Anatomy of the superior hypogastric plexus and its application in nerve-sparing paraaortic lymphadenectomy

Abstract

Background:The purpose of this study was to clarify the anatomy of the superior hypogastric plexus, which would contribute to advancement of nerve-sparing paraaortic lymphadenectomy. Materials and methods:Eighteen cadavers were dissected and morphometrically analyzed based on photographic images. Anatomical landmarks such as aortic bifurcation, transitional points of abdominal aorta to bilateral common iliac arteries, and cross point of the right ureter and pelvic brim, and cross point of sigmoid mesentery and pelvic brim were selected as reference points. Results:The left lowest lumbar splanchnic nerve was located more laterally to transitional point of abdominal aorta to in 11/18 specimens, whereas the right lowest lumbar splanchnic nerve passed onto the right transitional point in only one specimen. The lowest lumbar splanchnic 2 nerves or the superior hypogastric plexus covered the aortic bifurcation in 11/18 specimens. The superior hypogastric plexus was separate from the cross point of right ureter and pelvic brim as well as cross point of sigmoid mesentery and pelvic brim. Conclusions:The SHP is at risk of injury during paraaortic lymphadenectomy because of its topography. Preservation of the superior hypogastric plexus regarding its anatomic basis during paraaortic lymphadenectomy is required.

Superior Hypogastric Plexus Neurolysis to Manage Metastatic Pelvic Pain in a Forty-Five-Year-Old Spina Bifida Patient: A Case Report

“…The plexus is formed by two lateral roots and one medial root [ 16 ]. The lateral roots originate mainly from the lowest lumbar splanchnic nerves and contain a sympathetic component, while the medial root is a continuation of the abdominal aortic plexus from the inferior mesenteric plexus and has both sympathetic and parasympathetic components [ 17 ]. It is therefore a predominantly sympathetic plexus from the afferent tracts innervating the pelvic organs.…”

Surgical Anatomy and Dissection of the Hypogastric Plexus in Nerve-Sparing Radical Hysterectomy

“…Variations in the morphology (condensation of nerves and shape) of the SHP are often encountered: a plexiform structure, two distinct nerves, a thick single nerve, a broadened band-like nerve trunk, etc. [ 1 , 2 , 16 , 17 ]. A dissection of the SHP from the posterior parietal peritoneum and loose connective tissue is usually straightforward [ 5 ].…”

“…These nerves have a cranial direction from the IHP via both the left and right hypogastric nerves [ 5 ]. In addition, the median root of the SHP, as the caudal continuation of the preaortic plexus, also contains sympathetic and parasympathetic fibers [ 2 , 5 , 16 , 17 ].…”

“…The lateral border of the presacral space differs according to the dissection level, where at the most cranial (superior) level, the border is on the left–left common iliac vein, whereas the right border is at the right common iliac artery; nevertheless, the bilateral ureter lies at the lateral edges of the presacral space [ 28 ]. The SHP is located mainly between the common iliac arteries, anterior to the sacral promontory, and the left common iliac vein is at the caudal level of the origin of the inferior mesenteric artery [ 16 , 17 , 29 ]. A vessel loop is placed around the SHP.…”

“…Following the inferior (caudal) limit of the SHP at the retrorectal plane, the paired HNs are easily identified ( Figure 9 ). Surgeons should remain vigilant to prevent iatrogenic injuries to the ureters, SHP, HNs, inferior mesenteric artery, superior rectal artery, left common iliac vein, and middle sacral vessels during SHP dissection [ 16 , 17 ].…”