Laparoscopic treatment of pelvic congestion syndrome

This video shows the treatment of congestive pelvic pain by laparoscopy. Three different techniques are shown according to the anatomy of the round ligament and the position of the uterus. Treatment results are not discussed and will be the object of further publications. We stress on the technical aspects and operative techniques of these surgical interventions. The diagnostic criteria and treatment options of this syndrome are still controversial.

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Laparoscopic treatment of pelvic congestion syndrome

Authors

A Wattiez, J Nassif, I Miranda-Mendoza, V Thoma, J Marescaux

Abstract

This video shows the treatment of congestive pelvic pain by laparoscopy. Three different techniques are shown according to the anatomy of the round ligament and the position of the uterus. Treatment results are not discussed and will be the object of further publications. We stress on the technical aspects and operative techniques of these surgical interventions. The diagnostic criteria and treatment options of this syndrome are still controversial.

Classification

routine cases

Keywords

laparoscopy, treatment of pelvic congestion syndrome, congestive pelvic pain

Media type

Surgical video

Duration

07'00''

Publication

2008-12

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E-publication

WeBSurg.com, Dec 2008;8(12).
URL: http://www.websurg.com/doi-vd01en2330.htm

Laparoscopic treatment of pelvic congestion syndrome

1. Simple round ligament plication 00'11''

We present in this video three techniques for the treatment of pelvic congestion syndrome. First, simple round ligament plication. We begin on the right side, on which we pass the suture through the aponeurosis lateral to the internal inguinal ring. We can see skin depression on the external view. After the aponeurosis anchoring, we perform the plication of the round ligament with a non-absorbable suture. This technique is indicated for both distal atrophy of the round ligament associated with a normal proximal part and for uterine retroversion. We pass the needle through the thickness of the round ligament to avoid ligament ischemia and subsequent tendonitis and necrosis. We tie the suture using an extracorporeal knot. We perform the same procedure on the left side; we anchor the aponeurosis, perform the plication and tie the knot extracorporeally. We infiltrate the round ligament with local anesthetics to minimize post-operative pain.

2. Retrouterine plicature of the round ligaments 02'00''

The second operative technique is the retrouterine plicature of round ligaments. Pelvic congestion can be identified through a hypervascularized peritoneum. It is indicated for proximal atrophy of the round ligament with a normal distal part and for uterine retroflexion. After inspection of the round ligament’s anatomy, we open the right broad ligament using bipolar and monopolar energy and do the same on the left side. We see the peritoneal opening from the ovarian fossa side. We then pass the needle through the left and right openings. We, then pass the suture through the right round ligament, taking care to pass inside the ligament and not below it to avoid ischemia. We pass behind the right broad ligament again, we then fix the round ligaments to the uterus. Then, the suture is passed through the left broad ligament opening too. We use a non absorbable suture, that we pass finally through the left round ligament and we use extracorporeal knotting. In order to avoid internal bowel herniation, we fix the round ligaments with an additional stitch to the uterus. As we can see the final result is good, we also inject local anesthetics to manage postoperative pain.

3. Anterior fixation of the round ligaments to the aponeurosis 04'33''

The third and final operative technique is the anterior fixation of round ligaments to the aponeurosis. We perform a skin incision 3 cm medially to the anterior superior iliac spine facing the external inguinal ring. We introduce a Kocher forceps and pull the round ligament through the abdominal wall. Surgical treatment for pelvic congestive syndrome is still controversial. We suggest that patients’ selection and good surgical techniques are important factors for treatment’s success. We pull the round ligament through the incision after having exsufflated the abdominal cavity. We place a non absorbable suture on the round ligament that we attach to the fascia. This technique is indicated for distal atrophy of the round ligament with a normal proximal part and for uterine retroversion. We think that this technique gives the strongest hold of the uterus in the anteverted position. We tie the knot from the external side. And, we perform the same procedure on the right side. We always exsufflate the abdominal cavity before we tie the knot. We finally inject local anesthetics under the fascia for postoperative pain control. As we can see the anatomical as well the functional results are good with small incisions.