· enema on preoperative night to clean and flatten bowel
· shave abdomen and pubis
· insert IDC
· supine
· place small of back over flexion crease in table
· improve exposure wrt abdominal contents
· break table to hyperextend lumbar spine
· tilt table to place head down
Vertical
· midline incision
· distal extent
· 3 fingerbreadths above pubis
· proximal extent
· L5 – 1 fingerbreadth above umbilicus
· L4 – 3 fingerbreadths above umbilicus
· pull umbilicus to right hand side
Transverse
· another option is curved transverse ‘smile’ incision
· better cosmetic result
· involves splitting rectus abdominis
· alternately can lift skin flaps and divide linea alba vertically as for vertical incision
· open linea alba in midline
· identify and open peritoneum
· grasp with 2 blunt forceps
· open with scissors
· retract abdominal contents
· bowel loops to right
· sigmoid colon to left
· hold with moist sponges
· one each side
· one superiorly
· insert retractors
· self retainer
· malleable inferiorly
· open posterior peritoneum
· pick up and open carefully with scissors
· can first inject with saline to dissect off vessels
· lift retroperitoneal flaps
· identify structures by palpation
· sacral promontory and L5-S1 disc
· aorta and iliac vessels
· retract vessels
· start plane just to right of left common iliac artery
· sweep left common iliac vessels to left
· use peanuts to clear smaller structures
· presacral sympathetic plexus pushed to left
· sacral vessels ligated or pushed to right
· check level with x-ray
· needle in L5-S1 disc
· insert 4 Steinmann pins for retraction
Presacral plexus
· superior hypogastric nerves
· sympathetic fibres
· run in front of aorta
· carry ejaculation fibres from L2 sympathetic ganglion
· become presacral nerves between iliac vessels
· may be in one of three configurations
1. trunkal type - 2 or 3 longitudinal trunks (40%)
2. plexiform type - 3-5 trunks and numerous anastomoses (40%)
3. lamellar type – flattened network of fibres (20%)
· bifurcate to form left and right hypogastric nerves
· join inferior hypogastric plexus
Prevertebral vessels
Arteries
· enters abdominal cavity under crus of diaphragm at T12
· lies to left of vertebral bodies
· bifurcates into common iliac arteries to left of midline
· bifurcation variable
· usually at L4-5 disc
· thus left common iliac artery more vertical and more short than right common iliac artery
Veins
· common iliac veins join in front of L5 behind right common iliac artery
· IVC ascends to right of aorta
· left common iliac vein lies within aortic bifurcation