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Anatomy of Pelvic structures and It's correlation
- 1. SURGICAL ANATOMY OF FEMALE PELVIS Chairperson-DRINDIRA PALO Presented by-DR AYASHA PANDA
- 2. CONTENTS • ABDOMINAL WALL •VULVAL & ERECTILE STRUCTURES • PELVIC FLOOR • PELVIC VISCERA • PELVIC CONNECTIVE TISSUE • EXTRAPERITONEAL SURGICAL SPACES • RETROPERITONEAL SPACES & LATERAL PELVIC WALL
- 3.
- 4. ABDOMINAL WALL LAYERS 1.Skin 2.Subcutaneouslayer 3.Musculo aponeurotic layer 4.Transversalis fascia 5.Pre-peritoneal fat 6.Peritoneum
- 5. Skin & subcutaneoustissue Fibers in dermal layer of abdominal skin- transversely oriented →more tension on the skin of a vertical incision and in a wide scar. Subcutaneous tissues -2 layers Superficial- Camper fascia – fatty layer Deep- Scarpa fascia – membranous layer Scarpa fascia -best developed laterally, not seen well-defined in midline vertical inscision
- 6. Musculo-aponeurotic layer Twogroups of muscles: 1.vertical muscles – rectus abdominis, pyramidalis 2.oblique flank muscles- external oblique, internal oblique, and transversus abdominis. Broad, sheet like tendons of these muscles form aponeurosis that unite with their corresponding member of other side, forming the rectus sheath
- 7. Vertical muscles Rectusabdominis muscle- -originates from sternum and cartilages of ribs 5 to 7 -inserts into anterior surface of the pubic bone. Fibrous interruptions within the muscle firmly attach it to the rectus abdominis sheath. Rectus sheath is attached to the rectus muscle and these two structures become difficult to separate during Pfannenstiel incision. Pyramidalis muscle arises from the pubic bones and insert into the linea alba
- 8. Flank Muscles Externaloblique- fibers run obliquely anteriorly and inferiorly origin - lower 8 ribs Aponeurotic insertion- iliac crest pubic tubercle n linea alba. Inferior margin thickened to form inguinal lig Internal oblique muscle-fibres perpendicular to the fibers of the external oblique ms origin - anterior 2/3rd of iliac crest, lateral part of the inguinal ligament, and thoracolumbar fascia Insertion- 10-12th ribs ,pecten pubis and linea alba
- 9. Flank Muscles • Transversusabdominis Origin- 7-12 costal cartilages, thoracolumbar fascia, anterior 3/4th of iliac crest, lateral inguinal ligament. Insertion- pubic crest, pecten pubis via cojoint tendon linea alba caudally fused with internal oblique ms form conjoint tendon • Weakening of conjoint tendon- direct inguinal hernia • Transverse orientation and transverse pull of muscular fibers place vertical suture lines in the rectus sheath under more tension -more prone to dehiscence
- 10. Rectus sheath • Broad,sheet like tendons of these muscles form aponeurosis that unite with their corresponding member of other side, forming the rectus sheath • Neurovascular plane -between internal oblique and transverse abdominis A:above arcuate line- anterior sheath - external oblique and split aponeurosis of internal oblique posterior sheath -aponeurosis of transverse abdominal muscle and split aponeurosis of the internal oblique muscle. B: below arcuate line (linea semicircularis) -all of the fascial aponeuroses form ant rectus sheath
- 11. • Low transverseincisions should not exceed lateral margin of rectus muscles to avoid nerve and inferior epigastric vessel injury • Sutures extending lateral to edges of inscision avoided as they entrap illiohypogastric and iilioinguinal nerve causing denervation injury and pain • Lateral border of the rectus muscle is marked by the semilunar line of the rectus sheath- hernia through lenia semilunaris – spigelian hernia
- 12. • Inguinal canallies at lower edge of musculofascial layer of abdominal wall. • Through the inguinal canal, the round ligament terminate in labium majus, ilioinguinal nerve and genital branch of the genitofemoral nerve passes. • Midinguinal point –halfway between ASIS & pubic symphysis- femoral pulse palpated • Canal is lined by processus vaginalis- failure to regress- indirect inguinal hernia
- 13. Transversalis Fascia, Peritoneumand Bladder Reflection • Transversalis fascia-a layer of fibrous tissue that lines the abdomino-pelvic cavity. • Peritoneum -single layer of serosa- thrown into 5 vertical folds converging toward the umbilicus. • Single median umbilical fold - presence of the urachus (median umbilical ligament). • Paired medial umbilical folds - obliterated umbilical arteries • Lateral umbilical folds- inferior epigastric arteries and veins.
- 14. Umbilical area • Importantsurgical landmark • Mc point of entry during endoscopic surgery • All layers of anterolateral abd wall fuse here • Level- L3 L4 • T10 dermatome • Illiac vein join to form venacava • Abdominal aorta bifurcates • Contains umbilical ring –defect in linea alba, window for umbilical hernia- round lig of liver, median n medial umbilical lig attached
- 15. Vascular supply ofabdominal wall Superficial vessels-skin & sc tissue 1.Superficial epigastric vessels from femoral vessels toward umbilicus, position- between skin and musculofascial layer 2.External pudendal artery – from femoral artery medially supply mons pubis. many midline branches lead to heavy bleeding in its territory of distribution 3.Superficial circumflex iliac vessels - laterally from femoral vessels toward flank.
- 16. Vascular supply ofabdominal wall Deep vessels-supply musculofascial layer 1. Deep circumflex illiac artery – Branch of iiliac artery Between internal oblique and transverse abdominal muscle. 2.inferior epigastric artery and its two veins - Originate lateral to the rectus muscle. Run towards umbilicus and intersect the muscle's lateral border midway between pubis and umbilicus.
- 17. Angle betweenvessel and border of rectus muscle forms apex of Hesselbach triangle Base -inguinal ligament. Lateral laparoscopic trocars placed where injury to inferior epigastric and superficial epigastric vessels can occur easily. Just above pubic symphysis vessels lie 5.5 cm from the midline,at umbilicus- 4.5 cm from the midline Placement either lateral or medial to the line connecting these points minimizes potential vascular injury. Location of inferior epigastric vessels seen by following round ligament to its point of entry into deep inguinal ring-vessel lies just medial to this point. Round ligament
- 18. Saggital view offemale pelvis
- 19. Nerves of abdominalwall 1.Intercostal nerves 7 through 11 2. subcostal nerve (T12) • pierces lateral border of rectus sheath to supply rectus muscle- Incisions along lateral border of rectus - denervation of the muscle - atrophic and weaken abdominal wall. • rectus sheath elevation during Pfannenstiel incision stretches perforating nerve- sometimes ligated for hemostasis from accompanying artery - cutaneous anesthesia. 3. Iliohypogastric (L1)- suprapubic area skin 4. Ilioinguinal nerves L1-lower abdominal wall labia majora and medial thigh • pass medial to ASIS,entrapped in lateral closure of transverse incision- chronic pain syndrome • minimised if trocar placed superior to ASIS • low transverse inscision not extend beyond rectus ms
- 20. 5.Genitofemoral nerve(L1,L2) -Lies onthe psoas muscle ,retractor can damage it -anesthesia in medial thigh and lateral labia. -Injured during pelvic lymphadenectomy 6.Lateralcutaneous nerve(L2,L3) -Compressed by a retractor blade lateral to psoas or by too much flexion of the hip in lithotomy position - anesthesia over anterior thigh-meralgia parasthetica
- 21. 7.Femoral nerves (L2-L4) •Pass under inguinal lig • Nerve compress by lateral blade of retractor • In lithotomy compress against ingunal lig d/t thigh hyperflexion >90 degree excess hip abduction lateral rotation- • c/f inability to flex thigh extend knee absent patellar reflex sensory loss ant thigh medial leg 8.Obturator nerve (L2-L4) • Exit obturator canal supplies adductor muscles skin over medial thigh • Injured during pelvic lymphadenectomy incontinence, pelvic support procedure • C/F-inability to adduct thigh , sensory loss over inner thigh
- 22. VULVA & ERECTILESTRUCTURES • Pudendum or vulva – part of female external genitalia found on superficial pouch of ant perineal triangle • Ant triangle (urogenital) Anterolaterally -pubic arch ,ischiopubic ramii • Post triangle (anal ) Posterolaterally-sacrotuberous lig coccyx • Both share a common base i.e line between ischial tuberosities
- 23. Layers and pouchesof the Anterior Triangle of the Perineum 1.Skin 2.Subcutaneous perineal pouch Fatty layer-Camper fascia Membranous layer-Colles fascia 3.Superficial space Superficial fascia of perineal muscle Clitoris and its crura Bulb of vestibule Bartholin gland Ischiocavernous muscle Bulbocavernous muscle Superficial transverse perineal muscle 4.Deep space- Perineal membrane External urethral spincter Compressor urethrae Urethrovaginal sphincter
- 24. Subcutaneous tissues ofvulva Consist of mons, labia, clitoris, vestibule, and erectile structures. 1.Mons -hair-bearing skin over a cushion of adipose tissue on pubic bone 2.Labia majora • hair-bearing skin and adipose tissue • Homologous with scrotum • Join medially below mons -ant commissure infront of anus -posterior commissure • contain the termination of the round ligaments and obliterated processus vaginalis (canal of Nuck). • round ligament can give rise to leiomyomas in this region • Rich venous plexus – injury – hematoma formation
- 25. Subcutaneous tissues ofvulva 3.Labia minora • hairless skin folds devoid of fats and hair follicles • Homologous to ventral aspect of penis • Anteriorly divide to enclose clitoris ant- prepuce/hood n post-frenulum • Posteriorly unite-fourchette • Fossa navicularis – between fourchette and vaginal orifice
- 26. Subcutaneous tissues ofvulva 3.Labia minora • Cutaneous structures of labia minora and vestibule lie on a loossely organised connective tissue stratum that permits mobility of the skin during intercourse and allows the skin to be easily dissected off the underlying fascia during skinning vulvectomy • Highly sensitive d/t vast sensory inervations- surgical reduction done for dysparenuia is a/w complication hypoasthesia • Chronic derma disease like lichen sclerosis – atrophy of labia minora • Surgery for removal of prepuce /adjacent skin – injury to dorsal nerve of the clitoris
- 27. • Bartholin glandduct –2cm Opens at junction of ant. 2/3rd and post.1/3rd in groove between hymen and labium minor- posterior lateral vestibule 3-4 mm outside the hymenal ring • Minor vestibular gland openings- along a line extending anteriorly from this point, parallel to hymenal ring and extending toward the urethral orrifice • Skene ducts open into the inner aspect of these labia in paraurethral area
- 28. • Holocrine sebaceousglands of labia majora are a/w hair shafts, and in labia minora, they are freestanding. • Apocrine sweat glands -lateral to introitus and anus - undergo change with menstrual cycle with increased secretory activity in premenstrual period • Chronic infection- hidradenitis suppurativa • Neoplasia-hidradenomas =require surgical therapy • Eccrine sweat glands - form palpable masses as syringomas. Interlacing fibrous septa of subcutaneous tissue attach laterally to ischiopubic rami and fuse posteriorly with posterior edge of perineal membrane Anteriorly -no connection to pubic rami, and this permits communication between area deep to this layer and abdominal wall. Fibrous attachments to the ischiopubic rami and the posterior aspect of the perineal membrane limit the spread of hematomas or infection in this compartment posterolaterally but allow spread into the abdomen and vice versa
- 29. Superficial perineal pouch/Compartment • Space between fascia of perineal muscle and perineal membrane • Contains clitoris, crura, vestibular bulbs, and ischiocavernous and bulbospongiosus muscle
- 30. 1.Clitoris – complex erectilehighly sensitive organ • Parts- glans ,body and 2 crura • homologous to male penis derived from genital tubercle • dorsal nerve n vessels of clitoris lie outside tunica albuginea but inside clitoral fascia
- 31. 2. Ischiocavernous muscles-originate at ischial tuberosities and insert on crura and body of clitoris. 3.Superficial transverse perineal muscles, originate at ischial tuberosity and insert to perineal body. 4.Vestibular bulbs richly vascular spongy erectile tissue -Homologus to bulb of penis n corpus spongiosum -lie below vestibular skin covered by bulbospongiosus muscles -Cover bartholin glands 5.bulbospongiosus muscles -originate in perineal body and insert into body of clitoris All muscles in superficial perineal pouch are covered by fascia –perineal fascia continuous with clitoral fascia
- 32. 6. Bartholin gland •at post end of vestibule bulb • Homologus to bulbourethral gland of male • connected to vestibular mucosa by duct lined with squamous epithelium linning. • lies on perineal membrane and beneath bulbospongiosus muscle whose contraction results in secretion • Enormously vascular erectile tissue of the vestibular bulb and the Bartholin gland is responsible for the hemorrhage associated with its removal
- 33. VESTIBULE • Triangular space- antclitoris post- fourchette lateral- labia minora • 4 openings- ext. urethral meatus vaginal orifice 2 bartholin gland openings • Vagina incompletely closed by a septum of mucous membrane- hymen • carunculae myritiformis during child birth hymen lacerated as cicatrised nodule
- 34. VULVA BLOOD SUPPLY OFVULVA Artery - Branches of internal pudental artery - Branches of Femoral artery Superficial and deep pudental. Vein - internal pudental vein - vesical and vaginal venous plexus - long saphenous vein NERVE SUPPLY OF VULVA Anterosuperior - Cut.br. of Ilioinguinal N Genital br. of Genitofemural N.(L1,2) Middle part Labial and perineal br. Of Pudental N. (S2,3,4 ) Posteroinferior Pudental br. of posterior cut. Nerve of thigh (S2,3,4 ) LYMPHATIC DRAINAGE OF VULVA Inguinal and Femoral LN. Ext. Iliac Common iliac Aortic group of LN.
- 35. Pudendal nerves andvessels • Pudendal nerve - sensory and motor nerve of the perineum. • Arises from sacral plexus (S2-S4) • Pudendal nerves & vessels leave the pelvis through greater sciatic foramen by hooking around the ischial spine and sacrospinous ligament to enter the pudendal (Alcock) canal through the lesser sciatic foramen.
- 36. Internal Pudendal arteryoriginate from anterior division of internal iliac artery.
- 37. Internal pudendal arterybranches
- 38. 1.Dorsal nerve ofclitoris-supply clitoris. 2. Perineal nerve-supply bulbocavernosus, ischiocavernous, and transverse perineal muscles.skin of the inner portions of labia majora, labia minora, and vestibule. 3. Inferior rectal nerve- external anal sphincter and perianal skin Pudendal nerve have three branches:
- 39. Autonomic innervation to erectilestructures • Cavernous nerve of clitoris i.e from uterovaginal plexus component of inferior hypogastric plexus • Consists of sympathetic n parasympathetic components • Injury during radical hysterectomy, pelvic & perineal surgery- voiding sexual defeacatory dysfunction
- 40. Lymphatic drainage • Inguinallymph nodes • 2 groups- superficial and deep nodes. • 1. superficial-12 to 20 superficial nodes lie in a T-shaped distribution parallel to and 1 cm below the inguinal ligament, with stem extending down along saphenous vein. lie superficial to fascia lata. . • 2.Deep-Lymphatics from superficial nodes enter fossa ovalis (3 cm below the inguinal ligament)and drain into 1-3 deep inguinal nodes, which lie in femoral canal of femoral triangle.
- 41. Femoral triangle – •space of the upper one third of thigh. • Bounded by the inguinal ligament, sartorius muscle, and adductor longus muscle. • floor by the pectineal, adductor longus, and iliopsoas muscles. • lateral to medial – NAVEL: femoral Nerve, Artery, Vein, Empty space Lymph nodes.
- 42.
- 43. PELVIC FLOOR Muscular partitionseparating the pelvic cavity from anatomical perineum 1.perineal membrane 2.perineal body 3.posterior triangle – ischioanal fossa 4. anal spincters 5.Levator ani muscles
- 44. 1.Perineal membrane Triangular sheetof dense, fibromuscular tissue over anterior half of pelvic outlet previously called urogenital diaphragm Separate superficial and deep perineal pouch origin- ischiopubic rami and crura of clitoris. Medial - urethra, walls of the vagina Anteriorly - compressor urethrae ms and urethrovaginal sphincters Posteriorly - transverse vaginal muscle & smooth ms • Dorsal and deep nerve and vessels of clitoris found within this membrane • Provide support for posterior vaginal wall by attaching perineal body and vagina to ischiopubic rami and preventing downward descent • downward descent can be assessed by EUA by placing a finger in the rectum, hooking it forward, and gently pulling the perineal body downward
- 45. 2. Perineal body •Mass of connective tissue bounded by- lower vagina, perineal skin, and anus • central tendon of perineum • Attached to inferior pubic rami and ischial tuberosities through perineal membrane and superficial transverse perineal muscles. • Ant- insertion of bulbocavernosus muscles. • lateral- fibers of pelvic diaphragm. • Posteriorly - attached to coccyx by external anal sphincter • Anchor perineal body to bony pelvis and help to keep it in place.
- 46. 3.Posterior triangle- ischioanalfossa Posterior triangle / anal triangle • formed by coccyx, sacrotuberous ligaments, and an imaginary line between ischial tuberosities. • contains anal canal and two ischiorectal (ischioanal) fossae lie on either side • Ischioanal fossa • lies between pelvic walls and levator ani muscles • Bounded medially - levator ani muscles, external anal sphincters anterolaterally -obturator internus muscle. posterior portion -extends above the gluteus maximus. • Pudendal canal with neurovascular bundle lie on lateral wall
- 47. 4.Anal sphincters External sphincterlies in posterior triangle of perineum Divided into 3 portions. 1.subcutaneous portion -attached to perianal skin and forms ring around anal canal - characteristic radially oriented folds in the perianal skin 2.superficial part- attaches to coccyx posteriorly and perineal body anteriorly forms bulk of anal sphincter 3.deep part -encircle rectum and blend with puborectalis Internal anal sphincter - thickened circular smooth muscle of anal wall. • involuntary • lies inside external anal sphincter separated by intersphincteric groove containing longitudinal smooth ms fibres of bowel and levator ani fibres
- 48. 5.Levator ani muscles Bonypelvis is spanned by levator muscles of pelvic diaphragm. Pelvic diaphragm consists of two components (a) thin horizontal shelf-like layer formed by iliococcygeal muscle (b) thicker “U”-shaped sling of muscles that surround levator hiatus (medial pubococcygeal and lateral puborectal muscles) • Levator hiatus-open area within the U through which urethra, vagina, and rectum pass • Urogenital hiatus- portion of hiatus anterior to perineal body • Levator muscles are Strong fatigue resistrant striated ms with three components on each side 1.pubococcygeous 2.illiococcygeous 3.ischiococcygeous
- 49. 1.pubococcygeal muscle Origin- pubicrami Insertion -lateral vagina, perineal body, anus coccyx • pubovisceral muscle as majority of attachments to vagina and anus, • puborectal muscle is distinct from pubococcygeal muscle and lies lateral to it. originate from lower pubis and perineal membrane. 2. Iliococcygeal muscle Origin- from tendinous arc of levator anii Insertion- into anococcygeal body(illiococygeal raphe n coccyx) 3.Ischiococcygeus(coccygeous) muscle Origin- ischial spine and sacrospinous ligament Insertion- into coccyx and sacrum.
- 50. Pelvic diaphragm- levatorani and ischiococcygeous muscles and their fasciae together • normal tone of the muscles of the pelvic diaphragm keep the base of the U pressed against the backs of the pubic bones, keeping the vagina and rectum closed. levator plate- region of the levator ani between the anus and coccyx formed by the anococcygeal body and illiococcygeal raphe • forms supportive shelf on which rectum, upper vagina, and uterus can rest. • horizontal position of levator plate due to anterior traction by the pubococcygeal and puborectal muscles is important to vaginal and uterine support. • levator ani muscles receive their innervation from nerve to levator ani.i.e an anterior branch of the ventral ramus of the third and fourth sacral nerves .
- 51.
- 52. PELVIC VISCERA 1.Genital structures- Vagina Uterus Adenexa Broadligament 2.Blood supply and lymphatics 3.Lower urinary tract- Ureter Bladder Urethra 4.Sigmoid colon and rectum
- 53. 1.Vagina • Pliable hollowviscus organ - fibromusculomembranous • Lower portion of the vagina is constricted - passes through the urogenital hiatus in the levator ani. • 45˚ with horizontal,Long. Axis - right angle with uterus.cervix typically lies within anterior vaginal wall, making it shorter than posterior wall by about 3 cm. • Anterior and Posterior columns- anterior and posterior walls have a midline ridge, caused by the impression of the urethra and bladder and rectum on vaginal lumen. • Urethral carina-caudal portion of anterior column • Anterior ,Posterior and Lateral fornices- recesses in front ,behind and lateral to the cervix
- 54. Relations 1. Lower third- Anteriorly fused with urethra Posteriorly with perineal body Laterally to each levator ani by “fibers of Luschka., bulbocavernosus, vestibular bulb, bartholine glands Portion of pubococcygeous attached to vagina- pubovaginalis 2.Middle third Anteriorly - vesical neck and trigone Posteriorly- rectum Laterally-levators. 3. Upper third Anteriorly bladder Posteriorly- cul-de-sac Laterally- cardinal ligaments
- 55. • vaginal wall- mucosa, submucosa, muscularis, and adventitia • It has no serosa, except area covered by cul-de- sac, • mucosa - nonkeratinized stratified squamous without any glands • Submucosa- vascular tissue • Muscularis –inner circular outer longitudinal • Adventitia- portion of endopelvic fascia • When it is dissected the muscularis is adherent to it, and this combination of specialized adventitia and muscularis is the surgeon's “fascia,” called fibromuscular layer of vagina
- 56. 2. Uterus • Hollowpyriform fibromuscular organ • shape, weight, and dimensions vary depending on both estrogenic stimulation and previous parturition. • 2 portions -upper muscular body and lower fibrous cervix • reproductive age- body larger than cervix • before menarche, and after menopause body = cervix • triangular shaped endometrial cavity surrounded by a thick muscular wall. • portion of uterus that extends above the top of the endometrial cavity i.e., above the insertions of the fallopian tubes is called the fundus.
- 57. Normal position ofuterus- Anteversion- 90degree axis of cx to vx Anteflexion- 120 degree axis of body to cx
- 58. 1. muscular corpus A)Perimetrium– serous coat invests the entire organ except on lateral borders B)Myometrium - complex pattern of uterine musculature due to the origin of the uterus from paired paramesonephric primordia, with the fibers from each half crisscrossing diagonally with those of the opposite side. C)Endometrium- columnar epithelium that forms glands and a specialized stroma. no submucosa • Superficial portion- undergoes cyclic change with the menstrual cycle. Spasm of hormonally sensitive spiral arterioles that lie within the endometrium causes shedding of this layer after each cycle Deeper basal layer of the endometrium remains to regenerate a new lining. Separate arteries supply basal endometrium, explains its preservation at the time of menses.
- 59. 2.Cervix 2 portions: a)vaginalpart b)supravaginal Dense fibrous connective tissue n about 10% smooth muscle. Smooth muscle in periphery easily dissected off fibrous cervix and form layer reflected during intrafascial hysterectomy. Circularly arranged around fibrous cervix into which cardinal and uterosacral ligament • Vaginal part - covered by nonkeratinizing squamous epithelium • Supravaginal -canal is lined by a columnar mucus secreting epithelium • Internal os - widens out into endometrial cavity • External os - contains transition from squamous epithelium to columnar epithelium of the endocervical canal- changes with hormonal variation most susceptible to malignant transformation, infection
- 60. 3.Adenexal structure andbroad ligament • Ovaries and tubes constitute uterine adnexa • Fallopian tubes -paired tubular structures 7 to 12 cm in length • 4 portions 1.interstitial/intramural - passes through cornu 2.isthmic portion- emerging from corpus 3. ampulla- expanding lumen and convoluted mucosa. 4. infundibulum-fimbriated end - frondlike projections for ovum pickup. • Distal end of fallopian tube attached to ovary by ovarian fimbria, which is a smooth muscle band responsible for bringing fimbria and ovary close to one another at the time of ovulation • Tube's muscularis - composed of outer longitudinal fibers & inner circular fibres
- 61. Ovaries • Lateraly- attachedto pelvic wall by infundibulopelvic ligament(suspensary lig of ovary) containing ovarian artery, vein ,lymphatics nerve plexuxes • Medially - uterus through utero-ovarian ligament • Posteriorly – broad lig by mesovarium • Reproductive life- measures 2.5 to 5 cm long, 1.5 to 3 cm thick, and 0.7 to 1.5 cm wide, Cuboidal to columnar covering • Consists of a cortex and medulla • Medulla- fibromuscular, with blood vessels and connective tissue. • Cortex - composed of stroma, punctuated with follicles, corpora lutea, and corpora albicantia.
- 62. Ovarian fossa Depression onlateral wall of pelvis, where in ovary lies. • superiorly: external iliac artery and vein • anteriorly and inferiorly: broad ligament • posteriorly: ureter, internal iliac artery and vein • inferiorly: obturator nerve, artery and vein
- 63. Round ligament – Extensionsof the uterine musculature Homolog of the gubernaculum testis Arise on each lateral aspect of the anterior corpus. Enter the retroperitoneal tissue, pass lateral to the deep inferior epigastric vessels Enter each internal inguinal ring exit the external ring and enter the subcutaneous tissue of the labia majora.
- 64. Broad ligament • Pairedmüllerian ducts and ovaries arise from lateral abdominopelvic walls and migrate toward midline pulling a mesentery of peritoneum is pulled out from pelvic wall. This leaves midline uterus connected on either side to pelvic wall by a double layer of peritoneum called broad lig. • Superior margin of broad lig lie fallopian tubes, round ligaments, and ovaries • Lower margin of broad ligament lies cardinal and uterosacral ligaments • Ovary, tube, and round ligament each have their own separate mesentery, called mesovarium, mesosalpinx and mesoteres, • Arrangement- Round ligament placed ventrally ,exits pelvis through inguinal ligament Ovary placed dorsally Tube is in middle and most cephalic At the lateral end of fallopian tube and ovary, the broad ligament ends where infundibulopelvic ligament blends with pelvic wall.
- 65. 4.Blood supply andlymphatics of genital tract 1.ovarian arteries 2. internal iliac arteries-uterine and vaginal br 3.continuous arterial arcade connects these vessels on the lateral border of the adnexa, uterus, and vagina 1. ovarian arteries - From aorta supplies adenexa. Accompanying plexus of veins drains into vena cava on right and renal vein on left. Small branch through mesosalpinx supply fallopian tube, including a prominent fimbrial branch at lateral end of tube.
- 66. 2.Uterine artery From internaliliac artery Joins near junction of body and cervix Uterine veins accompany uterine artery -drain corpus and cervix. At lateral border of the uterus (after passing over the ureter and giving off branch) uterine artery flows into the side of marginal artery that runs along the side of the uterus.Through this, it sends blood both upward to corpus and downward to cervix. Descending branch of uterine artery crosses over the cervicovaginal junction and lies on side of vagina.
- 67. • vagina –from vaginal branch of uterine artery and vaginal branch of internal iliac artery. • Anastomotic arcade along the lateral aspect of the vagina at 3- and 9-o'clock positions • Branch from these vessels merge along anterior and posterior vaginal walls. • Distal vagina also receives a supply from pudendal vessels • Posterior wall - from the middle and inferior rectal vessels.
- 68. Fallopian tube Arterial supply-Uterineand Ovarian A. Veinous drainage- Pampiniform plexus--Ovarian veins. Ovaries Arterial supply-ovarian A Venous-pampiniform plexus – ovarian veins Uterus Arterial-uterine A vaginal A & ovarian A Venous- uterine vein –Int illiac vein Vagina Arterial-uterine A vaginal br, vaginal A Middle rectalA, int pudendal A Vein-internal illiac, int pudendal
- 69. Lymphatic drainage • Uppertwo thirds of the vagina and uterus -obturator and internal and external iliac nodes • Distal vagina & vulva- inguinal nodes • Some lymphatic channels from uterine corpus extend along the round ligament to the superficial inguinal nodes • Some nodes extend posteriorly along uterosacral ligaments to lateral sacral nodes. • Ovary -follows ovarian vessels to aorta & drain into paraaortic nodes.
- 70. Ureter • Tubular viscus •25 -30 cm long • Divided -abdominal and pelvic portions of equal length • Inner longitudinal and outer circular muscle layer. • In abdomen- extraperitoneal on posterior abdominal wall
- 71. Bladder • Hollow muscularorgan • 2 portions- body(dome) and fundus (base) • Musculature -meshwork of intertwining muscle bundles • Dome musculature is thin when bladder distended • Base thicker, varies less with distension • Base- Urinary trigone and Detrusor loop • Detrusor loop- U shaped band of musculature, open posteriorly, that forms the bladder base anterior to intramural portion of ureter. • Trigone is made of smooth muscle that arises from ureters occupy two of its three corners. • Continues as the muscle of the vesical neck and urethra.
- 72. Relation – Anteriorly-pubic boneand lower abdominal wall. Laterally and inferiorly - pubic bones Posteriorly – vagina ant fornix and cervix. Bladder base - α-adrenergic receptors Contract when stimulated - favor continence. Dome -β or cholinergic stimulation, with contraction that causes bladder emptying. • Sympathetic-pelvic plexus-pain of overdistension • Parasympathetic-S234- micturition
- 73. Artery-superior vesical artery(obliterated umbilical artery) Inferior vesical artery,either an independent br of internal pudendal artery or from vaginal artery. Vein- vesicle & vaginal plexus –int illiac veins Lymphatics- ext & int illiac lymph nodes
- 74. Urethra • Neck ofbladder to external urethral meatus • 4cm lengh, 6mm diam • Normal PUV(post urethrovesical) angle=100 • Open 2.5cm below clitoris • vesical neck- urethral lumen traverses bladder base • Ant- upper2/3rd free, lower 1/3rd attached to pubic ramii-pubourethral lig • Post-upper 1/3rd free, distal 2/3rd fused with vagina
- 75. • Muscle layer-outer,circular skeletal muscle layer (urogenital sphincter) and smooth muscle fibers. Inner longitudinal smooth muscle • Submucosa – vascular with paraurethral gland • Mucosa-nonkeratinized squamous epithelium that responds to estrogenic stimulation Proximal urethral lumen lined by urothelial cells At perineal membrane- skeletal ms form spincter urethrovaginalis and compressor urethrae • Blood supply-inferior extension of vesical vessels and internal pudendal vessels. • Nerve supply-Striated ms –somatic innervation via pudendal nerve or sacral plexus Smooth ms- inferior hypogastric plexus
- 76. • Chronic infection-urethral diverticula • Obstruction of terminal duct –cyst • Skene glands are most distal & largest paraurethral gland drain outside urethral lumen posterolateral to external urethral orrifice
- 77. Sigmoid colon andRectum Sigmoid colon Begins S-shaped curve at pelvic brim Characteristic- three tenia coli lying over a circular smooth muscle layer. Blood supply- sigmoid arteries, branches from inferior mesenteric artery enters pelvis straightens its course and becomes rectum
- 78. Rectum- Devoid of taeniaecoli Passes posterior to vagina & expands into rectal ampulla. Anorectal junction is bent at an angle of 90 degrees Pulled ventrally by puborectalis fibers' attachment to pubes Posteriorly by external anal sphincter's dorsal attachment to coccyx
- 79. Anus- • Thickened circularinvoluntary muscle- internal sphincter • Series of anal valves for closure • Lower border(dentate/pectinate line), • Mucosa becomes transitional layer of non-hair-bearing squamous epithelium then the hair-bearing perineal skin at anocutaneous line. Relations of rectum and anus – • Posteriorly- sacrum and levator plate • Anteriorly - vagina. • Inferiorly- each half of the levator ani abuts its lateral wall • Distal terminus by the external anal sphincter.
- 80. Lining epithelium: Upper 2/3-Columnar epi Lower 1/3- St. Squamous epi. Arterial supply 1. Superior rectal A. – Br. of IMA.- in sigmoid mesocolon supply upto rectum 2. Middle rectal A. – Br. of Ant. Div. of Internal iliac A. – rectum n ampulla 3. Inferior rectal A.- Br. of Internal pudental A.- anus n ext spincter Venous drainage: Rectum and upper 1/3 of anal canal- Superior rectal V.- to portal circulation Lower 2/3 of anal canal - Inferior rectal V.- to systemic circulation. Lymphatics of rectum and anal canal Rectum and upper 1/3 of anal canal- Internal Iliac & preaortic nodes. Lower 2/3 of anal canal – superficial inguinal nodes.
- 81. PELVIC CONNECTIVE TISSUE •Endopelvic fascia-connect the muscularis of the visceral organs to pelvic wall muscles • Composed of blood vessels and nerves, interspersed with a supportive meshwork of irregular connective tissue containing collagen and elastin
- 82. Uterine ligaments Broad ligament Partsof broad ligament Infundibulopelvic Ligament (Suspensory Ligament of Ovary): It includes the portion of broad lig. which extends from the infundibulum of the follopian tube to the lateral pelvic wall. It contains: 1.ovarian vessels and nerves and lymphatics from the ovary 2. fallopian tube 3. body of the uterus. Mesovarium Ovary is attached to the posterior layer of the broad lig. by a fold of peritoneum called mesovarium It contains: 1.ovarian vessels, nerves and lymphatics. Ovary is NOT enclosed within the broad ligament.
- 83. Mesosalpinx It is thepart of broad lig. between the fallopian tube and the level of attachment of the ovary. It contains: 1. Utero-ovarian anastomotic vessels. 2. vestigial remnants. Mesometrium Part of broad lig. below mesosalpinx. Longest portion which is related with the lateral border of the uterus. Contents of the broad lig. 1. Fallopian tube. 2. Uterine and ovarian A. , their anastomosis and corresponding veins. 3. Nerves and lymphatics from uterus , fallopian tube and ovary.
- 84. 4. Round ligament 5.Ovarian ligament 6. Parametrium containing loose areolar tissue and fat. The terminal part of the ureter, uterine a., paracervical nerve, and lymphatic plexus are lying at the base of the broad lig. 7. Vestigial structures , such as Duct of Gartner, Epoophoron and paraoophoron. Function-as packing material and has got steadying effect to maintain the uterus in position.
- 85. EXTRAPERITONEAL SURGICAL SPACES Anteriorcul-de-sac • Recess between the dome of the bladder and the anterior surface of the uterus • Peritoneum is loosely applied in the anterior culde-sac, allows the bladder to expand without stretching its overlying peritoneum. • Loose peritoneum forms the vesico-uterine fold, which can easily be lifted and incised to create a bladder flap during abdominal hysterectomy or cesarean section. • Point at which the vesico-cervical space is normally accessed during abdominal surgery.
- 86. EXTRAPERITONEAL SURGICAL SPACES Posteriorcul de sac /recto uterine space • Upper 1/3rd vagina-anteriorly • Rectosigmoid posteriorly • Uterosacral ligaments laterally. • Peritoneum extends for approximately 4 cm along the posterior vaginal wall below the posterior vaginal fornix where the vaginal wall attaches to the cervix. This allows direct entry into the peritoneum from the vagina when performing a vaginal hysterectomy, culdocentesis, or colpotomy. The anatomy here contrasts with the anterior cul-de-sac. • Anteriorly, the peritoneum lies several centimeters above the vagina whereas posteriorly, the peritoneum covers the vagina. Keeping this anatomic difference in mind facilitates entering both the anterior and the posterior cul-de-sacs during vaginal hysterectomy.
- 87. EXTRAPERITONEAL SURGICAL SPACES Rectopubicspace/prevesical space /spaceof Retzius Separated from the undersurface of the rectus abdominis muscles by the transversalis fascia and can be entered by perforating this layer. • Ventrolaterally- bony pelvis and the muscles of the pelvic wall • Cranially - abdominal wall. • Dorsally- proximal urethra and bladder • Content-Dorsal vein of clitoris Obturator nerve and vessels as they enter the obturator canal. Vascular connections between external and internal illiac system present passing over pubic ramii called pubic vessels – dissection in this area should be careful
- 88. EXTRAPERITONEAL SURGICAL SPACES Vesicovaginaland Vesicocervical Space • Space between the lower urinary tract and the genital tract • Lower extent-junction prox 1/3rd n distal 2/3rd urethra Rectovaginal space • Apex of the perineal body, about 2 to 3 cm above the hymenal ringI • Extends upward to the cul-de-sac • laterally around the sides of the rectum to the attachment of the rectovaginal septum to the parietal endopelvic fascia. • It contains loose areolar tissue and is easily opened with finger dissection. • At the level of the cervix, some fibers of the cardinal-uterosacral ligament complex extend downward behind the vagina, connecting it to the lateral walls of the rectum and then to the sacrum. These are called the rectal pillars.
- 89.