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Three layers of the uterus

Serosa - thin outer lining layer of the uterus

Apposition of the cervix

Anterior - bladder
Lateral - broad ligament
Posterior - Anterior boundary of the pelvic posterior cul-de-sac (pouch of douglas)

Uterine support structures

Uterosacral and cardinal ligament complex
Round ligaments - extensions of the uterine musculature

Round ligaments beginning

Begin at uterine fundus as extensions of the uterine musculature --> anterior and inferior to the fallopian tubes

They then travel anterior and inferior to the fallopian tubes and travel retroperitoneally through the layers of the broad ligament, enter the inguinal canal, and terminate in the labia majora.

Male homolog of the round ligaments

Gubernaculum testis

Broad ligament boundaries

Sup - round ligaments
Post - infundibulopelvicligaments
Inf - cardinal and uterosacral ligament complex

Divisions of the broad ligament

Composed of anterior and posterior leaves
Also has mesosalpinx (near fallopian tubes)
Mesovarium (near ovary)

Cardinal ligament divisiosn

upper - near junction of uterine body
lower - junction of cervix and vagina

Pelvic ureters are crossed by what arteries

Uterine artery crosses the lower third of the pelvic ureter obliquely lateral and cephalad to the tuerus
Ureter may be crossed again by the inferior vesical artery as it enters the bladder.

Distal ureter is pretty darn close to the anterolateral fornix of the vagina

How do the ureters gain entrance to the pelvis

Crosses lateromedially over the psoas muscle and over the common iliac vessels at the point where the external and internal iliac arteries bifurcate.

Ureter descends into the pelvis medail ot the internal iliac and the obturator fossa.

Left ureter complicated by position of the sigmoid colon and the IMA....

Crosses the common iliac artery in concert with the ovarian arteries and descends into the pelvis following a similar course to the right ureter.

What level is the bracnh of the right and left common iliacs


Hypogastric artery divisions

anterior and posterior.

Anterior - bladder, uterus, vagina, obturator, andinternus, terminates in the inferior gluteal and interanl pudendal arteries.

Posterior - plungs downint the deep recesses of the pelvis near the ischial spines, in turn branching into a large superior gluteal artery and a smaller lateral sacral acrtery.

Main uterine support

Cardinal ligaments, which exten from roughly the level of the cervicoisthmic junction peripherally ina fan like fashion laterally and posteriorly where it blends with the fat and fascia of the pelvic side wall.

Uterosacral ligament course

Connects to the cardinal ligaments at the latter's cervical attachment and extends posteriorly and inferiorly twoards the ischial spines and sacrum

Round ligaments

Arise from the anterolateral fundus and extend ventrally and laterally to the anterior abdominal wall entering the inguinal canal and terminating in the fat of the labium

Why are the round ligaments different

composed mainly of smooth muscle

Infundibulopelvic ligaments

Peritoneal vascular conduits which carry the ovarian vessels from the posterolateral pelvic brim in an anteromedial direction to gain attachment to the uterus a tthe level of the cornua.;

Supporting structures of the ovaries

Utero-ovarian ligament

Infundibulopelvic ligament (aka suspensory ligament of the ovary) - attaches the ovary to the pelvic sidewall

Broad ligament - condenses to form the mesovarium

If ovaries are conserved during a hysterectomy, what ligaments are transected

What about salpingo-oophorectomy?

Uteroovarian ligaments

If ovaries are removed, infundibulopelvic ligaments

Where do the fallopian tubes originate

Arise from the uterine corpus posterior and superior to the round ligaments

Lumen of the fallopian tubes communicate with what

Uterine cavity
Intraabdominal cavity

Distinct portions of the fallopian tube

Interstitial portion - uterine connection
Isthmus - narrow lumen and thick muscular wall
Ampulla - large lumen and mucosal folds
Fimbria - endof the tube

Umbilicus is sig why

Location on abdominal wall with the shortest distnace from skin to peritoneum. Therefore commonly used as entry point for first trocar insertion.

Inferior epigastric vessels perfuse what

Rectus abdominis muscles, arising from the inferior epigastric artery

They run lateral to the medial umbilical ligaments.

What should you try not to hit in lower abdominal ports for laparoscopy

Inferior and superficial epigatric vessels, through transillumination.

Useful landmark for identifying uterine artery

Oblitered umbilical arteries --> often share an origin with the uterine arteries. Tugging on them may help identify the uterine artery in cases of distorted pelvic anatomy.

Branches of the posterior division of the internal iliac artery

Travels toward the ischial apsine, branches into the lateral sacral, iliolumbar, and superior gluteal arteries

Branches of the anterior division of the internal iliac

Obliterated umbilical
Superior vesical
Inferior gluteal
Internal pudendal arteries


Surgical treatment of atonic uterine hemorrhage.
(A) Ligation of the uterine artery. The artery crosses over the ureter and is ligated beyond this point at the uterine corpus.
(B) Hypogastric artery ligation. Ligation of the anterior division of the internal iliac artery is performed after careful identification and retraction of the ureter, which usually overlies the bifurcation of the iliac artery into the external and internal iliac branches.

Uterine artery travels through what structure

Cardinal ligament

Joins uterus near level of the internal cervical os and gives off branches that run superiorly toward the corpus and inferiorly toward the cervix. They anastomose with vessels that derive from the ovarian arteries.

Ovarian artery origin and course

Abdominal aorta
Travel through the infundibulopelvic ligaments in close proximity to the ureter, along the medial aspect of the psoas muscle

Pelvic lymph nodes

Common iliac
External iliac
Internal iliac
Medial sacral
Pararectal lymph nodes

Boundaries of pelvic lymph node dissection

Ureter medially
Body of psoas and genitofemoral nerve lat
Midportion of hte common iliac artery superiorly to the deep circumflex iliac vein inferiorly
Posterior - obturator nerve at the base of the obuturator fossa.

Lymphatic drainage of the uterus and prox vagina

Obturator and internal and external iliac lymph nodes
Ultimately to the common iliac

Ovarian lymphatic drainage

Ovarian vessels to the paraaortic lymph nodes

Distal vagina and vulva lymphatic drainage

Inguinal nodes

Borders of the posterior cul de sac

aka pouch of douglas.
Vagina anteriorly
Rectosigmoid colon posteriorly
Uterosacral ligaments laterally

Uterine artery origin

Anterior division of the internal iliac arteries in the retroperitoneum. They travel through the cardina ligament and pass ove rht eureter

Ureters travel into the pelvis along with what

Ovarian vessels. Ureter usually lies posterior and medially to the infundibulopelvic ligament, but in cases where it lies in close prox, it may be necessary to open retroperitoneal space lateral to the infundibulopelvic ligament to create a window b/w the ovarian vessels and the ureter in order to safely secure the ovarian vascular pedicle.

What gets good retroperitoneal access in salpingo-oophorectomy at time of hysterectomy

Opening th ebroad ligament between the round lig and the infundibulopelvic lig

Ureter is usually how close to the uterus

2 cm lat, but may be nearer

Where does the ureter pass beneath the uterine artery

Just inferior to the internal cervical os, approx 1.5 cm lat.

Ureter then courses medially as the tuterosacral ligament is traced from the sacrum toward the vagina. At level of ishial spin, ureter is approx 2.3cm lat to uterosacral ligament.

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