Handa 9781496386441 Full Sample Chap 1

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SECTION I  Preparing for Surgery

Sympathetic trunk

Quadratus lumborum

Iliohypogastric n.

I

Ramus communicans

Ilioinguinal n.

Iliac crest

Obturator n.

L5

Lumbosacral trunk

Lateral cutaneous n.

S1 S2 S3 S4

Sciatic n.

Femoral branch of genitofemoral n.

Pudendal n.

Femoral n.

Inguinal ligament

Genital branch of genitofemoral n.

Ganglion impar

Common fibular n.

Tibial n.

FIGURE 1.10  Nerves of the lumbosacral plexus: Note that several branches (femoral nerve, lateral cutaneous nerve of the thigh, and femoral branch of genitofemoral nerve) pass under inguinal ligament and can be compressed in lithotomy. (Reprinted with permission from Agur AM, Dalley AF. Grant’s atlas of anatomy , 14th ed. Baltimore, MD: Wolters Kluwer, 2016. Figure 4.78.)

lateral blades of retractors. During vaginal surgery, fem- oral nerve injury is most often attributed to lithotomy positioning. The nerve can be compressed against the inguinal ligament with thigh hyperflexion (>90 degrees) or with excessive hip abduction and/or lateral rota- tion. Clinical manifestations of femoral nerve injury may include difficulty or inability to flex the thigh and extend the knee, absent patellar reflexes, and sensory loss over the anterior thigh and medial aspect of the leg. The obturator nerve (L2–L4) is the only branch of the lumbar plexus that courses through the lesser (true) pelvis ( FIG. 1.11 ). It exits through the obturator canal

and enters the thigh to supply the adductor muscles and skin over the medial thigh. The obturator nerve may be injured during pelvic lymphadenectomies or incon- tinence or pelvic support procedures where the retropu- bic space or the thigh compartment is entered. Clinical manifestations of obturator nerve injury include diffi- culty or inability adducting the thigh and sensory loss over the inner thigh. If obturator nerve transection is recognized intraoperatively, appropriate surgical con- sultation is warranted as microsurgical reapproxima- tion can result in almost complete recovery of motor function.

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