Research Information System
GYNECOLOGY AND MINIMALLY INVASIVE THERAPY, vol.0, no.0, pp.1-3, 2024 (ESCI, Scopus)
Objective: To present the anatomical landmarks of a standardized and reproducible surgical approach enabling laparoscopic sciatic nerve dissection utilising the ‘’ medial’’ approach.
Design: Narrated surgical video. Local institutional review board approved the video as meeting the ethical criteria for publication. Patient consent was obtained.
Patients: The sciatic nerve can be compressed by a number of gynecological and obstetrical causes leading to sciatica, with endometriosis being the commonest gynecological aetiology [1]. Sciatic nerve dissection can be performed laparoscopically via a ‘’lateral’’ or a ‘’medial’’ approach.[2-5]. The ‘’lateral’’ approach utilises a plane of dissection lateral to external iliac vessels, whereas, in the ‘’medial’’ approach, the surgeon dissects medially to the external iliac vessels.
28 year-old patient with chronic pelvic pain radiating to the posterior aspect of her right lower limb. Pre-operative imaging did not identify any pathology accounting for her symptomatology, however, due to the severity of symptoms, an exploratory laparoscopy was decided upon.
Interventions: Laparoscopic sciatic nerve dissection utilising the ‘’medial’’ approach can be performed by following these steps: 1. Horizontal incision of the peritoneum, parallel to the gonadal vessels, in the triangle that is formed by the adnexa, the external iliac vessels and the round ligament. 2. Identification of the ureter that is kept on the medial border of the dissection plane. 3. Identification of the obturator nerve and vessels laterally. 4. Deepening the dissection caudally, in order to reach the hypogastric vein. Careful skeletonization of this vessel is necessary to avoid haemorrhage. 5. Fine dissection lateral and caudal to the hypogastric vein leads to the identification of the lumbosacral trunk and sciatic nerve.
Conclusion: The ‘’medial’’ approach described here represents a safe and standardized approach to dissect the sciatic nerve laparoscopically. We call this approach ‘’non-oncological’’, as it does not require a dissection lateral to the external iliac vessels and is, in our view, easier to perform by endoscopists with no oncological training background.