During laparoscopic anterior resection for a mid-rectal cancer, the sympathetic hypogastric plexus is at risk. At what anatomical level does the superior hypogastric plexus divide into right and left hypogastric nerves?

• A At the level of L5/S1 disc, anterior to the sacral promontory ✓
• B At the aortic bifurcation (L4 level)
• C At the sacral foramina S2-S4
• D At the pelvic brim, lateral to the common iliac vessels

Explanation

The superior hypogastric plexus (presacral nerve) descends over the aortic bifurcation and divides at the level of the L5/S1 disc, just anterior to the sacral promontory, into two hypogastric nerves. These then course laterally along the pelvic side wall. Injury during presacral dissection causes sympathetic dysfunction resulting in bladder dysfunction and retrograde ejaculation in men. The parasympathetic nervi erigentes (S2-S4) join the hypogastric nerves to form the pelvic plexus (inferior hypogastric plexus) laterally.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.