DOCSLIB.ORG

Laparoscopic Anatomy of the Pelvis

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Laparoscopic Anatomy of the Pelvis 2 Laparoscopic Anatomy of the Pelvis Intra-Abdominal Anatomy of the Male Pelvic Region Prostatic Fascia Bladder Denonvilliers’ Fascia Medial Umbilical Ligaments Rectourethralis Muscle Lateral Umbilical Ligaments Prostatic Neurovascular Plexus Spermatic Cords Accessory Pudendal Arteries Iliac Vessels Sphincteric Complex Ureters Urethra Seminal Vesicular Complex Rhabdomyosphincter Rectum and Sigmoid Colon Intra-Abdominal Anatomy of the Female Pelvic Region Retropubic Space Overview and Compartments Pubis Bladder and Urethra Obturator Muscles Vagina, Cervix, and Uterus Bladder Ovaries and Fallopian Tubes Endopelvic Fascia Ureters Santorini’s Plexus Vascular and Lymphatic Supplies Prostatic Fascia and Prostatic Pedicles Nerve Supply Intra-Abdominal Anatomy of the spermatic vessels can be visualized entering the Male Pelvic Region deep inguinal ring (Figure 2.1). Bladder A view of the anterior pelvic wall within the abdomen shows three cord-like peritoneal folds that appear to The dome of the bladder is the mobile portion of attach the bladder to the umbilicus: the median the bladder, and it stands out centrally. The anatomic umbilical ligament (or median umbilical fold) and relationships of the bladder change according two medial umbilical ligaments (or medial umbilical to its level of fullness. Because a Foley catheter folds). The median umbilical ligament extends from must be inserted into the bladder before the pneu- the dome of the bladder to the umbilicus and cor- moperitoneum is created, the bladder is initially responds to the remnants of the fetal urachus. The empty and its limits are not clearly demarcated. medial umbilical ligaments arise from the pelvis as As the bladder fills, its limits become more clearly a continuation of the internal iliac artery and extend delineated. Laterally, it expands toward the medial to the umbilicus. These are the obliterated segments umbilical ligaments; anterior and superiorly, it of the fetal hypogastric arteries. More laterally, the expands toward the median umbilical ligament lateral umbilical ligaments consist of peritoneal folds and the umbilicus, to which it is attached through covering the epigastric vessels. Further laterally, the the urachus. 17 18 2. Laparoscopic Anatomy of the Pelvis Figure 2.1. Umbilical ligaments (transperitoneal view of right hemipelvis). UL = median umbilical ligament, MUL = medial umbilical ligament, LUL = lateral umbilical ligament, B = bladder, V = vas deferens, SpV = spermatic ves- sels, EIV = external iliac vein, U = ureter The median umbilical ligament (urachus) consti- The pouch of Douglas (Figure 2.2) appears as a tutes a fibromuscular cord, broad at its attachment cul-de-sac between the bladder anteriorly and the to the bladder but narrowing as it ascends. It is a rectum posteriorly. Its depth varies among patients, vascularized structure with few vessels that need to and it is used to make a posterior approach to the be controlled during dissection of the bladder. This seminal vesicles. The exact location of the seminal fulguration can be avoided in case the urachus is vesicles cannot be readily visualized, but they are spared. Laterally, the median umbilical ligament is often found about 2 cm above the deepest part of separated from the medial umbilical ligament by the pouch of Douglas. The outline of the seminal the medial umbilical fossa, an anatomic landmark vesicles and the distal portions of the vas deferens to access the space of Retzius. are occasionally visible in thin patients. It is important to emphasize the coalescence of The visceral peritoneum and the underlying fat, the urachus and medial umbilical ligaments to the which compose the anterior aspect of the pouch anterior parietal peritoneal wall during embryo- of Douglas that covers the bladder posteriorly, logic development to understand the planes that are rich in small vessels that should be fulgurated need to be incised during avascular access to the when incised to gain access to the seminal vesi- space of Retzius. Similar to the coalescence of cles so that the surgical field is kept as bloodless the colonic gutters to the parietal peritoneal wall as possible. to form the fascias of Toldt, both the urachus and umbilical ligaments coalesce to the anterior pari- Medial Umbilical Ligaments etal peritoneal wall; this is the plane that must be identified and developed to dissect the bladder off In the fetus, the hypogastric artery is twice as large the anterior wall in a bloodless field (see laparo- as the external iliac artery, and it is the direct con- scopic radical prostatectomy, Chapter 9). tinuation of the common iliac artery. It ascends Intra-Abdominal Anatomy of the Male Pelvic Region 19 Figure 2.2. Pouch of Douglas. B = bladder, V = vas deferens, U = ureter, IIA = internal iliac artery, EIV = external iliac vein, R = rectum, Si = sigmoid colon along the side of the bladder and runs upward on The ureter travels over the iliac vessels to run the back of the anterior abdominal wall to converge medial and deep to the medial umbilical ligament. at the umbilicus with the hypogastric artery of the Therefore, as long as the surgeon is able to visualize opposite side. Having passed through the umbilical the umbilical ligament during pelvic lymph node opening, the two arteries, now termed umbilical, dissection and dissect lateral to it, the ureter will not enter the umbilical cord, where they are coiled be at risk (see Chapter 7). around the umbilical vein, and ultimately ramify in Laterally, the medial umbilical ligament is sepa- the placenta. rated from the lateral umbilical ligament (the fold At birth, when the placental circulation ceases, of peritoneum covering the inferior epigastric only the pelvic portion of the artery remains patent artery) by the medial umbilical fossa. This fossa and constitutes the hypogastric and the first part of is transversely divided into two portions by the the superior vesical artery in the adult; the remain- vas deferens to form a quadrangle anteriorly and a der of the umbilical artery is converted into a solid triangle posteriorly. While the anterior quadrangle fibrous cord, the medial umbilical ligament. This delimits an avascular access to Retzius’ space, the ligament is rarely vascularized and most often com- posterior triangle is crucial to gain access to the pletely obliterated. The prominence of the medial obturator fossa for pelvic lymph node dissection. umbilical ligaments varies depending on the amount The vas deferens forms its base anteriorly, the of adipose tissue around it. The medial umbilical external iliac vein laterally, and the medial umbili- ligaments are particularly easy to see in laparoscopy cal ligament medially; the ureter can be visualized and represent an important anatomic landmark for at the apex of the triangle (as it crosses over the dissection not only of the pelvic lymph nodes but iliac vessels) as well as deep on its medial aspect also of Retzius’ space. (Figure 2.3). 20 2. Laparoscopic Anatomy of the Pelvis Figure 2.3. Base of vasculodeferential triangle composed of vas deferens (V) anteriorly, of medial umbilical liga- ment (MUL) medially, and of medial aspect of external iliac vein (EIV) laterally; triangle contains obturator lymph nodes along with obturator nerve and vessels (not visible). SpV = spermatic vessels, EIA = external iliac artery, GFN = genitofemoral nerve, B = bladder, U = ureter, IIA = internal iliac artery Lateral Umbilical Ligaments ilioinguinal and sympathetic spermatic plexus), and the gonadal vessels. The gonadal artery runs The inferior epigastric artery is a medial branch over the iliopsoas muscle and joins the vas deferens of the distal segment of the external iliac artery. It before entering the deep inguinal ring. The gonadal ascends along the medial margin of the deep inguinal veins ascend on the psoas major, behind the peri- ring, continues between the rectus abdominis mus- toneum, lying on each side of the gonadal artery. cle and the posterior lamina of its sheath, and then They unite to form a single vein, which opens on abuts on the anterior parietal peritoneum to create the right side at an acute angle into the inferior the lateral umbilical ligament. This ligament is the vena cava, and on the left side at a right angle into least pronounced of the three aforementioned peri- the left renal vein. toneal folds, and it is not always readily visualized. The vas deferens is rarely visible at the postero- However, knowledge of its location is important to lateral aspect of the prostate but becomes more vis- avoid injury to these vessels during either insertion ible as its course becomes more superficial laterally of the lateral trocars or dissection of the space of as it crosses over the external iliac vessels. Retzius. Again, the vas deferens and the medial umbili- cal ligament are major landmarks for pelvic lymph node dissection: the vertical incision of the parietal Spermatic Cords peritoneum lateral to the medial umbilical liga- ment and posterior to the vas deferens provides the The spermatic cord is formed by the convergence initial access to the obturator fossa. The external of the lymphovascular packet draining the testes, iliac vein can be immediately identified laterally, the vas deferens, the corresponding nerves (the with the external iliac artery located further genital branch of the genitofemoral nerve and the anterolaterally. Spermatic Cords 21 Iliac Vessels The obturator nerve is located posterior and medial to the external iliac vein. It appears as a The external iliac artery is easily recognized pul- white, shining, striated, usually flattened cord that sating below the overlying parietal peritoneum enters the obturator fossa distally. Proximally, fold at the level where the vas deferens joins the it is located at the convergence of the internal and gonadal vessels. external iliac veins. The obturator artery, a primary Lateral to the external iliac artery is the geni- or secondary branch of the internal or even external tofemoral nerve, which can eventually be used iliac artery, usually runs posterior to the obturator for nerve grafting after resection of the prostatic nerve, and the obturator vein is commonly located neurovascular bundle.
Load more

Recommended publications
  • Surgical Approaches to Fractures of the Acetabulum and Pelvis Joel M
    Surgical Approaches to Fractures of the Acetabulum and Pelvis Joel M. Matta, M.D. Sponsored by Mizuho OSI APPROACHES TO THE The table will also stably position the ACETABULUM limb in a number of different positions. No one surgical approach is applicable for all acetabulum fractures. KOCHER-LANGENBECK After examination of the plain films as well as the CT scan the surgeon should APPROACH be knowledgeable of the precise anatomy of the fracture he or she is The Kocher-Langenbeck approach is dealing with. A surgical approach will primarily an approach to the posterior be selected with the expectation that column of the Acetabulum. There is the entire reduction and fixation can excellent exposure of the be performed through the surgical retroacetabular surface from the approach. A precise knowledge of the ischial tuberosity to the inferior portion capabilities of each surgical approach of the iliac wing. The quadrilateral is also necessary. In order to maximize surface is accessible by palpation the capabilities of each surgical through the greater or lesser sciatic approach it is advantageous to operate notch. A less effective though often the patient on the PROfx® Pelvic very useful approach to the anterior Reconstruction Orthopedic Fracture column is available by manipulation Table which can apply traction in a through the greater sciatic notch or by distal and/or lateral direction during intra-articular manipulation through the operation. the Acetabulum (Figure 1). Figure 2. Fractures operated through the Kocher-Langenbeck approach. Figure 3. Positioning of the patient on the PROfx® surgical table for operations through the Kocher-Lagenbeck approach.
    [Show full text]
  • Axial CT Cystogram
    81 y/o male with abdominal pain s/p cystoscopy Edward Gillis, DO David Karimeddini, MD Axial CT Cystogram Axial CT Cystogram Axial CT Cystogram Coronal CT Cystogram ? Intra- and extraperitoneal bladder rupture Axial CT Cystogram: At the mid pelvis, contrast is seen extravasating into the left paracolic gutter, indicating an intraperitoneal component. Axial CT Cystogram: Lower down, perivesical contrast is seen. Foley catheter is present within the bladder. Axial CT Cystogram: Contrast extravasation localized around the right ureterovesical junction. Coronal CT Cystogram: Perivesical contrast around the dome of the bladder (blue arrow). Contrast is also demonstrated in the left paracolic gutter, indicating an intraperitoneal component (green arrow). Sagittal CT Cystogram: Defect in the bladder dome (yellow arrow) with perivesical contrast. Bladder Rupture Imaging Features • Intraperitoneal rupture – Contrast extravasates into the paracolic gutters and outlines loops of bowel. – Layering of contrast in dependent areas (Pouch of Douglas, Morrison’s Pouch) – Look for bladder dome defect • Extraperitoneal Rupture – Extravasation into extraperitoneal spaces, most commonly the retropubic space of Retzius – May see contrast extravasation into the anterior abdominal wall, thigh, and scrotum Bladder Rupture General Features • Extraperitoneal – 62% of all bladder ruptures – Usually secondary to pelvic fracture; fragment lacerates the base of the bladder. – Treatment is usually medical management with Abx and catheterization • Intraperitoneal – 25% of bladder ruptures – Trauma to abdomen with full bladder – May mimic acute renal failure – Treatment requires surgery to repair bladder dome • Combined – 12% of ruptures – Findings of both intraperitoneal and extraperitoneal ruptures References 1. Brant, W. E., & Helms, C. A. (2012). Fundamentals of diagnostic radiology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins 2.
    [Show full text]
  • Anatomy of Pelvic Floor Dysfunction
    Anatomy of Pelvic Floor Dysfunction Marlene M. Corton, MD KEYWORDS Pelvic floor Levator ani muscles Pelvic connective tissue Ureter Retropubic space Prevesical space NORMAL PELVIC ORGAN SUPPORT The main support of the uterus and vagina is provided by the interaction between the levator ani (LA) muscles (Fig. 1) and the connective tissue that attaches the cervix and vagina to the pelvic walls (Fig. 2).1 The relative contribution of the connective tissue and levator ani muscles to the normal support anatomy has been the subject of controversy for more than a century.2–5 Consequently, many inconsistencies in termi- nology are found in the literature describing pelvic floor muscles and connective tissue. The information presented in this article is based on a current review of the literature. LEVATOR ANI MUSCLE SUPPORT The LA muscles are the most important muscles in the pelvic floor and represent a crit- ical component of pelvic organ support (see Fig. 1). The normal levators maintain a constant state of contraction, thus providing an active floor that supports the weight of the abdominopelvic contents against the forces of intra-abdominal pressure.6 This action is thought to prevent constant or excessive strain on the pelvic ‘‘ligaments’’ and ‘‘fascia’’ (Fig. 3A). The normal resting contraction of the levators is maintained by the action of type I (slow twitch) fibers, which predominate in this muscle.7 This baseline activity of the levators keeps the urogenital hiatus (UGH) closed and draws the distal parts of the urethra, vagina, and rectum toward the pubic bones. Type II (fast twitch) muscle fibers allow for reflex muscle contraction elicited by sudden increases in abdominal pressure (Fig.
    [Show full text]
  • Pelvis + Perineum Pelvic Cavity
    Pelvis + Perineum Pelvic Cavity Enclosed by bony, ligamentous and muscular wall Contains the urinary bladder, ureters, pelvic genital organs, rectum, blood vessels, lymphatics and nerves Pelvic inlet (superior pelvic aperture) Pelvic outlet (inferior pelvic aperture) Superior Apeture Inferior Pelvic Border Lesser (True) Pelvis (pelvis minor) Location of pelvic viscera – the urinary bladder and reproductive organs such as the uterus and ovaries Bounded by the hip bones, sacrum, and coccyx Limited inferiorly by the musculofascial pelvic diaphragm Pelvic Walls and Floors Anterior pelvic wall – is formed primarily by the bodies and rami of the pubic bones and the pubic symphysis Lateral pelvic walls – formed by the hip bones and the obturator internus muscles Anterior Pelvic Wall Pelvic Walls and Floor Posterior Pelvic Wall – formed by the sacrum and coccyx, adjacent parts of the ilia, and the S-I joints; piriformis muscle covers the area Posterior Pelvic Wall Pelvic Floor Formed by the funnel shaped pelvic diaphragm – consists of the levator ani and coccygeus muscles and their fascia Stretches between the pubis anteriorly and the coccyx posteriorly and from one lateral pelvic wall to the other Levator Ani Three parts – the pubococcygeus, the puborectalis and the iliococcygeus. Collectively they run from the body of the pubis, the tendinous arch of the obturator fascia and the ischial spine TO the perineal body, the coccyx, the anococcygeal ligament, the walls of the prostate or vagina, the rectum and the anal canal Innervated
    [Show full text]
  • Session I - Anterior Abdominal Wall - Rectus Sheath
    ABDOMEN Session I - Anterior abdominal wall - Rectus sheath Surface landmarks Dissection Costal margins- right & left S u p e r f i c i a l f a s c i a ( f a t t y l a y e r, Pubic symphysis, tubercle membranous layer) Anterior superior iliac spine External oblique muscle Iliac crest Superficial inguinal ring Umbilicus, linea semilunaris Linea alba Mid-inguinal point & Lateral and anterior cutaneous branches of lower intercostal nerves Midpoint of inguinal ligament Anterior wall of rectus sheath Transpyloric & transtubercular planes Rectus abdominis & pyramidalis Right & left lateral (vertical) planes Superior & inferior epigastric vessels Nine abdominal regions – right & left hypochondriac, epigastric, right & left Posterior wall, arcuate line lumbar, umbilical, right & left iliac fossae, Internal oblique & transversus abdominis hypogastric muscles Region of external genitalia (tenth region) Fascia transversalis Terms of common usage for regions in the abdomen — Self-study Abdomen proper, pelvis, perineum, loin, Attachments, nerve supply & actions of groin, flanks external oblique, internal oblique, t r a n s v e r s u s a b d o m i n i s , r e c t u s abdominis, pyramidalis Bones Formation, contents and applied Lumbar vertebrae, sacrum, coccyx anatomy of rectus sheath Nerve supply, blood supply & lymphatic drainage of anterior abdominal wall ABDOMEN Session II - Inguinal Canal Dissection Self-study Aponeurosis of external oblique Boundaries of inguinal canal Superficial inguinal ring Contents of inguinal canal (in males and Inguinal
    [Show full text]
  • Presacral Space K C D P Silvaa, P J S Randombageb, W I Gankandac, S N Samarakkodyd, I G D C Ilukpitiyae, R D Jeewanthaf
    CME CME Drive safely through the pelvis – know your pelvic roads: Presacral space K C D P Silvaa, P J S Randombageb, W I Gankandac, S N Samarakkodyd, I G D C Ilukpitiyae, R D Jeewanthaf This is the fifth article in the series of articles unfolding on the left. The floor is continuous with the laevator avascular spaces of the pelvis. Authors recommend ani muscles. It also communicates with the pararectal reading the series of articles starting from “Drive safely spaces anterolateraly. through the pelvis – know your pelvic roads: Retropubic space of Retzius” published in the Sri Lanka This space contains the sacral venous plexus (lateral Journal of Obstetrics and Gynaecololgy1. and medial sacral veins, and the middle sacral vessels), left and right hypogastric nerves (which connects the Entry in to the presacral space is by division of the superior and inferior hypogastric plexuses) and the peritoneum overlying the sacral promontory. It is a superior hypogastric plexus (the sympathetic supply thin, small retroperitoneal space situated behind the to the pelvis) and the anterior longitudinal ligament of rectosigmoid which is partially covered by the the spine4. mesorectum anteriorly2. Care must be taken to dissect only the peritoneum as there are numerous essential Figure 1 gives an overview of the anatomy of the pelvic structures underlying the presacral space3. spaces. The boundaries of the presacral space are; roof formed by the sigmoidmesentery and the peritoneum, posterior Table 1 describes the surgical procedures, which use border by the sacral promontory, anterior border by these spaces. the posterior surface of the rectum and mesorectum.
    [Show full text]
  • Retropubic Sling
    501 19th Street, Trustee Towers FORT SANDERS WOMEN’S SPECIALISTS 1924 Pinnacle Point Way Suite 401, Knoxville Tn 37916 P# 865-331-1122 F# 865-331-1976 Suite 200, Knoxville Tn 37922 Dr. Curtis Elam, M.D., FACOG, AIMIS, Dr. David Owen, M.D., FACOG, Dr. Steven Pierce M.D. Dr. Dean Turner M.D., FACOG, ASCCP, Dr. F. Robert McKeown III, M.D., FACOG, AIMIS Dr. Brooke Foulk, M.D., FACOG, Dr. G. Walton Smith, M.D., FACOG, Dr. Susan Robertson M.D., FACOG RETROPUBIC SLING Please read and sign the following consent form when you feel that you completely understand the surgical procedure that is to be performed and after you have asked all of your questions. If you have any further questions or concerns, please contact our office prior to your procedure so that we may clarify any pertinent issues. Definition: Retropubic Sling (SPARC) is a surgical procedure that uses a narrow strip of permanent mesh to correct stress urinary incontinence (SUI). This procedure is completed through the vagina and two small incisions on the lower abdomen just above the pubic bone; it creates stabilization and support for the urethra, the tube carrying urine from the bladder to the outside of the body. Once placed, the sling creates a V-shape that supports the urethra, therefore preventing urinary leakage during episodes of increased abdominal pressures, such as coughing, sneezing, or lifting. Procedure: After sedation from general anesthesia is achieved, a catheter is placed in the bladder. The surgeon will begin by making a small incision in the vagina under the urethra and two small incisions on the lower abdominal wall just above the pubic symphysis.
    [Show full text]
  • Joint Report on Terminology for Surgical Procedures to Treat Pelvic
    AUGS-IUGA JOINT PUBLICATION Joint Report on Terminology for Surgical Procedures to Treat Pelvic Organ Prolapse Developed by the Joint Writing Group of the American Urogynecologic Society and the International Urogynecological Association. Individual contributors are noted in the acknowledgment section. 03/02/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3JfJeJsayAVVC6IBQr6djgLHr3m8XRMZF6k61FXizrL9aj3Mm1iL7ZA== by https://journals.lww.com/jpelvicsurgery from Downloaded meaningful data about specific procedures, standardized and Downloaded Abstract: Surgeries for pelvic organ prolapse (POP) are common, but widely accepted terminology must be adopted. Each term for a standardization of surgical terms is needed to improve the quality of in- given procedure must indicate to researchers, clinicians, and from vestigation and clinical care around these procedures. The American learners a specific and reliable minimal set of steps. The aim of https://journals.lww.com/jpelvicsurgery Urogynecologic Society and the International Urogynecologic Associ- this document is to propose a standardized terminology to de- ation convened a joint writing group consisting of 5 designees from scribe common surgeries for POP. each society to standardize terminology around common surgical terms in POP repair including the following: sacrocolpopexy (including sacral colpoperineopexy), sacrocervicopexy, uterosacral ligament suspension, sacrospinous ligament fixation, iliococcygeus fixation, uterine preserva- tion prolapse procedures or hysteropexy
    [Show full text]
  • Drive Safely Through the Pelvis – Know Your Pelvic Roads Retropubic Space of Retzius K C D P Silvaa , S N Samarakkodyb
    CME CME Drive safely through the pelvis – know your pelvic roads Retropubic space of Retzius K C D P Silvaa , S N Samarakkodyb This article is the first in the series of articles describing planes. Creation of the penumoperitoneum in laparo- avascular spaces of the pelvis useful in gynaecological scopy significantly helps in this dissection by opening laparoscopic surgery. It will describe the relevant up these spaces. Dissection planes are well demarcated anatomy and the principles underlying surgical pro- by the bubbles and arrows created by the gas. It shows cedures which uses these spaces. the pelvic surgeon the roads to drive through. With proper dissection even the smallest blood vessels are Almost all of the surgical procedures done by gynae- visible and can be coagulated, making the surgery clean cological surgeons are carried out within the pelvic and almost bloodless, which contributes to an excellent cavity. Pelvis is a unique space packed with a large surgical outcome. Also, all neurovascular bundles can number of organs, vessels and nerves placed in close be preserved thus preserving functionality of pelvic proximity to each other. These organs belong to organs. different systems of the body. Conventional learning of a trainee is to study each of these organs separately For descriptive and educational purposes the retro- related to the respective systems. Relationship between peritoneal spaces are divided into lateral and medial each of these entities and their position relative to each pelvic spaces. But in reality, all the spaces are con- other (topographic anatomy) is usually not highlighted tinuous with each other. The arbitrary demarcations even in postgraduate training.
    [Show full text]
  • 3. Abdominal Visceral Procedures
    BWH ANATOMICAL BASIS OF SURGERY COURSE 3. ABDOMINAL VISCERAL PROCEDURES CONTENTS 1. EXPLORATORY LAPAROTOMY, LYSIS OF ADHESIONS (LOA) ................................................................... 15 2. SMALL BOWEL RESECTION ...................................................................................................................... 29 3. COLON MOBILIZATION AND RESECTION ................................................................................................ 33 4. LEFT VISCERAL MEDIAL ROTATION (MATTOX MANEUVER) .................................................................. 25 5. OPEN CHOLECYSTECTOMY ...................................................................................................................... 39 6. MOBILIZATION OF THE LIVER .................................................................................................................. 45 7. LIVER “WEDGE” RESECTION (PARTIAL HEPATECTOMY, NONANATOMIC) ........................................... 47 8. HEPATECTOMY, ANATOMIC .................................................................................................................... 49 9. PANCREATIC AND SPLENIC RESECTIONS ................................................................................................ 57 10. OPEN SPLENECTOMY ............................................................................................................................... 75 11. OPEN NEPHRECTOMY .............................................................................................................................
    [Show full text]
  • MALE and FEMALE PELVIC VISCERA and PERITONEAL REFLECTIONS (Grants Dissector [16Th Ed.] Pp
    MALE AND FEMALE PELVIC VISCERA AND PERITONEAL REFLECTIONS (Grants Dissector [16th Ed.] pp. 171-175 [Female] pp. 154-157 [Male reflections] MALE AND FEMALE PELVIC VISCERA; PELVIC NEUROVASCULATURE (Grant's Dissector [16th Ed.] pp. 154-165 [Male]; 175-182 [Female]) ____________________________________________________________________________________ TODAY’S GOALS: 1. Identify the peritoneal reflections in the male and female. 2. Identify the female internal genitalia and adnexa. 3. Identify the broad ligament of the uterus. 4. Identify the musculature of the lateral and posterior pelvic walls and the component muscles of the pelvic diaphragm. 5. Identify major branches of the internal iliac artery. 6. Identify the branches of the sacral plexus. 7. Identify internal features of male and female pelvic viscera. 8. Identify internal features and relationships of the anal canal. MALE AND FEMALE PELVIC VISCERA AND PERITONEAL REFLECTIONS DISSECTION NOTES: Male: Peritoneal Reflections (Fig. 5.15 and 5.17): Peritoneum reflects off the anterior abdominal wall onto the superior surface of the bladder (space of Retzius – retropubic space). It reflects along the sides of the bladder forming the paravesical fossae. At the posterior margin of the bladder, peritoneum reflects inferiorly and caps the superior aspect of the seminal vesicles. From here it lines the rectovesical fossae and is reflected onto the anterior surface of the middle part of the rectum and then along the sides of the rectum to form the pararectal fossae. Female: Peritoneal reflections (Fig. 5.28 and 5.32): Peritoneum reflects off the anterior abdominal wall (space of Retzius – retropubic space) onto the superior surface of the bladder. It reflects along the sides of the bladder forming the paravesical fossae.
    [Show full text]
  • Pelvic Floor
    PELVIC FLOOR Dr.Shailaja Shetty, Professor & HOD, Dept. of Anatomy, MSRMC, Bangalore OUTLINE INTRODUCTION UROGENITAL DIAPHRAGM PELVIC DIAPHRAGM PERINEAL BODY PELVIC PERITONEUM INTRODUCTION The outlet of the true pelvis is called the pelvic floor. It is gutter shaped. Inclined at an angle of 5-15 degrees from the horizontal. UROGENITAL DIAPHRAGM It is a musculo-fascial partition across the pubic arch, between the ischial tuberosities and the pubic symphysis. Lies superficial to the pelvic diaphragm In female the U-G diaphragm is less defined due to the presence of vagina. Hence it is also called triangular ligament UROGENITAL DIAPHRAGM Consist of: 2 muscles: Sphincter urethrae and Transversus perinei profundus 2 fasciae: Superior and inferior fasciae of urogenital diaphragm 2 structures piercing it: vagina behind and urethra in front UROGENITAL DIAPHRAGM MUSCLES FORMING U-G DIAPHRAGM 1. SPHINCTER URETHRAE: 2. TRANSVERSE PERINEI It encircles the membranous PROFUNDUS: urethra Situated behind the sphincter It has a superficial part and urethrae deep part. SPHINCTER URETHRAE Superficial part: Arise from the transverse perineal ligament and adjacent pubic arch Passes backwards by the side of the urethra Inserted into the perineal body Deep part: Arise from the inner side of the ischio-pubic ramus and pudendal canal. It encircles the urethra and is continuous with similar fibers of opposite side TRANSVERSE PERINEI PROFUNDUS Arises from the inner surface of the ischial ramus . Inserted into the perineal body where it intermingles with the opposite side muscles. NERVE SUPPLY: Both muscles are supplied by muscular branches of the perineal nerve. RELATIONS Below: Contents of the superficial perineal pouch Above: Neck of the urinary bladder in female Anterior fibres of the levator ani muscles Anterior recesses of the ischiorectal fossae In front: Triangular gap between arcuate pubic ligament and transverse perineal ligament .
    [Show full text]