Pelvic Neuroanatomy: An Overview of Commonly Encountered Pelvic Nerves in Gynecologic Surgery

Objective This video tutorial identifies key anatomic landmarks useful in identifying the path of the most commonly encountered pelvic nerves in benign gynecologic surgery. Design This is a narrated overview of commonly encountered pelvic nerves during benign gynecology, their origin, sensory, and motor function, as well as sequelae related to injury. Setting The unintended injury of pelvic neural connections can be a complication of any pelvic surgery, however, surgery for malignancy or endometriosis may increase the likelihood of encountering these nerves. The majority of focus surrounding surgical nerve injury, however, relates to patient positioning [ 1 Abdalmageed OS Bedaiwy MA Falcone T Nerve injuries in gynecologic laparoscopy. J Minim Invasive Gynecol. 2017; 24: 16-27 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar ]. Injury to the pelvic nerves can lead to lifelong sexual, bladder, and defecatory dysfunction [ 2 Ceccaroni M Clarizia R Roviglione G Nerve-sparing surgery for deep infiltrating endometriosis: laparoscopic eradication of deep infiltrating endometriosis with rectal and parametrial resection according to the Negrar method. J Minim Invasive Gynecol. 2020; 27: 263-264 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar ]. Interventions We review the Genitofemoral, Lateral Femoral Cutaneous, Ilioinguinal, Obturator, Superior and Inferior Hypogastric nerves, Pelvic Splanchnic nerves, and the Sacral nerves. Surgical illustrations are used (Fig. 1) alongside real-time narrated video to help viewers recognize the normal course of commonly encountered pelvic nerves at the time of gynecologic surgery (Figs2–3). Conclusion The surgical management of complex pelvic disease can unfortunately carry significant patient morbidity [ 3 Lemos N Souza C Marques RM Kamergorodsky G Schor E Girão MJ Laparoscopic anatomy of the autonomic nerves of the pelvis and the concept of nerve-sparing surgery by direct visualization of the autonomic nerve bundles. Fertil Steril. 2015; 104: e11-e12 Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar ]. The neural pathways traveling through the pelvis via the hypogastric nerves are responsible for proprioception, vaginal lubrication, and proper functioning or the urethral and anal sphincters [ 4 Seracchioli R Mabrouk M Mastronardi M et al. Anatomic cartography of the hypogastric nerves and surgical insights for autonomic preservation during radical pelvic procedures. J Minim Invasive Gynecol. 2019; 26: 1340-1345 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar ]. Sparing these nerves during pelvic surgery, and especially when anatomic planes are distorted by pelvic disease, requires surgical expertise and an immense understanding of pelvic neuroanatomy [ 4 Seracchioli R Mabrouk M Mastronardi M et al. Anatomic cartography of the hypogastric nerves and surgical insights for autonomic preservation during radical pelvic procedures. J Minim Invasive Gynecol. 2019; 26: 1340-1345 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar , 5 Charoenkwan K. A simplified technique for nerve-sparing type III radical hysterectomy: by reorganizing their surgical sequence, surgeons could more easily identify key nerves. Am J Obstet Gynecol. 2010; 203: 600.e1-600.e6 Abstract Full Text Full Text PDF Scopus (19) Google Scholar ]. Preservation of the pelvic neural pathways is necessary to deliver the best patient outcomes while minimizing unwanted surgical complications. This video tutorial also highlights the origin of these nerves, their anatomic location, procedures in which these nerves may be encountered, and what sequelae occur from their unintended injury.