we detail:
1) transperitoneal identification of the hypogastric nerve, assisted by the pulling maneuver
2) Opening of the retroperitoneum at the level of the pelvic brim and retroperitoneal identification of the ureter
3) Medial dissection and identification of the hypogastric nerve
4) Lateralization of the hypogastric nerve, allowing for safe peritoneal resection.
The hypogastric nerve follows a predictable course and can identified, dissected, and spared during pelvic surgery and is an important landmark for the preservation of pelvic autonomic innervation.