Spatial Mapping of Pelvic Anatomy Focused on vNOTES Apical Suspension Procedures

Friday, October 25, 2024

3:12 PM – 3:16 PM EDT

Location: Liberty Ballroom (Meeting Level 4)

Pelvic Anatomy Relative to the Inner Retractor's Ring

Distance of the Retractor's Inner Ring from the Left Ischial Spine

Objectives: Familiarity with the anatomy of pelvic structures and their proximity to one another is critical through any surgical route. The description and location of pelvic structures relevant to urogynecologic procedures, to be performed through the vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) route, have yet to be described. The aim of this study was to describe the relationship of the inner ring of the vNOTES retractor, which is placed within the pelvis, to the adjacent anatomic landmarks with a focus on apical suspension procedures, including uterosacral ligament suspension (USLS) and Sacrocolpopexy (SCP).

Methods: Dissections were performed on 10 embalmed female cadavers treated with GreenMBalm to preserve tissue integrity for dissection while maintaining organ and vessel coloration and elasticity. A medium-sized vNOTES ring measuring 9.5 cm was used. Distances from the retractor’s inner ring to the following structures were measured: the ischial spine in sagittal and transverse planes (relevant during USLS suture placement due to restricted tactile feedback); urethra and trigone (relevant to assure ureteral patency in proximity of the trigone is not affected by the inner ring intra-operatively); the S1 root (relevant during SCP dissection for anterior longitudinal ligament exposure and vascular safety), pubic crest, and iliac vessels.

Results: Measurements indicated that the mean distance from the inner ring to the ischial spine on either side was 1.4 cm (range 0.85-1.25, SD 0.13) in sagittal and 3.62 cm (range 2.95-4.9, SD 0.64) in transverse planes, respectively. From the ring's midpoint, the S1 foramen lay at a mean of 6.41 cm (range 4.95-7.95, SD 1.04).

Similarly, the distance in the sagittal plane from the proximal urethra was 2.55 cm (range 1.7-3.5, SD 0.95), and the trigone at 1.90 cm (range 1.35-3.45, SD 0.72). Whereas the edge of the ring to the external iliac vessels was 3.22 cm (range 2.05-4.05, SD 0.69) away, it was located at a mean distance of 2.7 cm (range 1.55-3.25, SD 0.54) from the pubic crest.

Conclusions: The spatial metrics provided in this study demonstrate an adequate safety margin for essential pelvic structures and help guide surgeons during vNOTES apical suspension procedures. Knowing the wide safety margin to landmarks such as greater vessels, promontory, and pelvic brim as it relates to the working space of laparoscopic instruments can enhance understanding and familiarity for surgeons performing those procedures.

Disclosure(s):

Veronica Lerner, MD: No relevant disclosure to display

Dani Zoorob, MD MHA MBA MHI: No relevant disclosure to display

Mathew Root, MD: No financial relationships to disclose

Michael Andrew Mahoney, MD, II: No financial relationships to disclose

Christopher Menefee, MD: No financial relationships to disclose

Adegbenro OJ Fakoya, MD, MSC, MBA, PHD: No financial relationships to disclose

Hosne Ara, MD, PhD: No financial relationships to disclose

Kristy Waltman, MD: No financial relationships to disclose

Presenting Author(s)

Veronica Lerner, MD (she/her/hers)

Director of Simulation
Northwell Health/Lenox Hill Hospital
New York, New York, United States

Disclosure(s): No relevant disclosure to display

Co-Author(s)

Dani Zoorob, MD MHA MBA MHI

Chairman, Division Director
LSU Health Sciences Center in Shreveport
Shreveport, Louisiana, United States

Disclosure(s): No relevant disclosure to display

Co-Author(s)

MR

Mathew Root, MD

Resident
LSU Health Sciences Center in Shreveport
Shreveport, Louisiana, United States

Disclosure(s): No financial relationships to disclose
MM

Michael Andrew Mahoney, II, MD

Resident Physician
LSU Health Sciences Center in Shreveport
Shreveport, Louisiana, United States

Disclosure(s): No financial relationships to disclose
CM

Christopher Menefee, MD

Resident Physician
LSU Health- Shreveport
Shreveport, Louisiana, United States

Disclosure(s): No financial relationships to disclose
AF

Adegbenro OJ Fakoya, MD, MSC, MBA, PHD

Professor
LSU HEALTH SCIENCES CENTER SHREVEPORT
Shreveport, Louisiana, United States

Disclosure(s): No financial relationships to disclose
HA

Hosne Ara, MD, PhD

Instructor of Anatomy
LSU health Shreveport
Shreveport, Louisiana, United States

Disclosure(s): No financial relationships to disclose
KW

Kristy Waltman, MD

Vice-Chairman
LSU Health Sciences Center in Shreveport
Shreveport, Louisiana, United States

Disclosure(s): No financial relationships to disclose