Laparoscopic approach to intrapelvic nerve entrapments

Abstract

It is long known that a large portion of the lumbosacral plexus is located intra-abdominally, in the retroperitoneal space. However, most of literature descriptions of lesions on this plexus refer to its extra-abdominal parts whereas its intra-abdominal portions are often neglected. The objective of this review article is to describe the laparoscopic anatomy of intrapelvic nerve bundles, as well as the findings and advances already achieved by Neuropelveology practitioners.

Fig. 1.

Ilio-hypogastric (IHN), ilio-inguinalis (IIN) and genito-femoralis (GFN) nerves, with the overlying peritoneum intact (A) and exposed (B). PM, psoas muscle; LO, left ovary; IPL, infundibulopelvic ligament; LFA, left femoral artery.

Fig. 2.

The left femoral nerve (FN) entering the retroperitoneal space on the posterolateral aspect of the psoas muscle (PM). LC, left colon.

Fig. 3.

Nerves of the obturator space (right side). Picture (A) is the final aspect of a laparoscopic approach to Alcock’s Canal Syndrome, where the sacrospinous ligament has been transected to expose the pudendal nerve (PN). In picture B, the sacrospinous ligament (SSL) is intact. In both pictures, the internal and external iliac vessels are retracted medially. ON, obturator nerve; PM, psoas muscle; SN, sciatic nerve; LST, lumbosacral trunk; PN, pudendal nerve; IRF, ischiorectal fossa; IS, ischial spine; SB, sacral bone; PFM, pyriformis muscle.

Fig. 4.

The hypogastric nerve (HN) emerges from the superior hypogastric plexus (SHP) at the level of the sacral promontory (SP) and runs anteriorly and distally, juxta-laterally to the hypogastric fascia (HF), to merge with the pelvic splanchnic nerves to form the inferior hypogastric plexus (IHP).

Fig. 5.

The sacral nerve roots (S2–S4) can be found juxta-laterally to the hypogastric fascia (HGF) and give origin to the pelvic splanchnic nerves (PSN), which run anteriorly and distally to merge the hypogastric nerve and form the inferior hypogastric plexus (IHP).

Fig. 6.

Endometriosis (EDT) involving nerve Roots S2 and S3 and the sciatic nerve (SN). Further dissection (B) revealed an endometriotic cyst (EDT) in S3.

Fig. 7.

(A) Dense fibrotic tissue (FT) entrapping the left sciatic nerve (SN) against the pyriformis muscle. (B) final aspect after neurolysis. IM, iliac muscle; IS, ischial spine).

Fig. 8.

(A) Abnormal varicose vein (AV) entrapping S2 and S3 nerve roots against the pyriformis muscle (PM).

Fig. 9.

S2 and S3 nerve roots entrapped in between the pyriformis muscle (PM) fibers.

Fig. 10.

LION electrode placed on right sciatic and pudendal nerves. PM, psoas muscle; IS, ischial spine; SN, sciatic nerve; SSL, sacrospinous ligament.