A New Insight of the Fascia in Gynecologic Surgery, “the Dissectable Layer”

Abstract

<h3>Study Objective</h3> With recent development of the surgical visual system, laparoscopic surgeons have become more conscious of the fascial structures. It has been found that the three-dimensional fascial structure is heterogenous and variable, composed of extracellular matrix such as collagen fibers. A Japanese surgeon Prof. Shinohara advocated surgical meaning of these fascia and named it "the dissectable layer". The object of the video is to clarify this layer and apply the concept to gynecologic oncology or nerve sparing surgery. <h3>Design</h3> Video demonstration with narrated video. <h3>Setting</h3> A Japanese tertiary care hospital. <h3>Patients or Participants</h3> Patients who undertaken gynecologic surgery in our institution with informed consent were included in the study. <h3>Interventions</h3> We verified the detailed fascial structure in hysterectomy and pelvic/para-aortic lymphadenectomy by using 4K video system or robotic scope. <h3>Measurements and Main Results</h3> According to the fascial concept, the target organs were isolated without bleeding by consciously dissecting loose connective tissue, the dissectable layer, between the organs. Certainly, we can create the layer around any blood vessels or muscles or organs by pulling surrounding structure also in gynecologic surgery. Especially, en-bloc lymphadenectomy and nerve sparing radical hysterectomy were possible accurately by following the concept. <h3>Conclusion</h3> By being of aware of the "dissectable layers," bleeding may be minimized, and surgical accuracy may be improved. For malignancy, en-bloc removal is possible, and the margin can be adjusted as per tumor progression. For nerve sparing radical hysterectomy, autonomic nerves can be preserved by gathered thin nerve fibers with attached facia. The use of this concept may have the potential to improve oncologic outcomes.