Retroperitoneal Anatomy Research Articles

Surgical Strategies for Renal Transplantation: A Pictorial Essay.

This pictorial essay aims to navigate through the complexities and challenges of renal transplantation (RT), by weaving together visual imagery with clinical insights within a comprehensive illustrative surgical guide. Herein, we provide a detailed visual exploration of the intricate anatomy and surgical processes necessary for both renal graft retrieval from the donor and also for an adequate implantation in the recipient. Regarding graft retrieval, after reviewing the relevant retroperitoneal surgical anatomy, and donor nephrectomy techniques, graft preservation and optimal backbench graft dissection principles were meticulously analyzed. Thereafter, the recipient surgical strategy for graft implantation was addressed, focusing on preoperative preparations, the site of implantation selection, exposure, operative bed dissection, graft revascularization, and urinary tract reconstruction. Careful donor and recipient selection, meticulous surgical execution, and rigorous postoperative management clearly hold a pivotal role in optimizing patient outcomes. Fostering a deeper understanding of the surgical nuances and clinical management practices that contribute to successful results post-RT, we hope to provide a useful practical tool for clinicians about to embark on the treacherous road of RT surgery. Innovative technologies and surgical practices that have already significantly improved the safety and effectiveness of RT stand testament to the importance of further scientific inquiry, conceptual developments, and clinical integration. Moving forward, it is essential that the medical community continues to refine these strategies and advocate for equitable access to transplantation, ensuring that advancements in the field translate into real-world benefits for all patients grappling with ESRD. The collaborative efforts of multidisciplinary teams are essential in addressing the complex clinical challenges associated with RT, with the ultimate goal of improving patient survival, enhancing graft longevity, and reducing healthcare disparities.

Beyond Abdominal Cavity: Peritoneal and Retroperitoneal Anatomy as It Relates to Disease Spread—Part 2

Beyond Abdominal Cavity: Peritoneal and Retroperitoneal Anatomy as It Relates to Disease Spread—Part 2

Beyond Abdominal Cavity: Peritoneal and Retroperitoneal Anatomy as It Relates to Disease Spread—Part 2

Beyond Abdominal Cavity: Peritoneal and Retroperitoneal Anatomy as It Relates to Disease Spread—Part 2

Retroperitoneum revisited: a review of radiological literature and updated concept of retroperitoneal fascial anatomy with imaging features and correlating anatomy

PurposeSpread of disease in the retroperitoneum is dictated by the complex anatomy of retroperitoneal fasciae and is still incompletely understood. Conflicting reports have led to insufficient and incorrect anatomical concepts in radiological literature.MethodsThis review will discuss previous concepts prevalent in radiological literature and their shortcomings will be highlighted. New insights from recent anatomical and embryological research, together with imaging examples, will be used to clarify patterns of disease spread in the retroperitoneum that remain unexplained by these concepts.ResultsThe fusion fascia and the renal fascia in particular give rise to planes and spaces that act as vectors for spread of disease in the retroperitoneum. Some of these planes and structures, such as the caudal extension of the renal fascia, have previously not been described in radiological literature.ConclusionNew insights, including the various fasciae, potential spaces and planes, are incorporated into an updated combined retroperitoneal fascial concept.

Beyond Abdominal Cavity: Peritoneal and Retroperitoneal Anatomy as It Relates to Disease Spread—Part 1

Beyond Abdominal Cavity: Peritoneal and Retroperitoneal Anatomy as It Relates to Disease Spread—Part 1

Beyond Abdominal Cavity: Peritoneal and Retroperitoneal Anatomy as It Relates to Disease Spread—Part 1

Beyond Abdominal Cavity: Peritoneal and Retroperitoneal Anatomy as It Relates to Disease Spread—Part 1

VNOTES Radical Hysterectomy: A New Approach to Cervical Cancer

To demonstrate how a radical hysterectomy with sentinel node resection for cervical cancer can be performed via vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). Demonstration of the technique in 10 steps. making use of narrated original video footage SETTING: The surgical treatment of cervical cancer is traditionally performed via one of the following techniques: Wertheim radical hysterectomy via laparotomy, Schauta radical hysterectomy vaginally, laparoscopic radical hysterectomy or robotic radical hysterectomy. The results of the LACC trial showed that minimally invasive radical hysterectomy was associated with lower rates of disease-free survival and overall survival than open radical hysterectomy among women with early-stage cervical Cancer [1]. For endometrial cancer, a vNOTES retroperitoneal approach to sentinel node resection was first published in 2019 [2]. Based on the experience with this approach and with Schauta-Stoeckel radical hysterectomy for cervical cancer [3], a new approach was developed to perform a radical hysterectomy via vNOTES whereby most of the procedure is performed retroperitoneally [4]. This video article demonstrates in 10 steps how a radical hysterectomy via vNOTES is performed. Radical hysterectomy via vNOTES demonstrated making use of original video footage of a 57-year-old woman operated on for cervical adenocarcinoma 7 weeks after a LEEP cone. The steps of the procedure are: 1. Vaginal cuff creation, 2. Development of lateral retroperitoneal space and sentinel node resection, 3. Uterine artery and vein transection, 4. Hypogastric nerve dissection, 5. Development of central retroperitoneal space and rectum dissection, 6. Posterior colpotomy, 7. Parametrium dissection, 8. Bladder pillar dissection, 9. Anterior colpotomy, 10. Salpingo-oophorectomy or salpingectomy. 3 Patients were so far treated by this new technique that allowed for good hemostatic control. vNOTES enables a potentially less invasive approach to radical hysterectomy performed largely retroperitoneally and completely transvaginally, leaving no visible scars. The endoscopic approach offers excellent visualization of the retroperitoneal and parametrial anatomy. This is a new approach that requires further validation and should only be performed in a research setting, taking into account the current reservations about endoscopic surgery for cervical cancer resulting from the LACC trial. VIDEO ABSTRACT.

Hydrodissection During Computed Tomography-Guided Cryoablation for Renal Tumors: Where is the Effective Fluid Accumulation Space in the Retroperitoneum?

This study was performed to investigate the effectiveness of hydrodissection during computed tomography-guided renal cryoablation by evaluation of the fluid distribution based on the retroperitoneal anatomy with the interfascial plane. Between March 2014 and March 2021, 52 renal tumors were treated by cryoablation with hydrodissection (36 men; mean age 72.5years). The hydrodissection needle was located in perirenal space. The spreading fluid space based on the retroperitoneal anatomy with the interfascial plane was retrospectively evaluated. The fluid space that most effectively separated the tumor from the adjacent organs was defined. The relationship of the needle tip position in the perirenal space (renal capsule or fascia side) and the most effective fluid space was also evaluated. Cryoablation was successfully completed in all cases with no major complications. Hydrodissection was effective in all cases. The distance between the tumors and the adjacent organs was significantly longer after hydrodissection (from 7.50 ± 7.43 to 22.6 ± 9.86mm) (P < 0.0001). Although fluid spreading through multiple retroperitoneal spaces was frequently observed, the retromesenteric plane was observed more frequently as the most effective fluid space (67.3%) than the perirenal space (21.2%) (P < 0.0001). Regardless of the needle tip position, the most effective fluid space was also commonly the retromesenteric plane. The retromesenteric plane could be the most effective fluid space to separate the tumor from the adjacent organ, regardless of where the hydrodissection needle tip is positioned in the perirenal space. 3b.

Retroperitoneal anatomy with the aid of pathologic fluid: An imaging pictorial review.

The retroperitoneum, a complex anatomical space within the abdominopelvic region, encompasses various vital abdominal organs. It is compartmentalized by fascial planes and contains potential spaces critical in multiple disease processes, including inflammatory effusions, hematomas, and neoplastic conditions. A comprehensive understanding of the retroperitoneum and its potential spaces is essential for radiologists in identifying and accurately describing the extent of abdominopelvic disease. This pictorial review aims to describe the anatomy of the retroperitoneum while discussing commonly encountered pathologies within this region. Through a collection of illustrative images, this review will provide radiologists with valuable insights into the retroperitoneum, facilitating their diagnostic proficiency to aid in appropriate patient clinical management.

Usefulness of knowledge in anatomy of the internal iliac artery in its ligation during life-threatening pelvic haemorrhages

Introduction: Post-Partum haemorrhage is a significant cause of maternal mortality. Bilateral internal iliac artery ligation is a life-saving procedure to control massive obstetric and gynaecological haemorrhages. Bilateral internal iliac artery ligation results in toning down the pulsatility making the arterial flow a slow venous flow encouraging the clot formation of the damaged pelvic vessels. This study assesses the retroperitoneal anatomy and regional variations of the internal iliac artery.Methods: The study was based on examining 45 pelvic halves (23 right sides and 22 left sides), which were dissected during the gross anatomy laboratory at the faculty of medicine, Ragama, University of Kelaniya, from 2020 -2023. There were all adult pelvises. The internal iliac artery and its major branches were carefully dissected and examined. Adachi classification was used to classify the distribution pattern of the internal iliac artery. The study was done on the donated cadavers, and the nature of the study did not warrant any special ethical clearance. No conflict of interest.Results: No anatomical deviation has been noted with regard to the levels of division of aorta, common iliac artery, the division into internal and external iliac arteries and the division of anterior and posterior branches of the internal iliac artery from that of classical anatomical literature. It was also noted that there had been no significant deviation of anatomical relations with regard to the structures as described in the internal lilac artery in our study. In our study, Type Ia was found in 35/45 (78%) of the specimens, Type IIa in 3/45 (6%), Type III in 7 (16%), and no specimens were found with Type IV and. Type V.Conclusion: Our study showed no significant anomalies of the pelvic anatomical structural relations to the internal iliac artery. The type Ia branching pattern was found to be the commonest.

Renal Embolization-Induced Uremic Swine Model for Assessment of Next-Generation Implantable Hemodialyzers.

Reliable models of renal failure in large animals are critical to the successful translation of the next generation of renal replacement therapies (RRT) into humans. While models exist for the induction of renal failure, none are optimized for the implantation of devices to the retroperitoneal vasculature. We successfully piloted an embolization-to-implantation protocol enabling the first implant of a silicon nanopore membrane hemodialyzer (SNMHD) in a swine renal failure model. Renal arterial embolization is a non-invasive approach to near-total nephrectomy that preserves retroperitoneal anatomy for device implants. Silicon nanopore membranes (SNM) are efficient blood-compatible membranes that enable novel approaches to RRT. Yucatan minipigs underwent staged bilateral renal arterial embolization to induce renal failure, managed by intermittent hemodialysis. A small-scale arteriovenous SNMHD prototype was implanted into the retroperitoneum. Dialysate catheters were tunneled externally for connection to a dialysate recirculation pump. SNMHD clearance was determined by intermittent sampling of recirculating dialysate. Creatinine and urea clearance through the SNMHD were 76-105 mL/min/m2 and 140-165 mL/min/m2, respectively, without albumin leakage. Normalized creatinine and urea clearance measured in the SNMHD may translate to a fully implantable clinical-scale device. This pilot study establishes a path toward therapeutic testing of the clinical-scale SNMHD and other implantable RRT devices.

Risk of Injury to Retroperitoneal Structures in Prone and Lateral Decubitus Transpsoas Approaches to Lumbar Interbody Fusion: A Pilot Cadaveric Anatomical Study.

Introduction The retroperitoneal approach for lateral lumbar interbody fusion (LLIF) originally described an initial posterolateral fascial incision enabling finger dissection from behind the peritoneum and guidance of instruments through a second direct-lateral fascial incision. It has since become common for single direct-lateral incisional access to the retroperitoneum. This study attempted to quantify the distance of the peritoneum from posterior landmarks in the space, assess the risk of peritoneal violation in each access trajectory (i.e., posterolateral versus direct lateral retroperitoneal dissection), and determine whether there are differences based on patient position (prone versus lateral decubitus). Methods In three prone cadaveric torsos, Steinman pins were percutaneously placed mid-disc at each level L2-5 bilaterally (for a total of 18 prone approaches). Open dissections exposed the retroperitoneum including the quadratus lumborum and psoas muscles, maintaining the natural reflection of the peritoneum. Visual assessment qualified whether any pin violated any retroperitoneal structure. Distance from the anterior border of the quadratus lumborum to the posterior-most reflection of the peritoneum was measured. For comparison, three additional torsos were positioned in lateral decubitus, and the above steps were repeated, only unilaterally (for a total of nine lateral decubitus approaches). Results In prone, no pin violated the peritoneum; three (3/18 total approaches) violated the kidney, all at L2-3 (3/6 approaches at L2-3). In lateral decubitus, all three L2-3 pins violated the kidney (3/3 approaches at L2-3); five of the six remaining pins from L3-5 violated the peritoneum (totaling eight violations in the nine total approaches). The incidence of any violation was significantly greater in lateral decubitus vs. prone (8/9 vs. 3/18, p=0.0006). The structure at risk (kidney vs. peritoneum) was significantly associated with disc level (p=0.0041): all kidney violations occurred at L2-3 and all peritoneal violations occurred at L3-4 or L4-5. Distance from the quadratus lumborum to the posterior-most reflection of the peritoneum averaged 8.7 cm (range: 6-10) in prone, and 2.9 cm (range: 2.5-3.2) in lateral decubitus (p=0.0129). Conclusion A cadaveric study of retroperitoneal anatomy demonstrates that there is an increased distance from the quadratus lumborum to the peritoneum in prone versus lateral decubitus and that the trajectory of approach to the lumbar discs risks violation of the peritoneum more frequently when accessing directly laterally versus posterolaterally. In either approach, care should be taken to identify and release the peritoneal reflection to create a safe passage to the lumbar discs.

Laparoendoscopic single-site surgery for deep infiltrating endometriosis based on retroperitoneal pelvic spaces anatomy: a retrospective study

Transumbilical single-port laparoscopy is widely used in gynecological surgery. However, it is rarely used in the treatment of deep infiltrating endometriosis due to its own shortcomings and the complex condition of deep infiltrating endometriosis. The study aims to introduce a transumbilical single-port laparoscopic surgery based on retroperitoneal pelvic spaces anatomy, which can complete the operation of deep infiltrating endometriosis more easily. A retrospective analysis of 63 patients with deep infiltrating endometriosis treated by transumbilical single-port laparoscopy using this method was conducted. The operation duration was 120.00 (85.00 ± 170.00) (35–405) min, the estimated blood loss was 68.41 ± 39.35 ml, the postoperative hospital stay was 5.00 (4.00–6.00) days, and the incidence of postoperative complications was 4.76% (3/63). 1 patient was found to have intestinal injury during operation, 1 patient had ureteral injury after operation, and 1 patient had postoperative pelvic infection, with a recurrence rate of 9.52%. The postoperative scar score was 3.00 (3.00–4.00) and the postoperative satisfaction score was 9.00 (8.00–10.00). In summary, this study demonstrates the feasibility of transumbilical single-port laparoscopic surgery for deep infiltrating endometriosis based on retroperitoneal pelvic spaces anatomy. Hysterectomy, adenomyosis resection, etc. are also feasible with this method, boasting more obvious advantages. This method can make transumbilical single-port laparoscopy more widely used in deep infiltrating endometriosis.

Duodenal injury: A challenging diagnostic enigma for clinicians

The objective of the article is to familiarize clinicians with duodenal injury and to recognize timely intervention to prevent morbidity and mortality associated with such injury. Although uncommon, duodenal injury challenges a clinician’s ability to diagnose and treat it in a timely fashion to prevent any associated mortality. The retroperitoneal anatomy makes duodenal injury difficult to diagnose. However, a high degree of suspicion based on the mechanism of injury and appropriate, timely diagnostic study leads to the correct identification of injury to the duodenum. The specific treatment depends on the type of injury that is detected. In conclusion, early recognition, and timely intervention of duodenal injury leads to a successful outcome.

Celiac plexus neurolysis in pancreatic neoplasm with celiacomesenteric trunk: a case report

BackgroundCeliac plexus neurolysis is an effective mode of long-term palliation of somatic pain in inoperable upper gastro-intestinal neoplasm. CT guidance is the most accepted method of localising the tip of the needle, through which, the neurolytic agent, commonly Absolute Alcohol, is introduced along the celiac ganglion. Three dimensional assessment of the retroperitoneal anatomy avoids injury to adjacent viscera and vascular structures. Para-aortic needle tip position between the origins of celiac and superior mesenteric arteries is an accepted position to inject neurolytic agent. We report a case of successful celiac plexus neurolysis in a patient with a celiacomesenteric trunk. Till date no such case has been reported, primarily due to the Low incidence of celiacomesenteric trunk.Case presentationA 63-year-old man developed progressive icterus and severe abdominal pain over 3 months. The pain severity was 6/10. An Ultrasonography and contrast enhanced CT of the abdomen revealed inoperable carcinoma of head of pancreas and a celiacomesenteric trunk. The pancreatic mass extended along the right lateral border of the celiacomesenteric trunk, not extending upto the aorta. Considering the severity of pain, poor compliance to opioid pain medication, and a possibility of early tumour extension upto the aortic margin, celiac plexus neurolysis was considered. The procedure was performed under CT guidance and local anaesthesia, using a mixture of absolute alcohol, Bupivacaine and diluted iodinated contrast. Bilateral paravertebral antecrural access was performed, using 22 gauge Chiba needles, after localisation on preprocedural CT-scan. On the left, hydrodissection was performed using normal saline, to displace the left renal parenchyma from the trajectory of the needle to be used for neurolysis. The patient’s pain visual analogue scale score reduced to 0/10, immediately after the procedure. He had a post procedural hypotension, managed conservatively by complete bed rest for 1 day and intravenous fluid administration.ConclusionsCeliac plexus neurolysis can safely be done in aberrant upper abdominal vascular anatomy, under CT guidance and local anaesthesia. To avoid periprocedural complications, hydrodissection may be effectively used to displace normal anatomical structures from the trajectory of the access needle, through which a mixture of absolute alcohol and local anaesthetic may be delivered.

Laparoscopic Excision of Retroperitoneal Adnexal Cyst

To demonstrate the laparoscopic excision of a retroperitoneal adnexal cyst and describe the advanced surgical techniques and anatomic considerations in a patient with previous abdominopelvic surgery. Stepwise demonstration of advanced laparoscopic techniques with narrated video footage. Adnexal masses after hysterectomy are a common reason for repeat abdominal surgery.1 Up to 9% of patients may require future adnexal surgery if ovarian preservation was chosen at the time of hysterectomy.2 Indications for surgery can include persistent adnexal masses, masses with concern for malignancy, chronic pelvic pain, and risk-reducing surgery.2 This patient is a 53-year-old postmenopausal female with a history of a total abdominal hysterectomy and left salpingectomy who underwent excision of an 8 cm retroperitoneal left adnexal cyst (Still 1). Excision of a retroperitoneal adnexal cyst can be performed through a laparoscopic approach with several key strategies: CONCLUSION: Knowledge of retroperitoneal anatomy is crucial in the surgical management of retroperitoneal adnexal masses because dissection can be technically challenging and anatomy may be distorted due to pelvic adhesive disease. Use of advanced laparoscopic techniques and understanding surgical planes are important for safe dissection. High and early ligation of the infundibulopelvic ligament at the pelvic brim and a complete ureterolysis with parametrial excision are often necessary to remove all ovarian tissue to prevent an ovarian remnant.

Minimally invasive retroperitoneal necrosectomy: how do we do it?

: Acute pancreatitis (AP) is an inflammatory condition that includes local and systemic manifestations, showing a mild behavior in most patients. Infected pancreatic necrosis is the most aggressive scenario with a high mortality rate. According to the PANTER trial, the “step-up approach” has shown a lower rate of new-onset organ failure compared with open necrosectomy. Whenever possible, major surgical interventions in infected pancreatitis should be delayed as long as possible, ideally until the fourth week since the onset of symptoms. The selection and timing of the procedure are key points, taking into account the clinical condition of the patient, the location, the availability of equipment, and the experience of the surgical team. The technical description of the laparoscopic retroperitoneal necrosectomy is presented focused on the path to the retroperitoneum, anatomical aspects, and tips and tricks. Furthermore, the step-up approach flowchart, indications, contraindications, patient’s workup, post-operative management, advantages, complications, and technique video are included. Although laparoscopic necrosectomy requires mastery of retroperitoneal anatomy and good laparoscopic skills, it is an exceptional tool for the surgeon within the arsenal for this difficult and serious condition. The authors have adopted the laparoscopic retroperitoneal necrosectomy as part of the step-up approach and have found it very replicable and ergonomic.

8201 The Identifying Renal Artery Variant during Retroperitoneal Laparoscopic Para-Aortic Lymphadenectomy

<h3>Study Objective</h3> To demonstrate of identifying one of the renal artery variants, triple renal artery in left during laparoscopic para-aortic lymphadenectomy <h3>Design</h3> Case study. <h3>Setting</h3> University hospital in Korea. <h3>Patients or Participants</h3> A 54-year-old Korean woman with postmenopausal bleeding and thickened endometrium> 3cm presented to our department. The histopathology of biopsied endometrium revealed grade 2 endometrioid adenocarcinoma. The preoperative MRI shows an about 6cm sized large volume of tumor within the endometrial cavity. <h3>Interventions</h3> Laparoscopy. <h3>Measurements and Main Results</h3> We perform the laparoscopic staging surgery for endometrial cancer. Firstly, we performed peritoneal washing cytology, LAVH, BSO, pelvic lymphadenectomy. We designated four area for para-aortic lymphadenectomy. During the procedure in area 4, it was confirmed that two left renal arteries were derived from the trunk of the aorta below the left renal vein. The left lower segmental artery was derived from the middle part of the inferior mesenteric artery and left renal vein. The middle segmental artery was derived just below left renal vein. The left main renal artery was located on the dorsal side of the left renal vein at its normal position. We carefully resected the para-aortic lymph nodes to prevent variant renal artery damage. <h3>Conclusion</h3> Laparoscopy is a feasible and safe approach to diagnosis of vascular anomaly during para-aortic lymphadenectomy for gynecologic malignancies. It is very important for the gynecologic oncologist to have knowledge of retroperitoneal vascular anatomy, experience in laparoscopic surgery, and an accurate surgical technique to avoid vascular injury during laparoscopic para-aortic lymphadenectomy.

Laparoscopic Myomectomy in the Retzius Space

<h3>Study Objective</h3> To illustrate a laparoscopic approach for the excision of the rare fibroid found within the Retzius space, to showcase relevant anatomy of the paravesical and Retzius space as well as to review the retroperitoneal vascular anatomy of the female pelvis. <h3>Design</h3> Elective Laparoscopic Myomectomy. <h3>Setting</h3> After verification of informed consent, the patient was taken to the operating room where a safety surgical briefing was performed. The patient was given a general anesthetic. They were then prepped and draped in the dorsal lithotomy position. 2g of Ancef was given. A foley catheter was inserted under sterile conditions and a Mengeshkar uterine manipulator was placed. <h3>Patients or Participants</h3> Previously healthy 36-year-old G1P1 who presented with a growing abdominal mass, she was otherwise asymptomatic. She was consented for laparoscopic myomectomy and underwent GnRH agonist treatment for 3 months prior to surgery. <h3>Interventions</h3> Laparoscopic Surgery. <h3>Measurements and Main Results</h3> Estimated blood loss was 400cc. The patient had no postoperative complications and was discharged home on post-operative day 1. The final specimen pathology was leiomyoma with a specimen weight of 556g. <h3>Conclusion</h3> Leiomyomas within the Retzius space are rare and can be safely excised using a laparoscopic approach. Bladder insufflation along with recognition of pelvic anatomical landmarks optimizes surgical navigation. Awareness of vascular structures present within Retzius space is instrumental for safe dissection.

Laparoscopic Excision of Retroperitoneal Adnexal Cyst

<h3>Study Objective</h3> To demonstrate the laparoscopic excision of a retroperitoneal adnexal cyst and describe the advanced surgical techniques and anatomic considerations in a patient with prior abdominopelvic surgery. <h3>Design</h3> Stepwise demonstration of advanced laparoscopic techniques with narrated video footage. <h3>Setting</h3> Adnexal masses after hysterectomy are a common reason for repeat abdominal surgery. Up to 9% of patients may require future adnexal surgery if ovarian preservation was chosen at the time of hysterectomy. Indications for surgery can include persistent adnexal masses, masses with concern for malignancy, chronic pelvic pain, and risk-reducing surgery. <h3>Patients or Participants</h3> 53-year-old post-menopausal female with a history of a total abdominal hysterectomy and left salpingectomy who underwent the excision of an 8-centimeter retroperitoneal left adnexal cyst. <h3>Interventions</h3> Excision of a retroperitoneal adnexal cyst can be performed through a laparoscopic approach with several key strategies: 1. Use of advanced laparoscopic techniques, such as the "push and spread" method and quick bursts of bipolar energy to prevent injury to vessels, bowel and bladder 2. Use of traction and counter-traction techniques to aid in dissection 3. Knowledge of retroperitoneal anatomy and avascular spaces to assist with dissection 4. Early ligation of the infundibulopelvic ligament to minimize blood loss 5. High ligation of the infundibulopelvic ligament and complete ureterolysis from the level of the pelvic brim to bladder to completely excise ovarian tissue <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Knowledge of retroperitoneal anatomy is crucial in the surgical management of retroperitoneal adnexal masses as dissection can be technically challenging and anatomy may be distorted due to pelvic adhesive disease. Use of advanced laparoscopic techniques and understanding surgical planes are important for safe dissection. High ligation of the infundibulopelvic ligament at the pelvic brim and a complete ureterolysis with parametrial excision are often necessary to remove all ovarian tissue to prevent an ovarian remnant.