METHOD FOR LAPAROSCOPIC DECOMPRESSION OF PUDENDAL NERVE Russian patent published in 2025 - IPC A61B17/94 A61B17/34 A61M25/10 

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to neurosurgery, surgery, urology and coloproctology. Operation is performed under epidural anaesthesia and combined endotracheal anaesthesia. Patient is placed in a supine position, in a Trendelenburg position. Foley urinary catheter with a urine collector is inserted into the bladder, an aseptic treatment of the operating area is carried out, the surgical field is delimited, and a laparoscopic approach is performed. Central optical trocar 10 mm above or below the navel is placed. Carboxyperitoneum 12-14 mm Hg is applied, diagnostic laparoscopy is performed, 4 working trocars are installed in pairs symmetrically: two 5 mm trocars, one on the right, the other on the left along the pararectal line and 2 cm below the central trocar, and two 5 mm trocars 2 cm medial and 2 cm above external superior iliac spines on the right and on the left. Further, small intestinal loops are removed upwards, freeing up the working space, from one of the sides, where the pudendal nerve compression is detected, anatomical landmarks are determined: intersection of ureter with iliac vessels, umbilical artery, in males – vas deferens, and in females – round ligament of uterus, ultrasonic dissector is used to open peritoneum longitudinally of umbilical artery from level of ureter with iliac vessels to level of vas deferens in males or round ligament of uterus in females so that this artery is located medially, haemostasis is performed by bipolar coagulation by sequential layer-by-layer dissection in adipose tissue; an obturator fossa is approached; an obturator nerve and an underlying obturator vein are visualized as regular anatomical landmarks. When the obturator vein is reached, the dissection is continued directly under it; the internal obturator muscle is visualized. Dissection of adipose tissue is continued until separation of all following anatomical landmarks: muscle lifting anus, its tendinous arch, coccygeal muscle, obturator muscle and piriformis muscle. Further, an anatomical landmark is determined – an ischial spine, by its tactile “palpation” with the help of a laparoscopic dissector, wherein a reference point for searching for said spine is determined by a tendinous arch of the muscle lifting the anus, from which the ischial spine is located posteriorly and downwards. Thus, preparation for decompression of pudendal nerve located under sacrospinous ligament is performed. Coccygeal muscle lying on a sacrospinous ligament and preventing the visualization of this ligament is subjected to bipolar coagulation, after which the sacrospinous ligament is dissected, starting from the level of the lower edge of the piriform muscle, in the direction of the ischial spine. At the same time protection of underlying structures from action of tools is used. Sequential dissection and dissection technique is applied with orientation of a passive branch of ultrasonic scissors to underlying structures without touching them; along a dissection of a sacrospinous ligament, a pudendal neurovascular bundle containing a pudendal nerve, pudendal veins and an artery is separated. Said ligament is dissected at the ischial spine while preserving the neurovascular bundle of the pudendal nerve. Degree of ligament dissection and possible residual compression of the pudendal nerve by the levator anus muscle are assessed. Signs of the absence of compression are determined by the type of unchanged adipose tissue without fibrous constrictions and a nerve bundle released from compression. Further, the pudendal nerve is separated from under the ischial spine, the pudendal nerve is displaced medially and, using a bipolar dissector, without touching the nerve, the lateral branches of the pudendal vein are gradually coagulated under the ischial spine, visual assessment of completeness of release and decompression of the entire pudendal nerve: from the level of the lower edge of the piriform muscle, from under the sacrospinous ligament, from under the ischial spine, as well as in the Alcock canal, signs of the absence of compression and cicatricial changes along the entire length of the pudendal nerve are determined by visualization of unchanged adipose tissue without fibrous constrictions and adjacent tissues without cicatrical changes. Haemostasis is controlled, residual fluid is removed with an aspirator, the peritoneum is closed with a continuous interrupted suture with Vicryl suture 3-0, with a suture pitch of 12 to 15 mm. Instruments are removed, working trocars are removed under laparoscope control, and absence of trocar bleeding is controlled. Desufflation is performed from the central trocar, after which the latter is removed. Trocar wounds are sequentially sutured, aseptic dressings are installed.

EFFECT: method considerably reduces blood loss, reduces volume of injured tissues, reduces pain and drug load, frequency of pyoinflammatory complications, reduces length of stay in hospital and postoperative rehabilitation.

6 cl, 2 ex