Practical fundamentals of retroperitoneal spaces for safe pelvic surgery: possible answers to difficult questions

Separate works report a strong association between knowledge of pelvic anatomy and surgical competency (Lentz, 2001). The ability to manage several surgical procedures is considerably influenced by the level of training in anatomy and the ability to identify key anatomical structures (Arraez-Aybar, 2010). The importance of applied anatomy is suggested also by a 7-fold increase in claims made to UK Medical Defence Organizations between 1995 and 2000 (Waterston, 2005). The most easily identifiable anatomical structures are pelvic organs and blood vessels. Instead, retroperitoneum, nerves and lymphatics are the least identifiable. Furthermore, whilst laparoscopy has become the standard of gynaecological surgical care, ability to identify pelvic structures at laparoscopy was found less than both laparotomy (Sgroi, 2014). Preliminary data of ongoing multi-centric study conducted by Bologna University, assessing through a survey necessity and level of training of retroperitoneal anatomy among gynaecologists, have provided an overview of the poor knowledge and confidence of surgeons with this topic. Most of gynaecologists sustain retroperitoneal anatomy as an essential topic in their work, but they perceive limitations in their anatomical knowledge and training. Recognizing retroperitoneal structures is essential for management of complex surgery (i.e. deep endometriosis, oncology), but can be also crucial for so-called “every-day” surgery (Cruikshank, 1987; Gingold and Falcone, 2016; Sharma, 2014). We aim by this chapter to provide practical, basic knowledge about the retroperitoneal pelvic anatomy, referring to other chapters the dissertation of the remaining anatomical topics.