somatic and autonomous nerves (1). The aim of this special interest for exposure of these nerves was to reduce the

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1 The laparoscopic neurolysis of the sacral plexus and the sciatic nerve for extensive endometriosis of the pelvic wall Univ.-Prof. Prof. Dr. med. Marc Possover, MD, PhD 5 Introduction Over the last 6 years, during laparoscopic radical pelvic surgery for cervical cancer or for deep infiltrating endometriosis of the retroperitoneum, we systematically paid particular attention for exposure of all the pelvic 10 somatic and autonomous nerves (1). The aim of this special interest for exposure of these nerves was to reduce the risks of postoperative bladder and rectum dysfunctions and of functional troubles with the lower limb (2): During radical dissection of the pelvic wall, laparoscopic exposure of the sacral plexus as well as the sciatic nerves and its endopelvic branches becam systematic (3). In the present short serie, we reporte our first experience in patient with deep infiltrating endometriosis of the pelvic wall where not just laparoscopic exposure of the sacral roots and/or the 15 sciatic nerve in normal anatomic conditions have to be performed, but where technique of laparoscopic neurolysis was mandatory for complete removal of the endometriosis by sparing the pelvic somatic nerves. Technique For dissection of an infiltrating endometriosis of the pelvic wall, the principe of the procedure is the 20 systematic primary exposure the pelvic vessels and nerves bevor resection en bloc of the infiltrated area. In situation of infiltration of the pelvic wall dorsal to the level of the cardinal ligament the level of the sacral pelxus -, primary exposure of the sacral roots directly at their emergence outof the sacral foraminae is done lateraly to the sacral hypogastric fascia. The most important sacral roots for preservation of bladder and rectum voiding and continence functions are respectively S3 and S2. Confirmation of the correct exposure of the both sacral 25 roots is gained by using the LANN-technique (4): Stimulation of S3 nerves is confirm visually by a deepening and flattening of the buttock groove as well as a plantar flexion of the large toe and to a lesser extent of the smaller toes while stimulation of S2 produces an outward rotation of the leg and plantar flexion of the foots as well as a clamp- 1

2 like squeeze of the anal sphincter from anterior/posterior. By following S3 ventrally, the vesical and rectal splanchnic nerves are exposed and their differents anatomical patways into the pararectal space from the pelvic wall 30 to the inferior hypogastric plexus can be exposed (figure 1). Differentation between vesical and rectal fibers is also assessed intraoperatively by using the LANN-technique (5). For exposure of the sacral plexus ventraly to the level of the cardinal ligament, the laparoscopic approach throught the lumbosacral space is choiced. This space is opened laterally to the external iliac vessels and exposure of the obturatoric nerve as well as the lumbosacral trunk is systematically done in the deepness of this space. By 35 following the lumbosacral trunk distaly, the superior gluteal nerves could be exposed in the suprapyriform part of the sciatic foramen as well as the upper border of the sciatic nerve himself. Removal of the pelvic lymph nodes is not required since they can be detached with the surrounding fatt-tissue from the pelvic wall and retracted medially. Elective dissection of the differents vascular branches of the internal iliac vessels and proximal transection of the obturatoric vessels permit a well exposure of the distal part of the sacral plexus, the sciatic nerves and its endopelvic 40 distal branches and make the further dissection of the endometriosis safe; Special attention for avoiding lesion of the inferior gluteal vessels as well as the pudendal vein have to be paid. The dissection of the retroperitoneal endometriosis is than started so that in situation of bleeding, elective hemostasis by using bipolare coagulation could be done under respect the surrounding nerves. 45 Experience We reporte our experience in 21 consecutive patients collected over the last six years who underwent this procedure allone or in combination with further procedures. This operative data are collected in table 1. In fourteen patients who were send us for deep infiltrating endometriosis of the rectovaginal space, the patients reported in preoperative anamnesis the classical pelvic pain but more: 50 - in eight patients, troubles of the voiding of the bladder: the patients reported frequent need of abdominal press for voiding empty their bladder specially during the mens bleeding - in nine patients chronic dysaesthesien in the metamer of the sciatic nerve but without any motoric troubles of the lower limb, - in five further patients, a quite permanent unilateral distal sciatalgy with increasing of the pain and 55 sensation of less strongness for flexion of the toes during the mens bleeding. During vaginal examination, infiltration of the rectovaginal space with unilateral bulky attachment to the laterodorsal pelvic wall was found, in eleven patients on the right side and the last patient on the left side. Laparoscopic 2

3 examination of the pelvis shows in all fourteen patients a massive infiltration of the entire pararectal space, with strong attachement to the pelvic wall dorsaly to the level of the cardinal ligament and to the pelvic floor. The 60 dissection of the pararectal space was started very high at the level of the promontorium in order to found first an anatomical plane safe of endometriosis; after opening the sacral hypogastric fascia, we found in this patients a further infiltration surrounding the sacral roots by transfixion of the sacral hypogastric fascia. In no any patient, bilateral infiltration of the sacral plexus was observed. However, in all this patients, proximal portion of the sacral roots at the level of the sacral bone was free of endometriosis, so that dissection and exposure of the sacral roots could be started 65 systematically at this level. Complete removal of the endometriotic lesion required systematic and complete dissection of S1, S2 and S3, while S4/5 was never surrounded by endometriosis. Removal of the endometriosis from the sacral root itself never presents major difficulties since the endometriosis nerver infiltrates the epineurium of the roots. While the uterine vessels could remain intact in all fourteen patients, transection of the homolateral medial rectal vessels and a part of the homolateral parasympathetic pelvic nerves was required for mobilisation of the 70 endometriotic nodule. No intraoperative complications occured and no postoperative locomotion problems or dysfunction of the bladder/rectum were observed. Seven patients reported postoperatively dysaesthesie in the leggs on the side of the sacral dissection, which disappeared over the two-three months following the procedure. At the time of the manuscript, no any patient reported persistence or reapparition of the sciatalgies or recurrence of endometriosis in the rectovaginal space. 75 Seven further patients underwent a laparoscopy for the diagnosis and therapy of chronic pelvic pain by suspicious of endometriosis. All seven patients preoperatively reported homolateral chronic distal sciatalgies while two patients described some motoric difficulties with the homolateral plantar flexion/extension. Two patients described pelvic pain with perineal irradiation with exacerbation of the pain during seated position while three further patients reported dysaesthesie or hyperalgies in the gluteal region and the dorsal part of the Oberschenkel. 80 Intraoperatively massive infiltration of the rectovaginal space with lateral extension to the obturatoric space was found in four patients while in three patients a isolated and fixed endometriotic lesion to the peritoneum of the ovarian fossa without lesion of the rectovaginal space was found. Laparoscopic retroperitoneal dissection showed a fixed and diffuse infiltration of the entire obturatoric space in all seven patients. Complete dissection of the somatetic nerve wass done as described previously but in two of this patients, further dissection of the homolateral pudendal 85 nerve downwards over about two centimeters deep in the ischiorectal space was required. In six patients, endometriosis could completely removed while in one patient extended endometriosis infiltrated the sciatic foramen surrounding the sciatic nerve itself and ist branches. In this patient only the endopelvic part of the sciatic nerve and 3

4 ist branches could be freed while the further dissection in the gluteal region throught the sciatic foramen was expected to be too dangerous. All seven patients reported postoperativaly loss of pain and during the postoperative 90 neurologic examination no problems in standing up or walking could be observed. Four of this patients reported postoperatively that they had undergone previously extensive diagnosis for sciatalgie by orthopedic and/or neurosurgeons: the final evocated diagnosis was idiopathic sciatalgies. In this seven patients too, we observed that the lesions always surrounded the somatic nerves but never distroyed them or infiltrated their epineureum. This made the dissection of the lesions easier as no sharp dissection was required and just blunt dissection with traction on the 95 lesion permitted separation from the somatic nerves. We also observed that when the endometriosis more frequently infiltrated the left retroperitoneal space and the left ureter, the involvement of the nerves seem to be more frequent on the right side (six on the right side vs one on the left side). Discussion 100 From the clinical point of view, the endometriotic infiltration of the sacral plexus dorsally and ventraly to the cardinal ligament have to be diffenciated. By the proximal infiltration of the sacral roots in the pararectal space, infiltration could associated lesion of one or several sacral roots and of the pelvic splanchnic nerves which explain clinical combination of sciatalgies and dysfuntion of the bladder voiding. In situation of infiltration of the distal part of the plexus or of the sciatic nerve himself, infiltration of the inferiror gluteal nerve and consequently the posterior 105 cutaneus nerve but also of the pudendal nerve could be anatomically possible since this differents nerves are very close. While the endometrioisis is abble to infiltrated and distroyed sympathetic pelvic nerves (6), it seem to be not abble to distroyed so easely the somatetic nerves. Even when in our presented sreie the sacral roots were involved, the sacral hypoagstric fascia seem to be a very long time a anatomical barriere for the infiltration of the pelvic wall in the same matter that the Denonvillier fascia is a very long time an anatomical barriere for rectum infiltration. Thus 110 the challange of the routine examination in young patient with pelvic pain is to detected as earlier as possible before the fascia as anatomical barriere are not abble to stope the infiltration any more. Since patients with distal sciatalgies are commonly send to orthopedist, neurologist or neurosurgeons, it is of importance that our collegues know that in young patients with unexplained unilateral sciatalgie or Alcock-canal-syndrom (7,8), endometriosis respectively of the sciatic nerve or of the pudendal nerve has to be evocated as a potential etiology and the indication for 115 laparoscopy has to be discussed. However it is evident that for such a laparoscopic approach of the pelvic nerves, an absolute knowledge of the pelvic vacsular- and neuro-anatomy as well as high surgical skills in the laparoscoic field is mandatory as the high risk of intraoperative bleeding due to the presence of the different vessels of the vascular 4

5 portion of the cardinal ligament is very real. In our short series we have shown that this laparoscopic appoach could not plays only a diagnostic role in patients with unexplained sciatalgies but also offers a therapeutical option 120 since laparoscopy allows micro-neurosurgical dissection of all the pelvic autonomous and somatic nerves. Laparoscopic pelvic neurosurgery for deep infiltrating endometriosis could becom a further surgical field for the neurosurgeons or for the gynecologists and could be a further indications- and therapeutical fields of a the new discipline which we have called, the laparoscopic neuro-functional pelvic surgery. 125 References 1. Possover M, Stöber S, Plaul K, Schneider A. Identification and preservation of the motoric innervation of the bladder in radical hysterctomy type III or IV. Gyneco Onco 79, 2000, Possover M, Quakernack J, Chiantera V The LANN-technique for reduction the postoperative functional mobidity in laparoscopic radical pelvic surgery. In press in JAmCollSurg. 3. Possover M. Laparoscopic exposure and electrostimulation of the somatic and autonomous pelvic nerves: a new method for implantation of neuroprothesis in paralysed patients? Journal Gynecological Surgery Endoscopy, Imaging, and Allied Techniques 2004; 1: Possover M, Rhiem K., Chiantera V. The Laparoscopic Neuro-Navigation - LANN: from a functionnal cartography of the pelvic autonomous neurosystem to a new field of laparoscopic surgery. Min Invas Ther & Allied Technol 2004; 13: Possover M, Quakernach J, Flasskamp, Chiantera V. Electro-functional and anatomic study of the vesical and rectal splanchnic nerves in patients undergoing laparoscopic radical pelvic surgery. In press Possover M. The neurologic hypothesis, a new concept in the pathogenesis of the endometriosis? Amarenco G, Savatosky I, Budet C, Perrigot M. Nevralgies perineales et syndrome du canal c Alcock. Ann. Urol 1989; 6: Possover M, Quakernach J, Chiantera V. The laparoscopic neurolysis of the pudendal nerve for the therapy of the Alcock s Canal Syndrome after sacrospinous fixation for vaginal prolaps. In press in AmJ Obstet Gynecol 145 5