Laparoscopic Anatomy of the Pelvic Floor

Preface
	Why This Atlas?
	The Diagnosis of Pelvic Floor Defects Is Clinical
	Always a Place for Vaginal Access to Do Reconstructive Pelvic Surgery
	Now, a Great Place for Laparoscopy Using Meshes
	Which Laparoscopic Technique?
	This Atlas? A Hymn to Laparoscopy and Laparoscopists
Acknowledgements
Contents
Part I: Traditional Anatomy of the Pelvic Floor
	1: Introduction
		1.1	 Muscles, Fascias and Ligaments (Fig. 1.1)
	2: The Muscles
		2.1	 Two Categories of Pelvic Muscles Are Individualized (Fig. 2.1)
		2.2	 Lateral Muscles
		2.3	 Pelvic Floor Muscles
			2.3.1	 Obturator Internus Muscle
			2.3.2	 Levator Ani (L.A.)
			2.3.3	 L.A. Iliococcygeus
			2.3.4	 Coccygeus Muscle
			2.3.5	 Piriformis
		2.4	 The Superior View of the Pelvic Floor Muscles (Fig. 2.2a)
		2.5	 The Lateral View of the Pelvic Floor Muscles (Fig. 2.2b)
	3: The Fascias
		3.1	 Endopelvic Fascia (Figs. 3.1 and 3.2)
		3.2	 Visceral Fascia (Fig. 3.3)
	4: The Ligaments
		4.1	 The Pelvic Ligaments Seen by Laparoscopy
			4.1.1	 Round Ligament (Fig. 4.1)
			4.1.2	 Uterosacral Ligament (Fig. 4.2)
			4.1.3	 The Anatomical Landmarks of the Two Uterosacral Ligaments (Fig. 4.3)
		4.2	 Visceral Ligaments
			4.2.1	 The Visceral Ligaments for Pelvis Support (Fig. 4.4)
			4.2.2	 Ventro-Dorsal Axis (Also Called ‘Lame sacro-recto-génito-pubienne’ Described by Farabeuf)
			4.2.3	 Medio-Lateral Axis
	5: The Attachment Sites for the Surgeon
		5.1	 The Landmarks of the Pelvic Floor for the Surgeon (Figs. 5.1 and 5.2)
		5.2	 The Four Risks of the Attachment Site Risks
		5.3	 The Risks of the Promontory for the Surgeon (Fig. 5.4)
		5.4	 The Presacral Anatomy Below the Promontory (Fig. 5.5)
Part II: Laparoscopic Normal Anatomy of the Pelvic Floor Seen By Transperitoneal Vision
	6: Ventrolateral Abdominal Wall
		6.1	 Umbilical Artery (Fig. 6.1)
		6.2	 Inferior Epigastric Artery
		6.3	 Paravesical Fossa
	7: Lateral Anatomy
		7.1	 The Ureter (Fig. 7.1)
		7.2	 Laparoscopic Identification (Fig. 7.2)
	8: Landmarks of the Ureter
		8.1	 Ureter in the Promontory Area (Figs. 8.1 and 8.2)
		8.2	 Lateral Anatomy Below the Adnexa (Fig. 8.3)
		8.3	 The Ureter Below the Adnexa (Fig. 8.4)
	9: Dorsal and Lateral Anatomy of the Pelvis
		9.1	 Two Hypogastric Nerves, Right and Left (Figs. 9.1 and 9.2)
		9.2	 The Inferior Hypogastric Plexus (Fig. 9.3)
	10: Promontory Area
		10.1	 The Cranial Area (Fig. 10.1)
		10.2	 Middle Sacral Artery (Fig. 10.2)
		10.3	 Sigmoid Colon (Fig. 10.3)
		10.4	 Left Common Iliac Vein (Fig. 10.4)
		10.5	 The Vision in Female Cadaver (Fig. 10.5)
Part III: Laparoscopic Normal Retroperitoneal Anatomy of the Pelvic Floor Seen After Peritoneal Incision
	11: Prevesical Space, Cooper’s Ligament, Paravesical Space, Arcus Tendineus Fascia Pelvis
		11.1	 The Prevesical Space
			11.1.1	 Access to the Prevesical Space, After Filling the Bladder (Fig. 11.1)
			11.1.2	 Dissection of the Retzius Space in Avascular Loose Tissue (Fig. 11.2)
			11.1.3	 The ‘Champagne’ Bubbles (Fig. 11.3)
			11.1.4	 Progressive Dissection of the Prevesical Space (Fig. 11.4)
			11.1.5	 Focus on Cooper’s Ligament, Technique of Exposition, Left Side (Fig. 11.5)
			11.1.6	 Focus on Cooper’s Ligament, Technique of Suture, Left Side (Fig. 11.6)
		11.2	 The Prevesical Space (Continued)
			11.2.1	 Bladder (Fig. 11.7)
			11.2.2	 Complete Dissection of the Prevesical Space (Fig. 11.8)
			11.2.3	 Panoramic View of Dissection Between the Umbilico-Vesical Fascia and Bladder (Fig. 11.9)
		11.3	 The Paravesical Space
			11.3.1	 Focus on ATFP, Between Pubis and Ischial Spine (Right Side) (Fig. 11.10)
			11.3.2	 Focus on Obturator Pedicle, Between Pubis and Ischial Spine, at the Entry in the Obturator Canal, Left Side (Fig. 11.11)
			11.3.3	 Focus on Obturator Pedicle (Figs. 11.12, Right Side, and 11.13, Left Side)
			11.3.4	 Focus on Corona Mortis Artery (Fig. 11.14)
			11.3.5	 Relationship Between the Obturator Nerve and the Corona Mortis Artery (Fig. 11.15)
		11.4	 The Panoramic View of the Pre- and Paravesical Space
			11.4.1	 Prevesical Space (Fig. 11.16)
	12: The Vesicovaginal Space
		12.1	 Limits (Fig. 12.1)
		12.2	 Access to the Vesicovaginal Space (Fig. 12.2)
		12.3	 The Loose Connective Tissue (Fig. 12.3)
		12.4	 Section of the Bladder Pillars (Fig. 12.4)
		12.5	 The Cleavage Line (Fig. 12.5)
		12.6	 The Panoramic Vision (Fig. 12.6)
		12.7	 Vesicovaginal Space (Continued)
			12.7.1	 Bladder Pillars (Fig. 12.7)
			12.7.2	 Lateral to the Vesicovaginal Space (Figs. 12.8 and 12.9)
		12.8	 Deep Vesico-Cervico-Vaginal Dissection
			12.8.1	 Lateral to the Vesicovaginal Space (Fig. 12.10)
			12.8.2	 Visualization During Hysterectomy (Fig. 12.11)
			12.8.3	 Visualization with Magnification (Fig. 12.12)
	13: The Dorsolateral Dissection of the Uterine Artery
		13.1	 The Dorsal Approach to Preventive Occlusion (Fig. 13.1)
		13.2	 The Technique of Dorsal Approach of the Uterine Artery for Preventive Occlusion (Fig. 13.2)
		13.3	 Visualization of the Uterine Artery and of the Ureter (Fig. 13.3)
		13.4	 The Titanium Clip (Fig. 13.4)
	14: The Rectovaginal Septum
		14.1	 The Limits (Fig. 14.1)
		14.2	 Vaginal Venous Plexuses (Fig. 14.2)
	15: The Pararectal Space
		15.1	 Laparoscopic Access (Fig. 15.1)
		15.2	 The Middle Rectal Artery (Fig. 15.2)
		15.3	 Deep Dissection (Fig. 15.3)
		15.4	 Lateral Rectal Dissection in Cadaver (Fig. 15.4)
		15.5	 Situation of the Medial Pararectal Space of Okabayashi
		15.6	 Situation of Lateral Pararectal Space of Latzko
		15.7	 Pelvic Lymphadenectomy: The Main Benchmarks (Fig. 15.5)
		15.8	 The Pudendal Nerve, Laparoscopic Approach
			15.8.1	 Definition
		15.9	 Laparoscopic Dissection of the Right Pudendal Nerve
			15.9.1	 The View of the Pudendal Nerve by Laparoscopy
			15.9.2	 View of the Ischial Spine Area (Fig. 15.6)
			15.9.3	 Visualization of the Sacrospinous Ligament (Fig. 15.7)
			15.9.4	 Pudendal Nerve Release (Fig. 15.8)
			15.9.5	 The Pudendal Nerve Dissected Appears White (Fig. 15.9)
		15.10	 Laparoscopic Dissection of the Left Pudendal Nerve (Continued)
			15.10.1	 Dissection of the Pudendal Nerve (Fig. 15.10)
			15.10.2	 Progressive Vision of the Pudendal Nerve (Figs. 15.11 and 15.12)
Part IV: Laparoscopic Anatomy of the Pelvic Floor in Case of Genital Prolapse Seen By Clinical Examination and Transperitoneal Vision
	16: Cystocele
		16.1	 Definition (Fig. 16.1)
		16.2	 External Aspect of Exteriorized Lateral Cystocele, Associated with Procidentia (Uterine Descent) (Fig. 16.2)
		16.3	 External Aspect of Large Cystocele (Fig. 16.3)
		16.4	 Complete Prolapse (Fig. 16.4)
		16.5	 Correlation in Laparoscopy of Pelvic Floor Defects
			16.5.1	 Laparoscopic Aspect of Lateral Cystocele (Fig. 16.5)
			16.5.2	 Laparoscopic Aspect of Central and Lateral Cystocele (Fig. 16.6)
			16.5.3	 Laparoscopic Aspect of Cystocele and Procidentia (Fig. 16.7)
			16.5.4	 Laparoscopic Aspect of Exteriorized Cystocele After Total Hysterectomy (Fig. 16.8)
	17: External Aspects of Exteriorized Apical Prolapse and Rectocele
		17.1	 Trachelocele (Figs. 17.1 and 17.2)
		17.2	 Rectocele
		17.3	 Clinical Evaluation of the Posterior Pelvic Floor Defects (Fig. 17.3)
		17.4	 Usual Clinical Aspect of the Rectocele Associated with a Cystocele (Fig. 17.4)
		17.5	 Laparoscopic Aspect of Large Rectocele (Fig. 17.5)
		17.6	 Usual Laparoscopic Aspect of Rectocele (Fig. 17.6)
	18: External Aspects of Vaginal Vault Prolapse
		18.1	 Vaginal Vault Prolapse After Hysterectomy (Patient 1) (Fig. 18.1)
		18.2	 Evident Association with  Cystocele (Patient 2) (Fig. 18.2)
		18.3	 Same Patient (Patient 2) (Fig. 18.3)
		18.4	 Laparoscopic View, the Same Patient (Patient 2) (Fig. 18.4)
		18.5	 Exteriorized Vaginal Vault Prolapse (Patient 3) (Fig. 18.5)
		18.6	 Laparoscopic Aspect of Vaginal Vault Prolapse (Patient 3) (Fig. 18.6)
	19: External Aspects of Enterocele
		19.1	 Definition
		19.2	 Clinical Diagnosis Often Evident (Fig. 19.1)
		19.3	 Laparoscopic Aspect of Enterocele (Fig. 19.2)
		19.4	 Laparoscopic Exposition for Dissection (Same Patient) (Fig. 19.3)
Part V: Laparoscopic Anatomy of the Pelvic Floor in Women with a Genital Prolapse Seen After Peritoneal Incision
	20: Laparoscopic Aspects of Urethro-Cystocele
		20.1	 Stress Urinary Incontinence: Colposuspension or Burch Procedure (Fig. 20.1)
		20.2	 Laparoscopic Aspect of Lateral Cystocele Secondary to Paravaginal Defects (Fig. 20.2)
		20.3	 Paravaginal Repair: Passing Sutures Through the Vagina (Fig. 20.3)
		20.4	 Post-hysterectomy Paravaginal Repair (Fig. 20.4)
		20.5	 Paravaginal Repair (Right Side) (Fig. 20.5)
	21: Laparoscopic Aspects of Prolapses of Anterior, Median and Posterior Compartments
		21.1	 Lateral Detachment (Fig. 21.1)
		21.2	 Hernia (Fig. 21.2)
		21.3	 Another Aspect of Injuries of Levator Ani Muscle (Fig. 21.3)
		21.4	 Laparoscopic Aspect of Severe Paravaginal Defects (Fig. 21.4)
		21.5	 Rectocele and Corresponding Treatment (Fig. 21.5)
Part VI: Laparoscopic Lateral Suspension with Meshes to Treat Genital Prolapse (LLS)
	22: Techniques of Laparoscopic Lateral Suspension with Uterus Preservation
		22.1	 Dissection of the Vesicovaginal Space
			22.1.1	 Vesicovaginal Cleavage (Figs. 22.1, 22.2 and 22.3)
			22.1.2	 Final Dissection of the Vesicovaginal Space (Figs. 22.4 and 22.5)
			22.1.3	 Lateral Cleavage (Fig. 22.6)
		22.2	 The Choice of the Mesh
			22.2.1	 How to Choose a Mesh with Ideal Qualities?
			22.2.2	 The Shape of the Mesh (Fig. 22.7)
			22.2.3	 Mesh Preparation (Fig. 22.8)
		22.3	 Pelvic Positioning of the Mesh
			22.3.1	 Placement of the Median Strip of the Mesh (Fig. 22.9)
		22.4	 Pelvic Positioning of the Mesh (Continued)
			22.4.1	 Fixation of the Mesh to the Endopelvic Fascia and the Uterine Isthmus (Figs. 22.10, 22.11, 22.12, 22.13, 22.14 and 22.15)
		22.5	 Suspension by the Two Arms of the Mesh: Stretched Laterally
			22.5.1	 The Lateral Suspension (Figs. 22.16 and 22.17)
			22.5.2	 The Way of the Forceps (Figs. 22.18 and 22.19)
			22.5.3	 The Change of Direction (Fig. 22.20)
			22.5.4	 The Grasping of the Mesh on Both Sides (Figs. 22.21, 22.22, 22.23 and 22.24)
	23: Final Evaluation of the Correct Technique of Laparoscopic Lateral Suspension
		23.1	 The Final Evaluation
			23.1.1	 A Precise and Symmetrical Application (Fig. 23.1)
			23.1.2	 Positioning
			23.1.3	 End of Procedure (Fig. 23.2)
		23.2	 The Correct Technique of LLS
			23.2.1	 This Figure Precisely Shows the Direction of the Mesh (Fig. 23.3)
			23.2.2	 This Figure Shows the Final Good Technique (Fig. 23.4)
	24: Optional Treatment of the Posterior Compartment and Techniques of Laparoscopic Lateral Suspension for Vaginal Vault Prolapse
		24.1	 Treatment of the Posterior Compartment
			24.1.1	 Evaluation of the Posterior Compartment
			24.1.2	 Treatments of the Posterior Compartment
		24.2	 The Technique of LLS for Vaginal Vault Prolapse
			24.2.1	 Cross-Shaped Mesh (Fig. 24.3) and Vaginal Vault Prolapse Suspension (Figs. 24.4 and 24.5)
	25: Lateral Suspension: Focus on
		25.1	 LLS with Mesh, a Recent Technique
		25.2	 Literature Review and Discussion
		References
Part VII: Laparoscopic Sacrocolpopexy to Treat Genital Prolapse (SCP)
	26: Techniques of Laparoscopic Sacrocolpopexy (SCP) to Treat Genital Prolapse, With or Without Preservation of the Uterus
		26.1	 Exposition of the Promontory, Anterior Cul-de-sac and Cul-de-sac of Douglas (Fig. 26.2)
		26.2	 Dissection of the Presacral Space (Fig. 26.3)
		26.3	 Dissection of the Vesicovaginal Space
		26.4	 SCP: Posterior Compartment Correction (Figs. 26.4, 26.5 and 26.6)
		26.5	 SCP: Fixations of the Mesh (Figs. 26.7, 26.8 and 26.9)
		26.6	 Peritonization of the Mesh (Fig. 26.10)
	27: Sacrocolpopexy: Focus on
		References
Anatomical References