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Gynaecology > Pelvic visceral anatomy > Flashcards

Pelvic visceral anatomy Flashcards

1
Q

describe the path of the ureter

A

the ureter starts retroperitoneal, it crosses under the ovarian artery, over the common iliac, about the pelvic brim, runs with the internal iliac, then curves at the ischial spine medially, under the uterine artery, superior to the levator ani to the bladder, approx 5cm apart

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2
Q

What attaches to the ovary?

A

Mesovarium - part of the broad ligament is a peritoneal fold that suspends the ovary
Continuous with the mesovarium is the suspensory ligament of the ovary where the ovarian vessels / nerves/ lymphathics travel
Medially the ovarian ligament tethers the ovary to the uterus (remenant of the ovarian gubernaculum) just inferior to the uterotubal junction

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3
Q

Anatomy of the fallopian tubes

A

Suspended in mesosalpinx.
Infundibulum - distal end, opens into the peritoneum through the abdonimal ostium - it has a fimbrial end and one large ovarian fimbria attached to the ovary
Ampulla - ling middle part, fertilisation occurs here
Isthmus-think walled, enters the uterine horm
Uterine part - intramural segment of the tube, opens as uterine ostia

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4
Q

Blood supply of the ovary

A

Ovarian artery arises from the aorta, travel down posterior wall and cross the external iliacs and enter the suspensory ligament
Uterine artery travel up laterally (from int iliacs)
Ovarian and uterine arteries bifurcate into ovarian and tubal branches
Ovarian drainage Pampiniform plexus in the broad ligament merges into ovarian vein. R side - IVC L side renal vein
Tube drainage - ovarian vein or uterine venous plexus

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5
Q

layers of the uterus

A

Perimetrium - serosa - peritoneum and connective tissue
Myometrium
Endometrium
The cervix is mostly fibrous, and mainly collagen with small amounts of smooth muscle and elastin

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6
Q

Whats is the female gubernaculum

A

fibrous cord connecting ovary uterus and labia majora - represented by the ovarian ligament, and the round ligament. The round ligament passes through the inguinal canal to the subcut tissue of the labia

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7
Q

parts of the broad ligament

A

Mesometrium ( holds the uterus)
mesovarium (tolds the ovary)
Mesosalpinx (holds the tube)

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8
Q

What ligaments support the cervix

A

Cardinal ligament - Lateral parts of the vagina and supravaginal cervix to the lateral walls of the pelvis
Uterosacrals - superior and posteriorly of cx to the sacrum

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9
Q

Blood supply to the vagina

A

Superior part - uterine arteries
Middle and inferior - Vaginal and internal pudendal
Veins - vaginal venous plexus - these are continuous with the uterine ventous plexus and form the uterovaginal venous plexus and drain into the internal iliac through the uterine vein

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10
Q

lymphatics of the pelvis

A

External iliac lymph nodes - mainly lymphatics from the inguinal nodes but some from pelvic viscera - superior parts of middle to anterior pelvic organs - not travelling with the vein
Internal iliac lymph nodes - from pelvic viscera, deep perineum, gluteal region drain to common iliacs
sacral nodes - posteriorinferior pelvic viscera and drain to internal or common
Common iliac nodes - lie superior to the pelvis, along the common iliacs, passes to the lumbar nodes.

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11
Q

Pelvic floor muscles

A 
Levator ani 
- puborectalis / pubovaginalis
- pubococcygeas
- iliococcygeus 
Coccygeus - inferior sacrum and coccyx to ischial spine
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12
Q

Sacrospinous ligament

vs sacrotuberous ligament

A

Sacrospinous - sacrum to the ischial spine creating the greater from the lesser sciatic foramen
Sacrotuberous - sacrum to the ischial tuberosity

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13
Q

Attachment of
Obturator internus
Piriformis

A

Obturator internus - from pelvic side of ilium and ischium / obturatory membrane to grater trochanter
Piriformis Pelvic side of S2-4 and sacrotuberous ligament and greater sciatic notch to greater trochanter

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14
Q

path of the internal iliac

A

Common iliac bifurcates at the level of VI disc. Ureter crosses the common iliac at the level of the pelvic brim.
Travels posteriorly with the internal iliac vein and the lumbosacral trunk anterior to SIJ. Then laterally with the external iliac vein and the obturator nerve.
Ends at the superior edge of the greater sciatic foramen

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15
Q

Branches of the internal iliac

Anterior ( 7) and posterior (3) trunks

A 
Anterior
Umbilical
Obturator
Uterine
Vaginal 
Middle Rectal 
Internal Pudendal
Inferior gluteal

Posterior
Iliolumbar
lateral sacral
Superior gluteal

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16
Q

Umbilical artery

A

Occluded umbilical artery forms fibrous cord called medial umbilical ligament

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17
Q

Arteries supplying the pelvis

A

Internal iliacs
Ovarians
median sacral - arises from the posterior abdominal aorta (represents the caudal end of the dorsal aorta)
Supplies rectum / L5 arteries/ lateral sacral vessels
Superior rectal - direct continuation of the inferior mesenteric artery At the level of S3 it divides it each side of the rectum and supplies it down to the IAS.

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18
Q

Obturator nerve

What does the obturator artery supply

A

L2-4 anterior rami, lumbar plexus.
Runs through extraperitoneal fat in the lateral wall, Divides after it exits through the obturator canal in to anterior and posterior parts which supply the medial thigh muscles

The artery splits into the anterior and posterior obturator artery
anterior - artery in the thigh supplying leg muscles
posterior - into the thigh an anastamosis again with the anterior branch

19
Q

What is the Sacral promontory

What occurs at this level?

A

The ‘summit’ of the pelvis The sacral promontory S1 anterior projection

The common iliac vessels bifurcate into the internal and external iliac vessels at this level.

The ureter crosses over from the lateral to the medial side at this level over the bifurcation of the iliac vessels.

The superior hypogastric nerve plexus, as a parasympathetic nerve plexus, unites to form the left and right hypogastric nerves at this level. At this level the nerve fibers of the plexus are seen and, when traced inferiorly, form the hypogastric nerves.

The sacral promontory forms the initiation point for transperitoneal para‐aortic lymph node dissection.

The line of the small bowel mesentery crosses the sacral promontory on its way to the right sacroiliac joint

20
Q

What are the borders of the pararectal retroperitoneal space.

what are the approaches

A

lateral to the sacral promontory
dissection medial to the infundibulopelvic ligament

lateral approach is the oncological approach
medial - endometriotic approach

21
Q

What is the arbor vitae

A

The arbor vitae of the pelvis begin at the L1 level where the aorta bifurcates into the common iliac vessels
The region of vascular importance lies at the level of the sacral promontory where the common iliac vessels divide into the internal and external iliac vessels

22
Q

What is the path of the external iliac?

A

The external iliac artery travels along the iliopsoas muscles on its way to supply the lower limbs.
the external iliac artery here is that it has no branches on the anteromedial aspect of the vessels, which facilitates safer and easier ilio‐obturator lymph node dissection

23
Q

inferior epigastric artery

origin and path

A

The inferior epigastric artery arises from the anterior aspect of the external iliac artery, which travels above the transversalis fascia under the anterior abdominal wall.

24
Q

The anterior division of the internal iliac artery

Where is the ureter?

A

Relationships: The ureter always lies medial to the internal iliac artery. (External iliac laternal) The first branch of the internal iliac artery is the uterine artery, followed by the superior vesical artery, after which the vessel collapses to form the obliterated hypogastric artery or ligament.
There is 5-6 cm of anterior internal iliac before the uterine branches off

25
Q

Ureter blood supply

A

Initially renal artery
Then supply medial from the aorta
Then laterally from the internal iliac, superior vesical then inferior vesical .

26
Q

How do you ligate the internal artery and avoid the vein?

A

The internal iliac veins also lie parallel to the artery; hence caution must be taken to carefully ligate only the internal iliac artery and not the vein. This can be done by tracing it in a retrograde manner 2–3 cm from the origin of the uterine artery where a cleavage can safely be created to separate the internal iliac artery from the vein.

27
Q

What is the only lateral branch of the anterior internal iliac?

A

The only lateral branch of the internal iliac artery is the obturator artery, which lies in the lateral paravesical space (discussed later)
The obturator vessels lie exactly underneath the obturator nerve. Thus, the lower limit of obturator lymph node dissection is the appearance of the obturator nerve Dissection beyond this leads to damage to the obturator vessels and significant bleeding

28
Q

Branches of the uterine

A

It crosses over the ureter horizontally and anteriorly then divides into descending and ascending cervical branches before piercing the substance of the uterus. The uterine artery is best visualized in the pararectal space (discussed later).

The uterine artery lies anterior to the ureter, whereas the uterine vein lies posterior to the ureter

On occasion, a small branch from the uterine artery may supply the ureter near the ureteric tunnel. This needs to be identified and coagulated during tunnel dissection to prevent bleeding and obscuration of the field.

29
Q

Autonomic supply of pelvic organs

A

The inferior hypogastric nerve (T10–L2) provides sympathetic nerves and the pelvic splanchnic nerve (Figures S2–S4) provides the parasympathetic fibers.

Together these fibers merge and form the inferior hypogastric plexus, which supplies both the uterus and the urinary bladder.

30
Q

What are the spaces in the retroperitoneum

What is the base and surface of these structures

A 
Bilateral:
Pararectal space
Paravesical space
Unilateral/midline:
Prevesical space
Rectovaginal space
Retrorectal or presacral space

The peritoneal epithelial lining roofs all retroperitoneal spaces and the common floor is the levator ani muscles.

31
Q

Pararectal space

What are the borders

how to approach dissection

A 
Medial : rectum
Lateral: internal iliac 
roof: posterior leaf of the broad
base: levator ani 
Cranially : uterine artery

Splits in 2 by the ureter
medial - Okabayashi space-
This has the nerves of the superior hypogastric plexus lateral: Latzko space

32
Q

What is the paravesical space

What are its borders

A

Medial: bladder
Laterally: pelvic wall
inferiorly : uterine
Superor and anterior to the pararectal space

Divided into medial and lateral by the obliterated hypogastric artery

Lateral aspect has the 
obturator nerve (limit to posterior dissection)
33
Q

What lymph nodes are in the lateral paravesical space?

A

the lateral paravesical space contains in itself the obturator and pelvic lymph nodes, which need to be dissected during radical hysterectomy.

34
Q

Prevesical space

A

The prevesical space is a small midline retroperitoneal space that lies between the bladder and the anterior abdominal wall. It communicates with the paravesical space on both sides and is enclosed laterally by the lateral umbilical ligament, which is the continuation of the obliterated hypogastric artery onto the abdominal wall.

35
Q

Rectovaginal space

A

The retroperitoneal space lining the outside of the pouch of Douglas is known as the rectovaginal space. It is enclosed anteriorly by the uterus and the posterior vaginal wall, posteriorly by the rectum, and laterally by the uterosacral and the Mackenrodt ligament

The roof comprises the peritoneal reflections of the pouch of Douglas and the floor is formed by the levator ani muscle.

The Denonvilliers fascia is a two‐layered fascia present retroperitoneally yet between the rectum and the vagina: one layer covers the rectum and the second layer covers the vagina.

36
Q

What is the Denonvilliers fascia

A

The Denonvilliers fascia is a two‐layered fascia present retroperitoneally yet between the rectum and the vagina: one layer covers the rectum and the second layer covers the vagina. The vaginal veins are present underneath the Denonvilliers fascia, covering the vagina
Hence, the avascular plane is created exactly between the two layers of Denonvilliers fascia to dissect the rectovaginal space. This gives rise to the dictum: the “fat belongs to the bladder and fat belongs to the rectum.”

37
Q

What is the presacral space

A

A thin, small retroperitoneal space lying behind the rectum is covered by the mesorectum anteriorly and Waldeyer fascia posteriorly.

38
Q

What is Yabuki space

A

The Yabuki space, unlike other pelvic spaces, is not lined by peritoneal epithelial lining. The Yabuki fourth space, as it is also called, is a midline small retroperitoneal space confined within the anterior surface of uterus and the ureter inserting into the bladder
This space is lined by the cervicovesical fascia and contains parasympathetic nerves innervating the bladder. Careful dissection at this space helps in nerve‐sparing radical hysterectomy.

39
Q

What are the layers of the anterior abdominal wall

Above the arcuate line

Below the arcuate line

A 
Above
Skin
Subcut fat
fascia
muscle
external oblique fascia

Below

40
Q

What is the path of the pudendal nerve

Its nerve root

A

S2-4
Passes between the piriformis and the ischiococcygeus
it exists the greater sciatic foramen
Crosses the sacrospinous ligament
Reenters the lesser sciatic foramen Then it accompanies the pudental artery through the pudendal canal (formed by the fascia of the obturator internus)
supplies the perineum

41
Q

What are the 3 levels of support to the pelvic floor

A 
Level 1
Uterosacrals and cardial ligaments
Support the uterus and vagina apex 
2
Laterna lattachments of endopelvic fascia to the arcus tendineus fascia 
Support bladder vagina rectum 
3 
perineal membrane + perineum 
Support UVJ and perineum
42
Q

Function of the pudendal nerve

A

motor - levator ani muscles
Ischiocavernosis + bulbospongiosus + extrnal urethral sphincter
a branch of the pudendal is the inferior rectal and this innervates the EAS

Sensory
Inferior rectal innervates the perianal skin
Peirneal - labia and skin or perineum
Dorsal nerve of the clitoris

43
Q

How to administer a pudendal nerve block

A

Consent
lithotomy
Ischial spine is palpated transvaginally. Local anaesthetic is then injected 1cm medial and inferior into the tissues around the ischial spine.
initial injection just under the vaginal mucosa- this will be in the sacrospinous ligament then advance about 1 cm deeper and infiltrate into the loose areolar tissue , aspirate and inject.

Of note, pudendal nerve block does not abolish sensation to the anterior part of the perineum because this region is supplied by branches of the ilioinguinal and genitofemoral nerves.

Full efficacy 10-20 minutes
lasts 30-60 minutes

Gynaecology (27 decks)

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