Laparoscopic Sciatic Nerve Dissection: A Reproducible Approach

Educational surgical video with full narration. Local Institutional Review Board (IRB) approval was not required for the purposes of this video article.

Laparoscopic sciatic nerve dissection utilizing the “medial” approach.

The objective of this study was to present the anatomical landmarks of a standardized and reproducible surgical approach enabling laparoscopic sciatic nerve dissection utilizing the “medial” approach, medially to the external iliac vessels.

The sciatic nerve can be compressed by a number of gynecological and obstetrical causes leading to sciatica, with endometriosis being the commonest gynecological etiology.[ 1 ] Sciatic nerve dissection can be performed laparoscopically via a “lateral” or a “medial” approach.[ 2 3 4 5 6 7 8 ] The “lateral” approach utilizes a plane of dissection lateral to external iliac vessels, whereas, in the “medial” approach, the surgeon dissects medially to the external iliac vessels. 28 year-old patient with chronic pelvic pain radiating to the posterior aspect of her right lower limb. Pre-operative imaging did not identify any pathology accounting for her symptomatology; however, due to the severity of symptoms, an exploratory laparoscopy was decided upon.

Laparoscopic sciatic nerve dissection utilizing the “medial” approach can be performed by following these steps [ Video ]: 1. horizontal incision of the peritoneum, parallel to the gonadal vessels, in the triangle that is formed by the adnexa, the external iliac vessels, and the round ligament. 2. Identification of the ureter that is kept on the medial border of the dissection plane. 3. Identification of the obturator nerve and vessels laterally. 4. Deepening the dissection caudally, in order to reach the hypogastric vein. Careful skeletonization of this vessel is necessary to avoid hemorrhage. 5. Fine dissection lateral and caudal to the hypogastric vein leads to the identification of the lumbosacral trunk and sciatic nerve [ Figure 1 ]. Laparoscopic image demonstrating the right sciatic nerve (red), medial and caudal to the right obturator vessels (green), and lateral to the right hypogastric vein (yellow). http://www.apagemit.com/page/video/show.aspx?num=1371&kind=2&page=1 Following this procedure, our patient made an uneventful recovery and was discharged on postoperative day 1.

The “medial” approach described here represents a safe and standardized approach to dissect the sciatic nerve laparoscopically, employing a dissection plane medial to the external iliac vessels, thereby potentially reducing the risk of injuring them. Avoiding complications requires advanced laparoscopic skills and a thorough understanding of anatomy. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent form. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Conceptualization, HR; software, GG, IB; validation, HR, AD; data curation, GG; writing – original draft preparation, GG, IB; writing – review and editing, GG, IB; visualization, GG; supervision, HR, AD. All authors have read and agreed to the final version of the manuscript. Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Horace Roman declares that he has received personal fees from Ethicon Endo-Surgery, Plasma Surgical Ltd., Nordic Pharma, and Olympus for his involvement in workshops and masterclasses. All other authors declare that they have no conflicts of interest relevant to this article.