International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
Anatomy for Precision Endometriosis Surgery - Shaheen Khazali, MD
Thank you very much for inviting me to speak. I wish I could be with you in person. This is the second time that I'm missing this lovely event. I'm very grateful for the kind invitation. My name is Shahin Kali. I work in London. I have a particular interest in endometriosis. It's almost all my practice is advanced endometriosis surgery, and within that I have an interest in neurobiology. I've been asked to talk about anatomy mainly for precision in endometriosis surgery, and I have around 20 minutes to do so. So obviously I'm not going to be able to cover all the IC anatomy and I don't think you are going to need that. So I'm going to focus on two topics mainly. These are my affiliations. I'm going to cover principles of endometriosis, certainly very briefly talk about the social technique and why it is important for us to have a structured approach When we excise endometriosis, then we'll focus on neuroanatomy of the pelvis.
When it comes to fundamentals of endometriosis surgery, it really is the same as fundamentals of any surgery. No matter what field you're looking at, anatomy is the most important part of it. So the first principle is anatomy, anatomy and anatomy, but in my opinion, the second very important point is to have a structured approach, to have a step-by-step approach when it comes to surgery and in particular surgery for endometriosis. With that in mind and to avoid being someone like this, we published this paper a few years ago talking about a technique called sour, S-O-S-U-R-E, and you see that at the bottom left of the screen, S stands for survey and sigmoid mobilization. O stands for ovarian mobilization. S is the suspension of the uterus and the ovaries used for ureter, lysis and R is for entry into recor vaginal and para rectal spaces. And it's only then that we can talk about doing the actual excision.
So let's watch a video together, we are doing the survey. Without survey, we would've missed all of this endometriosis under small bowel. Then we mobilize sigmoid. We always start from this step because not only it allows us to get into the left pelvic sidewall and start our left ureter lysis, it actually mobilizes the sigmoid and allows us to have more space if we need to do anything in the anterior compartment. Here is when we do it, and the reason for that is that after this point, we're going to now suspend the uterus. This may be a step that not many people agree with or do routinely. In my practice. Suspension of the uterus routine is always done for posterior compartment endometriosis. So the way we do it is these days, although we started by doing straight needle proline sutures, but nowadays I put a figure of eight at the back of the uterus and then we do suspension of the ovaries.
Different people do it differently. Some use T lift. I use PDS because I leave the ovarian suspension for a few days after surgery. Again, the evidence is not conclusive on that, but our own randomized control trials show that it actually does help. And then we do the ureter lysis. As you saw, this is something that any endometriosis surgeon should be very comfortable with. And then we enter the par rectal space and the rect vaginal space. The important point here is again, touching on anatomy, is that when you're working in the rect vaginal space, you need to remember that the rectum is a voluminous structure and it may be flat and it may be quite lateral. So even if you're using a rectal manipulator or rectal probe, you need to always remember that the rectum may be very close to you like it was in this case that just the pulling of the tissue pulls the rectum towards you.
And if you're not careful, you can get in trouble while doing this part of the operation. So the point really is that the excision comes last. It's the famous quote that if you had a day to cut a tree, you spend 80% of that day sharpening your ax. And this is us having sharpened our ax, meaning optimizing the access and doing the preparation and making sure that everything is out of the way. Now we can do the excision in a very nice, safe manner and get a complete removal of all the endometriosis lesions. Okay, enough of that. Let's talk about anatomy now. We agreed I hope that anatomy is really the essence of any surgery, and today I just want to focus on neuroanatomy of the pelvis, partly because you probably know the rest of the anatomy very well, and partly because I think this is the part that many of us lack.
Before I went into this field, really I wasn't aware nerves for me were those yellow things that come and go in the anatomy books. I hadn't thought about what's the importance of those nerves within the pelvis. And if I didn't cut a ureter or didn't make a hole in the bowel and didn't cause bleeding, that was it. I didn't need to worry about that. The problem with the neuroanatomy of the pelvis, however, is that it doesn't come like the left side of this picture. It comes like the right side. It's quite a mishmash of structures and learning it is not easy. Let's start from the autonomic nervous system. This is something that any endometriosis surgeon should know. The somatic nerves, maybe you don't come across all the time as an endometriosis surgeon, but the autonomic nervous system really we should all know about. This is from a very nice paper by repairer in 2017.
And you can see here the superior hypogastric plexus, which sits slightly left of the sacral proman tree. It's a rectangular structure and around one to two centimeters in size, and it's mostly sympathetic, almost all sympathetic nerve that comes from the para aortic nodes. Then it divides into right and left hypogastric nerves. So we have superior hypogastric plexus dividing into right hypogastric nerve and left hypogastric nerve. Then they go down these two nerves and they join with S two S3 S four parasympathetic nerves, and together they each make inferior hypogastric plexus on the right and on the left. So you have one plexus at the top dividing into two nerves connecting those two nerves to two inferior hypogastric plexi. So this is from a robotic cadaveric course. You'll see that here that this is the structure we are talking about, the superior and inferior, sorry, the superior hypogastric plexus dividing into the right and the left hypogastric nerves.
They run within the hypogastric fascia. Now here you see S two S3 S four fibers coming towards the nerve so that together they make up the inferior hypogastric plexus. So you see that very clearly here. This is my case number two of doing robotic surgery I believe, but this was when I really was sold that the robot is the way forward. You can see a lot better. You can see all the fibers very clearly. You can see that even a simple uterosacral ligament excision of endometriosis that you can see here how close you are to the inferior hop gastric plexus and the branches of it. And if we are not careful, if we are not mindful of the fact that these nerves are there and they're there for a reason, they're not there for aesthetic reason, they have a function, then you would not be careful and therefore you may cut those nerves. Okay, let's go a little bit higher. Up in the pelvis, in the abdominal wall, you have the lumbar trunk that will give you the ilio, hypogastric, ilio, inguinal and genital femoral nerves amongst other smaller nerves.
The way I started learning this was to get my anatomy book up upside down because that's basically the picture you see robotically or laparoscopically. So first you have the ileal hypogastric, then you have the I inguinal, and then you have the genital femoral. Genital femoral is the one that you come across a lot more often, but actually the igual is the nerve that you can injure quite easily with your port placement. Or if you're doing laparotomy, and I hope you're not, then you can injure these nerves by your retractor. Let's have a look at them in this cadaver. So you have the SOAs muscle. This is the right side of the pelvis. You have the sous muscle here and you have the external ILI vein. And these are the nerves that we were talking about. The genital femoral nerve is the one on the sous.
You can see the ilio hypogastric nerve here that goes between, it starts here, but it pierces the transverse abdominis and then goes between transverses abdominis and your internal oblique muscle Ilio. Inguinal gets into two branches, one goes into the inguinal canal, follows the round ligament, and then pierces the fascia after the inguinal canal. The femoral nerve is a five millimeter nerve at the lateral aspect of the sous muscle. And then you have the genital femoral nerve, which you can always find over the sous muscle. Let's have a look at the somatic nerves. We don't have much time. So you can see the ator nerve. Those of you who do gyne oncology will be very familiar with them with the ator nerve. You can see the genital femoral. Again here we're doing a lateral approach. You have the large veins, the external iliac, and then you can see the lumbosacral trunk here, which is basically L four, L five together, and then it's joined by S one.
And between them you have the superior gluteal artery, which is this one. Okay, so lumbosacral trunk, which is L four, L five, and then you have S one, S two, and we'll see the other nerves as well. So this is the lateral approach. You see the opterator nerve and underneath you see the lumbosacral trunk. Again, another view of that with more dissection, superior gluteal artery, superior gluteal artery comes from the posterior division of the internal iliac artery, S one, S two, and then all of this together will become the sciatic nerve. You can see here this is the thickest nerve in your body. It's almost as thick as your thumb. So you see the sciatic nerve coming under the sacro spine ligament, which is partially divided here. And on the medial aspect of it, you see the pudendal nerve is the structure that goes with pudendal artery and pudendal V.
Okay, so let's have a look at this video. We are coming to the end of our time. We have time for this video, I believe. So first thing I want to draw your attention to is this lady we knew already from the MRI that has quite a large nodule in the ator internus and over the sciatic nerve. But look, all you can see from inside the peritoneum. Is this in drawing? Is this just a little bit that some people may think you can ablate? So we go and excise the endometriosis. That's not what we are interested in.
But let's start from this part. So the lateral approach starts from going between the external iliac artery and the SOS major muscle. You can see this fine structure here was the gen femoral nerve that we just saw. This is the SOS muscle. We go between the SOS muscle and the external iliac artery. Behind it, you see the external iliac vein. Very easy to injure. This is the acus tendons. We follow the muscle, we leave all the lymph nodes medially. Those belong to the artery and vein. We go very close to the muscle. Every single little vessel needs to be ligated coagulated, and you start seeing the opterator nerve here. So we alize the opterator nerve and stay over the muscle and we open the space completely because if you get a bleeder here or if an artery withdraws and extracts into the gluteal area, then that's very difficult to control. So here's the lumbosacral trunk that you start to see. We can see that in this lady. We had some apparent vessels going over them very slowly, very gently. These are all opened up until we get to the operator internist muscle, and we dissect all the muscles. These are the fibers of co juice muscle. And here you will see our endometriosis nodule that we're getting into. So this lady was very symptomatic with the endometriosis, had foot drop and had neuropathic pain in the right leg.
In this case, we could see the lesion on the MRI, but sometimes you can't see very clearly. So we follow the nerve. We know already that the disease is sitting over the nerve, and here is the brown material, the endometrioma, the chocolate material that comes from the endometriosis lesion. Again, if we hadn't done the right investigations, we probably wouldn't have chased the nerve to that level. So we continue our dissection. And the aim of the dissection is exactly the same as any other endometriosis. You want to first identify your important structures, the anatomical structures so that you're not damaging them, and then you go and remove the abnormality from the muscle and from the nerve. So we have now identified our nodule. We can see the pudendal nerve going medial to your sciatic nerve. We are now dividing the sacro spinous ligament. The robotic route here really is very, very useful because it's a really, really deep area that we need to go into. And having the steady hands and good visualization really helps us a lot.
I'm going to stop here because we are running out of time, but the whole topic of neurobiology and neuroanatomy is something that requires a lot of repetition, a lot of reviewing. Every time I operate, I still go and review the anatomy, just making sure that I've not forgotten anything. It's a confusing anatomy, but I believe that if you were having brain surgery and your brain surgeon told you that, I only know the first centimeter of the surface of the brain and anything deeper is beyond me, you really wouldn't want to have an operation with that person. And I think the same applies to our field, particularly endometriosis. Well, thank you again for inviting me. I hope you have lots of fun. I think you're having a very nice dinner in a very fancy place tonight. Have fun, and I really hope I can be with you for the future events. Goodbye.
