Uterosacral ligament and hypogastric nerve anatomical relationship. Application to deep endometriotic nodules surgery

Endometriosis is a concern for 10 to 15% of women of childbearing age. The uterosacral ligament is the most frequent localization of deep infiltrating endometriosis. Laparoscopic excision of endometriotic nodules may lead to functional consequences due to potential hypogastric nerve lesion. Our aim is to study the anatomical relationship between the hypogastric nerve and the uterosacral ligament in order to reduce the occurrence of such nerve lesions during pelvic surgeries. We based our study on an anatomical and surgical literature review and on the anatomical dissection of a 56-year-old fresh female subject. The hypogastric nerves cross the uterosacral ligament approximately 30 mm from the torus. They go through the pararectal space, 20 mm below the ureter and join the inferior hypogastric plexus at the level of the intersection between the ureter and the posterior wall of the uterine artery, at approximately 20 mm from the torus. No anatomical variation has been described to date in the path of the nerve, but in its presentation which may be polymorphous. Laparoscopy and robot-assisted laparoscopic surgery facilitate the pelvic nerves visualization and are the best approach for uterosacral endometriotic nodule nerve-sparing excision. Precise knowledge by the surgeon of the anatomical relationship between the hypogastric nerve and the uterosacral ligament is essential in order to decrease the risk of complication and postoperative morbidity for patient surgically treated for deep infiltrating endometriosis involving uterosacral ligament. (C) 2013 Elsevier Masson SAS. All rights reserved.