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3D ANATOMICAL BASIS FOR TRANSOBTURATOR SURGERIES

3D ANATOMICAL BASIS FOR TRANSOBTURATOR SURGERIES. Prof. Paulo Palma. Paradigm shifts. 1. Integral Theory, 1993 (Peter Petros) Creating neoligaments using tapes Reinforcement of pubourethral ligament Midurethral tape placement. 2. Transobturator Approach, 2001 (Delorme)

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3D ANATOMICAL BASIS FOR TRANSOBTURATOR SURGERIES

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  1. 3D ANATOMICAL BASIS FOR TRANSOBTURATOR SURGERIES Prof. Paulo Palma

  2. Paradigm shifts 1. Integral Theory, 1993 (Peter Petros) • Creating neoligaments using tapes • Reinforcement of pubourethral ligament • Midurethral tape placement. 2. Transobturator Approach, 2001 (Delorme) - Reinforcement of urethropelvic ligament - Less visceral and vascular complications - Less irritative voiding symptoms

  3. Urethropelvic Ligament Compartiments Anterior Median Posterior Uterus Sacrum P Bladder Pubourethral Ligament Sacro Uterine Ligament Tendineous Arc Vagina

  4. LIGAMENTS Sacrum P Pubourethral Ligament Sacro Uterine Ligament Tendineous Arc Vagina Urethropelvic Ligament

  5. Rest

  6. Straining

  7. Voiding

  8. First muscular layer 1. Superficial Transverse Muscle of perineum 2. Isquiocavernosous muscle 3. Bulbocavernosous Muscle 4. External Anal Esfincter 3 2 1 4

  9. Second Muscular Layer 5 5.Deep Transversal Muscle of perineum

  10. White Line 6 6. Pubovaginal 7. Puborectal 8. Ileococcigeous 7 8

  11. RECTOVAGINAL FASCIA

  12. VESICOVAGINAL FASCIA

  13. Bony Anatomy Obturator Canal Pubic Symphysis Ischial tuberosity Ischiopubic ramus

  14. Muscular Anatomy Gracilis Adductor longus Clitoris Adductor magnus

  15. Muscular Anatomy

  16. Obturator VesselsRetroperitoneal View Obturator nerve Obturator vessels Obturator canal

  17. Obturator Vascular Anatomy

  18. Obturator - Neuroanatomy • From anterior division of L2-4 • Innervates all muscles of the obturator region, except pectineus • Passes through obturator canal and splits to innervate the muscles that adduct the thigh and help with external rotation • Small sensory area on the medial thigh

  19. Anterior aginal Wall Defects Uterus Tendineous Arc P Vagina

  20. Lateral Defect Anterior aginal Wall Defects Uterus Tendineous Arc P Vagina

  21. Anterior aginal Wall Defects LateralDefect

  22. Central Defect Central Defect Uterus Tendineous Arc P Vagina

  23. Central Defect

  24. Central Defect: Treatment

  25. Anterior Vaginal Prolapse (AVP) Uterus Tendineous Arc P Pubourethral Ligament Vagina

  26. Anterior Vaginal Prolapse (AVP) Central Defect Uterus P Tendineous Arc Lateral Defect Vagina

  27. Anterior Vaginal Prolapse (AVP) Uterus P Vagina

  28. Evaluation of pelvic floor reconstructive surgery using tridimentional helical CT Fig 3. Notice the well supported bladder base and the TOT arms

  29. Posterior Defect Posterior Vaginal Prolapse (PVP) Rectum Uterus Tendineous Arc P Vagina Levator ani

  30. Posterior Vaginal Prolapse Repair Rectum Uterus Tendineous Arc P Sacrospinal Ligament Vagina Levator ani

  31. Evaluation of pelvic floor reconstructive surgery using tridimentional helical CT Fig 4. Infracoccigeal sacropexy showing indirectly the “neo rectovagianl fascia”

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