CHAPTER 38

Presacral Neurectomy

Pain fibers are transmitted from the uterus via the hypogastric plexus. The hypogastric plexus of nerves cascades downward as a continuation of the celiac plexus on the anterior aspect of the distal portion of the abdominal aorta (Fig. 38–1). The hypogastric plexus is variable in configuration but can be rather loosely separated into superior, middle, and inferior divisions. The middle hypogastric plexus typically divides into two main nerve trunks coursing inferiorly within the presacral space. The nerves are always medial to the common iliac arteries but cross over (anteriorly) the left common iliac vein (Fig. 38–2). The middle sacral vessels are located posterior (deep) to these nerves. The inferior hypogastric plexus continues to descend into the lower pelvis and joins with the pelvic plexus, receiving rectal, vesical, and uterine afferents and carrying sympathetic efferents.

The middle hypogastric plexus is accessed by reflecting the sigmoid to the left and anteriorly (Fig. 38–3). The peritoneum overlying the sacrum is grasped and incised vertically toward the sacral promontory (Fig. 38–4). Care is taken to identify the left common iliac vein, the left ureter, and the inferior mesenteric artery (and vein) (Fig. 38–5A, B).

The hypogastric nerves are dissected with a long tonsil clamp or right-angle clamp, with care taken to avoid injuring the middle sacral vessels (Fig. 38–6). A 3- to 4-cm segment of nerve is isolated. At the upper and lower extremes of the dissection, a permanent ligature is passed beneath the dissected hypogastric nerve and is tied tightly (Fig. 38–7

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