anatomy Flashcards
round ligament
attache to lateral aspect of uterus
passes through deep inguinal ring to attach to superficial tissue of the female perineum
proximal part in broad ligament
embryological remenant
most inferior point in an upright female
recto-uterine (pouch of Douglas)
broad ligament
double layer of peritoneum
helps maintain uterus in correct midline positions
connects - uterus, fallopian tubes + ovaries to pelvic wall
what does the broad ligament contain
ovaries
fallopian tubes
round ligament (proximal part)
3 laers of the uterus body
perimetrium
myometrium
endometrium
implantation anywhere else = ectopic pregnancy
3 levels of support for uterus
- strong ligaments - uterosacral ligaments
- endopelvic fascia
- muscles of pelvic floor - levator ani
–> weakness of these -> uterine prolapse (uterus moves inferiorly)
commonest position of uterus
anteverted + anteflexed
other = retroverted + retroflexed(tip pointed towards back)
where does fertilisation occur
ampulla
salpingo-oophrectomy
bilateral = removal of uterine tubes and ovaries
unilateral = removal of one uterine tube
where does the fimbriated end of the uterine tubes actually open into
peritoneal cavity
communication between genital tract + peritoneal cavity
-> in theory, infetion could pass between the 2 areas
what area must be sampled in a cervical screening?
squamo columnar junction (transformation zone)
what type of muscle is levator ani
skeletal muscle - voluntary
forms majority of pelvic diaphragm
what supplies levator ani
S2, 3, 4 sacral plexus
what is the perineal body?
bundle of collagenous + elastic tissue into which the perineal muscle attach
- important to pelvic floor strength
- can be disrupted during labour -> weak pelvic floor
border of breasts
ribs 2-6
lateral border of sternum to mid-axillary line
lies on deep fascia covering pec major + serratus anterior
where does retromammary space lie?
between fascia + breats
where does most lymph from the breast drain to?
ipsilateral axillary lymph nodes then to supraclavicular nodes (75%)
lymph from
- inner breast quadrant -> can drain to parasternal lymph nodes
- lower inner -> abdominal lymph nodes
- upper limb -> axillary lymph nodes
where can the 3 levels of axillary nodes be found respectively?
level I = inferior + lateral to pectoralis minor
level II = deep to pec minor
level III = superior + medial to pec minor
which artery do the majority of the arteries in the pelvis + perineum arise from? except what?
internal iliac
except
- gonadal artery (ovarian, testicular) - abdominal aorta
- superior rectal artery - continuation of IMA
where do the gonadal artery (ovarian, testicular) arise from?
abdominal aorta
where does the superior rectal artery arise from?
- continuation of IMA inferior mesenteric artery
artery that males have that females usually dont in pelvis?
inferior vesical artery ( they have superior tho)
which artery in the male perineum arises from a different location?
anterior scrotal artery
others - internal pudendal
which artery does the ureter pass under?
uterine artery
where does most of the venous drainage in the pelvis + perineum occur?
internal iliac
- some via superior rectal into hepatic portal system
- some via lateral sacral veins into internal vertebral venous plexus (spinal canal, important in infection spread)
is the ilium in the pelvic inlet or outlet?
inlet, as well as -
- superior pubic ramus
- pubic symphysis
- sacral promontory
attachments of inguinal ligament
ASIS -> pubic tubercle
what positions of a clock face are the ischial spines palpable on vaginal examination?
4 + 8 o’clock
2 key ligaments of pelvis? which foraminae do these form respectively?
sacrotuberous ligament - greater sciatic
sacrospinous ligament - lesser sciatic foramen
2 key ligaments of pelvis? which foraminae do these form respectively?
sacrotuberous ligament - greater sciatic
sacrospinous ligament - lesser sciatic foramen
difference in female vs male pelvis
AP + transverse diameters of female pelvis are larger, both at pelvic inlet + outlet
subpubic angle (+pubic arch) in female is wider
pelvic cavity is more shallow in female
vertex of foetal skull
anterior + posterior fontanelles + parietal eminences
how is the distance of foetal head from ischial spines described?
referred to as the station
- negative number = head superior to spines
positive = head is inferior
which position should the baby leave the pelvic cavity?
occipitoantierior (OA)
- during delivery foetal head should be in extension
describe the positions of the foetal head during childbirth
pelvic inlet - tranverse (side)
descent through pelvic cavity - rotate 45 + flexed
pelvic outlet - OA + extended
-> one head delivered, further rotation so shoulders can get through
how does pain from perineum differ from pain from uterus, vagina and adnexae?
perineum - somatic sensory
others - visceral afferents (except perineum part of vagina)
innervation to superior aspect of pelvic organs (touching peritoneum)
visceral afferents
run alongside SYMPATHETIC fibres
enter spinal cord between T11-L2
pain perceived as SUPRAPUBIC
innervation to inferior aspect of pelvic organs (NOT touching peritoneum)
visceral afferents
run alongside PARASYMPATHETIC fibres
enter spinal cord between S2, S3, S4
pain perceived IN S2, S3, S4 DERMATOME (PERINEUM)
above vs below levator ani innervation
above (in pelvis)
- visceral afferents
- parasympathetic
- s2, 3, 4
below (perineum)
- somatic sensory
- pudendal nerve
- s2,3,4
- localised pain within perineum
blood supply to the anterior abdominal wall
superior epigastric arteries
- continuation of internal thoracic
- emerges at superior aspect of abdominal wall
inferior epigastric arteries
- branch of external iliac artery
- emerges at inferior aspect of abdo wall
blood supply to lateral abdominal wall
intercostal + subcostal arteries
- continuation of posterior intercostal arteries
- emerge at lateral aspect
what direction should you incise in in relation to muscle fibres?
same direction
minimise traumatic injury
incision type use in C-section
LSCS (lower segment caesarean section)
- also used for abdominal hysterectomy
- vertical midline for laparotomy
layers passed when opening for a Csection?
skin + fascia
(anterior) rectus sheath
rectus abdominas
fascia + peritoneum
retract bladder
uterine wall
amniotic sac
layers to stitch closed post Csection
uterine wall with visceral peritoneum
rectus sheath
skin
layers when opening for a laparotomy? layers that need stitched closed?
layers when opening
- skin + fascia
- linea alba
- peritoneum
layers to stitch close ->all above
laparoscopy
sub-umbilical incision may be all that’s required
if lateral post require, must avoid INFERIOR EPIGASTRIC ARTERY
position of uterus can be manipulated by grasping cervix with forceps inserted via vagina
which artery must be avoided in laparoscopy?
inferior epigastic artery
- branch of external iliac
- emerges just medial to deep inguinal ring
- then passes in superomedial direction posterior to rectus abdominis
how can you differentiate from the ureter + uterine artery?
ureter passes inferior to artery (“water under the bridge”)
ureter often “vermiculates” when touched
layers of abdominal wall
external oblique
internal oblique
transversus abdominis
transveralis fascia
extra peritoneal fat
parietal peritoneum
!abominal organs!
3 layers of pelvic floor
pelvic diaphragm - levator ani, coccygeus
muscles of perineal pouches
perineal membranes
3 parts of levator ani
illiococcygeus - most lateral
pubococcygeus
puborectalise - most medial
levator Ani innervation
pudendal nerve + nerve to levator ani
LA tonically contracted most of time
what does the female superficial perineal pouch contain?
female erectile tissue + assoc muscles
- clitoris + crura - corpus cavernosum
- bulbs of vestibule - paired
- assoc muscles - bulbospongiosus, ischiocavernosus
gretaer vestibule glands
superficial transverse perineal muscle
branches of internal pudendal vessels
pudendal nerve
whats does the male superficial perineal puch contain?
root of penis
- bulb - corpus spongiosum
- crura - corpus cavernosum
- assoc muscles - bulbospongiosus, ischiocavernosus
proximal spongy urethra
superficial transverse perineal muscle
branches of pudendal vessels
pudendal nerve
prolapse treatment/repair
sacrospinous fixation
- sutures placed in sacrospinous ligament
- performed vaginally
- risk to pudendal NVB + sciatic nerve
incontinence surgery
- mesh through obturator canal
- create sling around urethra
- incision through vagina + groin
