Anatomy: How to Locate Vital Structures in Pelvis
The key to successfully operating in a difficult case is the ability to locate all the vital structures correctly and confidently. And for this one must know how to locate vital structures in a normal situation, that is, a case where there is no distortion of anatomy. The large and small intestines are fairly easy to differentiate; the presence of teniae coli indicates that the structure is the large intestine. The ureter can be seen transperitoneally on the either side the pouch of Douglas—provided the pouch of Douglas is free of adhesions, pus, or endometriosis. To locate the ureter, one must first divide the round ligament and separate the loose areolar tissue. One can find it running medially along the fold of the broad ligament after crossing the bifurcation of the common iliac artery. The bladder can be located by palpating the bulb of the Foley catheter.
Use of sharp dissection—avoid peeling, plucking out, or shelling out anything
Avoid indiscriminate use of cautery, especially when close to vital structures
Avoid taking deep stitches or applying clamps blindly
Do not force open a space, the bottom of which cannot be seen; should a vessel get torn, it will be very difficult to control the bleeding
Extend the incision to facilitate better exposure
The correct placement of ports is important in laparoscopic surgery, more port(s) must be inserted if necessary
The use of correct instruments; one should never hesitate to ask for another retractor or call for an extra assistant if required
Operative injuries are sometimes inevitable, but every time there is an injury, it should be a time to reflect, analyze, and introspect. It is always better to detect the injury on the operating table and perform the appropriate repair than discover it a few days later. Bowel perforation, stricture of the bowel, ureteric injuries, and urinary fistulae are always associated with severe morbidity, need for another surgery/intervention, and high treatment costs.
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