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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.
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.
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
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
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
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?
If ovaries are removed, infundibulopelvic ligaments
Where do the fallopian tubes originate
Arise from the uterine corpus posterior and superior to the round ligaments
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
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
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
Travel through the infundibulopelvic ligaments in close proximity to the ureter, along the medial aspect of the psoas muscle
Pelvic lymph nodes
Pararectal lymph nodes
Boundaries of pelvic lymph node dissection
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
Borders of the posterior cul de sac
aka pouch of douglas.
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
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