New laparoscopic approach to the pudendal nerve for neuromodulation based on an anatomic study

Abstract

AIMS:The aim was to develop a new laparoscopic technique for placement of a pudendal lead. METHODS: Development of a direct, feasible and reliable minimal-invasive laparoscopic approach to the pudendal nerve (PN). Thirty-one embalmed human specimens were dissected for the relevant anatomic structures of the pelvis.Stepby-step documentation and analysis of the laparoscopic approach in order to locate the PN directly in its course around the medial part of the sacrospinous ligament and test this approach for feasibility. Landmarks for intraoperative navigation towards the PN as well as the possible position of an lead were selected and demonstrated. RESULTS: The visible medial umbilical fold, the intrapelvine part of the internal pudendal artery, the coccygeus muscle and the sacrospinous ligament are the main landmarks. The PN traverses the medial part of the sacrospinous ligament dorsally, medially to the internal pudendal artery. The medial part of the sacrospinous ligament has to be exposed in order to display the nerve. An lead can be placed ventrally on the nerve or around it, depending on the lead type or shape. CONCLUSIONS: A precise and reliable identification of the PN by means of laparoscopy is feasible with an easy four-step approach: (1) identification of the medial umbilical fold; (2) identification of the internal iliac artery; (3) identification of the internal pudendal artery and incision of the coccygeus muscle ('white line', arcuated line); and (4) exposition of the medial part of the sacrospinous ligament to display the PN. K E Y W O R D Sinternal pudendal artery, laparoscopic approach, medial umbilical fold, neuromodulation, pudendal nerve, sacrospinous ligament

Peripheral Nerve Anatomy Revisited: Modern Requirements for Neuroimaging and Microsurgery

“…These nerves are regularly investigated with medical devices such as IONM and ultrasonography. Moreover, other medical disciplines like anesthesia or urology are claiming such devices to identify and manipulate peripheral nerves throughout the body (Gruber et al, ; Peters et al, ; Eichenberger et al, ; Aigner et al, ; Konschake et al, ). The appropriate training to perform professional nerve imaging and advanced surgical procedures requires translational anatomical research.…”

“…The further development and proper application of such devices require a detailed understanding of the exact and often complex anatomical topography in the region of interest. Hence, translational anatomical research helps patients by training doctors to avoid nerve damage during interventions and supports the search for alternative pathomechanisms, which may lead to novel therapeutic concepts, for example, in migraine surgery (Guyuron et al, ; Dralle et al, ; Kessler et al, ; Konschake and Fritsch, ; Caruana et al, ; Konschake et al, ; Konschake, ).…”

“…Macroscopic anatomic research itself is often criticized for not providing novel scientific results (Mazurek and Shin, ; Lippert, ). In contrast, over the years, a number of scientific questions concerning clinical and applied peripheral nerve anatomy have been raised and addressed with direct benefit for the patient (Eichenberger et al, ; Dralle et al, ; Konschake and Fritsch, ; Konschake et al, ; Konschake et al, ; Fernández‐Gibello et al, ; Konschake, ; Moroni et al, ). For example, the inferior laryngeal nerve (ILN) in endocrine surgery (Chiang et al, ; Konschake et al, ; Randolph and Kamani, ) and peripheral nerves of the head and neck in migraine surgery (supraorbital, supratrochlear, auriculotemporal, zygomaticotemporal, and occipital) have been in the focus of several studies (Mosser et al, ; Guyuron et al, ; Totonchi et al, ; Janis et al, , et al; Caruana et al, ; Berchtold et al, ; Gfrerer and Guyuron, ).…”

Endoscopic trans gluteal minimal‐invasive approach for nerve liberation (ENTRAMI technique) in case of pudendal and/or cluneal neuralgia by entrapment: One‐year follow‐up

“…4 There are different surgical approaches for pudendal and/or cluneal nerve liberation described in literature. [5][6][7] Recently, the short term results of a new endoscopic trans gluteal minimal invasive approach for pudendal nerve and inferior cluneal nerve release (endoscopic transgluteal minimal-invasive [ENTRAMI]) have been published. 8 This approach is based on the open trans gluteal approach which has proven its efficacy compared to medical treatment in a randomized control trial.…”

A new endoscopic minimal invasive approach for pudendal nerve and inferior cluneal nerve neurolysis: An anatomical study

“…Several techniques for the liberation of the pudendal nerve have been described in literature (transperineal, laparoscopic, and transgluteal approaches). Here, transperineal and abdominal laparoscopic approaches have been proposed, but none of the latter were able to visualize the entire course of the nerve path. Neither have they allowed to explore the main, currently known, potential entrapment sites .…”