ANATOMY BASIC SCIENCE FOR POSTGRADUATE STUDENTS OF OBSTETRICS AND GYNECOLOGY

1. FEMALE
PELVIC
ANATOMY
(part
2
:special
anatomy)
Osama
M
Warda
MD
Prof.
of
OBS/GYN
Faculty
of
Medicine-­‐Mansoura
University

2.
8 January 2019 Osama M. Warda, MD
Osama
M
Warda
MD
Prof.
of
OB/GYN
Faculty
of
Medicine
Mansoura
University
EGYPT

3. ANATOMY
OF
PELVIC
ORGAN
SUPPORT
1. Skeletal
(bony)
support
2. Ligaments
(fascia)
support
3. Muscles
(pelvic
floor)
support
4.
RelaLon
of
pelvic
organs
to
each
other
(dynamic
support)
and
pelvic
axes
O
Warda

4. Pelvic
structures
in
superior
view
O
Warda

5. The
Bony
Pelvis
The bony pelvis
gives insertions to
the ligaments and
muscles that
support the pelvic
organs
O
Warda

6. O
Warda

7. Pelvic
Fascia
• Endopelvic
fascia
– Meshwork
of
collagen,
elasLn
and
smooth
muscle
– Extends
from
the
level
of
uterine
artery
to
the
fusion
of
the
vagina
and
levator
ani
– ATached
to
uterus
is
parametrium
–
cardinal-­‐
uterosacral
ligament
complex
– ATached
to
vagina
is
paracolpium
–
pubocervical
and
rectovaginal
fasciae
i.e.
totally
invests
the
pelvic
organs
to
transmit
the
support
to
the
pelvic
side
walls
via
ligaments.
O
Warda

8. Fascial ligaments
O
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Deeper level

9. Ligaments
O
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10. O
Warda

11. O
Warda
The anatomy of three compartment of the pelvis viewed from above
anterior
middle
posterior

12. Muscles
of
the
Pelvic
Floor
(Pelvic
Diaphragm)
• The
pelvic
diaphragm
is
composed
of
two
paired
muscles
–
levator
ani
and
coccygeus
• These
muscles:
– Close
the
inferior
outlet
of
the
pelvis
– Support
the
pelvic
floor
– Elevate
the
pelvic
floor
to
help
release
feces
– Resist
increased
intra-­‐abdominal
pressure
• PD
is
is
pierced
by
the
rectum
and
urethra
and
vagina
in
females
• Region
inferior
to
the
pelvic
diaphragm
is
the
perineum
O
Warda

13. Muscles
of
the
Pelvic
Floor:
Pelvic
Diaphragm
O
Warda

14. Muscles
Inferior
to
the
Pelvic
Floor:
The
Urogenital
Diaphragm
• Muscles
inferior
to
the
pelvic
floor
• Stretches
between
two
sides
of
the
pubic
arch
in
the
anterior
half
of
the
perineum
• Contains
– Deep
transverse
perineal
muscle
– Extrnal
urethral
sphincter
muscle
• The
ischiocavernosus
and
bulbospongiosus
assist
in
erecLon
of
the
clitoris;
lie
superficial
to
the
urogenital
diaphragm
O
Warda

15. O
Warda

16. O
Warda
Muscles
Inferior
to
the
Pelvic
Floor:
The
Urogenital
Diaphragm

17. O
Warda
Muscles
Inferior
to
the
Pelvic
Floor:
The
Urogenital
Diaphragm

18. Perineum
-­‐ Anterior=
pubic
arch
-­‐
posterior=
coccyx
Lp,
-­‐ Lateral:
ischiopubic
rami,
ischial
tuberosiLes
and
sacrotuberous
ligaments
frame
the
perineum
into
a
diamond
shape
• Divided
into
two
angulated
Triangles
:
posterior
anal
triangle
contains
the
anal
canal
and
anterior
urogenital
triangle
contains
the
vagina
and
urethra
O
Warda

19. O
Warda
The
Perineum

20. Dynamic
Support
• Bladder,
upper
two-­‐third
vagina
and
rectum
lie
in
a
horizontal
axis
• Urethra,
distal
one-­‐third
vagina
and
anal
canal
are
verLcal
in
orientaLon
• Pelvic
floor
is
horizontal
and
like
a
hammock
–
levator
plate
• Levator
ani
muscles
and
perineal
body
support
the
verLcal
orientaLon
O
Warda

21. O
Warda
The 2 major muscular supporting structures: the upper, with the pelvic
diaphragm , and the lower with the perineal membrane (urogenital
diaphragm) anteriorly and anal sphincter posteriorly

22. Dynamic
Support
• Three
support
axes:
1-­‐Upper
verLcal
axis
:
-­‐cardinal-­‐uterosacral
ligament
complex
2-­‐Horizontal
axis:
-­‐
leads
to
lateral
and
paravaginal
supports
– Two
pla_orms
pubocervical
fascia
and
rectovaginal
septum
3-­‐Lower
verLcal
axis:
-­‐
supports
the
lower
third
of
the
vagina,
urethra
and
anal
canal
O
Warda

23. O
Warda
Normal vaginal
axis=130o
130o
(A) Normal tone in the levator ani with acute anorectal angle and horizontal
levator plate; note the normal vaginal axis. (B) with loss of the levator ani
tone, there is change in the vaginal axis; sagging of the levator plate, and
enlargement of the urogenital hiatus.

24. De
Lancey’s
three
levels
of
vaginal
support
• Apical
suspension
ü Upper
para-­‐colpium
suspends
apex
to
pelvic
walls
and
sacrum
!Damage
results
in
prolapse
of
vaginal
apex
(vault
prolapse)
• Mid-­‐vaginal
lateral
aQachment
ü Vaginal
aTachment
to
arcus
tendineus
fascia
and
levator
ani
muscle
fascia
ü Pubo-­‐cervical
and
recto-­‐vaginal
fasciae
support
bladder
and
anterior
rectum
!Avulsion
results
in
cystocele
or
rectocele
• Distal
perineal
fusion
ü Fusion
of
vagina
to
perineal
membrane,
body
and
levators
!Damage
results
in
deficient
perineal
body
or
urethrocele
O
Warda

25. O
Warda

26. O
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The hammock
theory;
the ant. Vaginal
wall with its
attachment to the
arcus tendineus of
pelvic fascia forms
a hammock under
the urethra &
bladder neck.

27. ANTERIOR
ABDOMINAL
WALL
Layers
of
anterior
abdominal
wall
:
(Lateral
side)
1-­‐
Skin.
2-­‐
Superficial
fascia.
3-­‐
External
oblique
muscle.
4-­‐
Internal
oblique
muscle.
5-­‐
Transversus
abdominis
muscle.
6-­‐
Fascia
transversalis.
7-­‐
Extraperitoneal
fascia
8-­‐
ParLal
peritoneum.
O
Warda

28. ANTERIOR
ABDOMINAL
WALL
Layers
of
anterior
abdominal
wall
:
(Medial
side)
1-­‐
Skin.
2-­‐
Superficial
fascia.
3-­‐
Anterior
wall
of
rectus
sheath.
4-­‐
Rectus
muscle.
5-­‐
Posterior
wall
of
rectus
sheath.
6-­‐
Fascia
transversalis.
7-­‐
Extraperitoneal
fascia.
8-­‐
ParLal
peritoneum.
O
Warda

29. O
Warda

30. O
Warda

31. ANTERIOR
ABDOMINAL
WALL
Skin
of
the
anterior
abdominal
wall
¬
Lines
of
cleavage
in
the
skin
run
downward
and
forward
almost
horizontally
around
the
trunk
¬
An
incision
along
a
cleavage
line
will
heal
as
a
narrow
scar,
while
one
that
crosses
the
lines
will
heal
as
a
wide
scar
O
Warda

32. ANTERIOR
ABDOMINAL
WALL
Cutaneous
nerves
of
AAW:
¬It
is
derived
from
the
anterior
rami
of
the
lower
six
thoracic
and
first
lumbar
nerves
¬Thoracic
nerves
are
the
lower
five
intercostal
and
the
subcostal
nerves
¬First
lumbar
nerve
is
represented
by
the
iliohypogastric
and
ilioinguinal
nerves
O
Warda

33. ANTERIOR
ABDOMINAL
WALL
Cutaneous
arteries
of
AAW:
¬
Skin
near
the
midline
is
supplied
by
branches
of
the
superior
epigastric
artery
(
internal
thoracic
artery)
and
the
inferior
epigastric
artery
(
external
iliac
artery)
.
¬
Skin
of
the
flanks
is
supplied
by
branches
from
intercostal,
lumbar
and
deep
circumflex
iliac
arteries
O
Warda

34. ANTERIOR
ABDOMINAL
WALL
Cutaneous
veins
of
AAW
¬Venous
blood
is
collected
into
a
network
of
veins
that
radiate
from
the
umbilicus
¬The
network
is
drained
above
into
the
axillary
vein
via
the
lateral
thoracic
vein
&
Below
into
the
femoral
vein
via
the
superficial
epigastric
and
the
great
saphenous
veins
¬Few
small
veins,
the
para-­‐umbilical
veins
form
a
clinically
important
portal-­‐system
venous
anastomosis
O
Warda

35. ANTERIOR
ABDOMINAL
WALL
Superficial
LymphaVcs
of
AAW
-­‐ Lymph
drainage
of
the
skin
of
the
anterior
abdominal
wall
above
the
umbilicus
is
upward
to
the
anterior
axillary
(pectoral
group
of
nodes)
-­‐ Below
the
level
of
umbilicus
drains
downward
and
laterally
to
the
superficial
inguinal
nodes
-­‐
A
few
drain
medially
and
deeply
to
the
parasternal
and
anterior
diaphragmaCc
lymph
nodes
O
Warda

36. FEMORAL
TRIANGLE
• BOUNDARIES
O
Warda

37. FEMORAL
TRIANGLE
• ROOF:
O
Warda

38. FEMORAL
TRIANGLE
FLOOR
O
Warda

39. FEMORAL
TRIANGLE
LEFT
THIGH
O
Warda

40. FEMORAL
TRIANGLE
O
Warda

41. FEMORAL
TRIANGLE
O
Warda

42. THE
PELVIC
URETER
The
retroperitoneal
space
of
pelvic
side
walls
contains:
1-­‐
Pelvic
ureter
2-­‐
Internal
iliac
vessels
3-­‐
Pelvic
lymph
nodes
4-­‐
Obturator
nerve
-­‐ Total
length
of
ureter
is
25-­‐30
cm.
diameter
3mm.
-­‐ The
abdominal
&
pelvic
porLons
are
almost
equal
each
is
12-­‐15
cm
long.
O
Warda

43. THE
PELVIC
URETER
COURSE
&
RELATIONS:
-­‐ In
the
pelvis,
the
ureter
first
runs
downward,
backward,
and
laterally
along
the
anterior
margin
of
the
greater
sciaLc
notch.
-­‐ Opposite
to
the
ischial
spine,
it
turns
forward
and
medially
to
reach
the
base
of
the
urinary
bladder.
-­‐ Where
it
enters
the
bladder
wall
obliquely.
-­‐
Within
the
bladder
wall,
it
narrows
down,
takes
a
sinuous
course,
and
opens
into
the
cavity
of
the
bladder
at
the
lateral
angle
of
its
trigone
as
ureteric
orifice.
O
Warda

44. THE
PELVIC
URETER
• RELATIONS
OF
THE
PELVIC
URETER:
-­‐
The
pelvic
part
of
the
ureter
crosses
in
front
of
all
the
nerves
and
vessels
on
the
lateral
pelvic
wall.
-­‐
Near
the
uterine
cervix,
the
uterine
artery
lies
above
and
in
front
of
it,
a
highly
important
surgical
relaLonship
(water
under
the
bridge).
O
Warda

45. THE
PELVIC
URETER
SITES
OF
ANATOMICAL
NARROWINGS:
-­‐ The
lumen
of
the
pelvic
ureter
is
not
uniform
throughout
and
presents
3
constricLons
at
the
following
sites.
1-­‐
At
the
pelvic
brim
where
it
crosses
the
common
iliac
artery.
2-­‐
At
the
uretero-­‐vesical
juncCon
(i.e.,
where
ureter
enters
into
the
bladder).
3-­‐
At
ureteric
orifice
O
Warda

46. THE
PELVIC
URETER
• ARTERIAL
SUPPLY:
The
ureter
derives
its
arterial
supply
from
the
branches
of
all
the
arteries
related
to
it.
The
important
arteries
supplying
ureter
from
above
downward
are:
1.
Renal.
2.
Ovarian.
3.
Direct
branches
from
aorta.
4.
Internal
iliac.
5.
Vesical
(superior
and
inferior).
6.
Middle
rectal.
7.
Uterine.
O
Warda

47. THE
PELVIC
URETER
• VENOUS
DRAINAGE:
The
venous
blood
from
the
ureter
is
drained
into
the
veins
corresponding
to
the
arteries.
• LYMPHATIC
DRAINAGE:
The
lymph
from
the
ureter
is
drained
into
lateral
aorLc
and
iliac
nodes.
•
NERVE
SUPPLY:
1.
The
sympatheLc
supply
of
the
ureter
is
derived
from
T12–
L1
spinal
segments
through
renal,
aorLc,
and
hypogastric
plexuses.
2.
The
parasympatheLc
supply
of
ureter
is
derived
from
S2–S4
spinal
segments
through
pelvic
splanchnic
nerves.
The
afferent
fibres
travel
with
both
sympatheLc
and
parasympatheLc
nerves.
O
Warda

48. THE
PELVIC
URETER
Ureteric
injuries
•
Overall
incidence
is
0.5
–
1
%
of
all
pelvic
operaLons.
Incidence
varies
from
0.4
–
2.5
%
for
benign
condiLons
as
reported
in
different
studies,
but
it
can
be
as
high
as
30%
in
operaLons
for
malignancies.
•
About
75
%
of
ureteric
injuries
occur
during
an
abdominal
gynecological
surgeries
with
incidence
0.5
–
1
%
for
abdominal
hysterectomy,
compared
to
0.1
%
for
vaginal
hysterectomy.
O
Warda

49. THE
PELVIC
URETER
Sites
vulnerable
to
injury
1.
At
the
pelvic
brim
during
ligaLon
of
Infundibulo-­‐
pelvic
ligaments.
2.
At
the
base
of
the
broad
ligament,
where
it
passes
beneath
the
uterine
arteries.
3.
As
it
passes
through
it’s
tunnel
in
the
cardinal
ligaments.
4.
Along
the
course
on
lateral
pelvic
wall
just
above
the
uterosacral
ligaments.
5.
At
the
anterior
fornix
of
vagina
as
it
enters
the
bladder.
O
Warda

50. THE
PELVIC
URETER
6.
Where
it
traverses
through
the
musculature
of
bladder
(Intra-­‐vesical
part).
7.
Lateral
pelvic
side
wall
over
the
iliac
vessels
during
lymph
node
dissecLon.
8.
Any
congenital
malformaLon
eg.
Duplex
ureter
makes
it
more
vulnerable
to
injury
at
any
of
these
sites.
O
Warda

51. O
Warda

52. THE
PELVIC
URETER
Nature
of
ureteral
injury
1.
Simple
kinking
or
angulaLon;à
obstrucLon
2.
Ischemic
injury
resulLng
from
trauma
to
ureteric
sheath
during
mobilizaLon
endangering
its
blood
supply.
3.
LigaLon
with
suture.
4.
Crushing
injury
by
clamps.
5.
TransecLon
-­‐
parLal
or
complete
6.
Segmental
resecLon
-­‐
Accidental
or
planned.
7.
Thermal
injury,
during
laparoscopic
surgeries.
8.
Injury
by
staplers.
O
Warda

53. THE
PELVIC
URETER
Gynecological
procedures
associated
with
ureteric
injuries:
ABDOMINAL
VAGINAL
LAPAROSCOPIC
-­‐ Hysterectomy
-­‐ Wertheim’s
hysterectomy
-­‐
Oophorectomy
-­‐ Uterine
suspension
-­‐ V
V
fistula
repair
-­‐Hysterectomy
-­‐Anterior
colporrhaphy
–-­‐VVF
repair
•
Cervical
biopsy
-­‐ Hysterectomy
-­‐
Colposuspension
-­‐ Treatment
of
endometriosis
-­‐
SterilisaLon
(especially
electrocoaguaL
on)
O
Warda

54. THE
PELVIC
URETER
PrevenVon
of
ureteric
injuries
• Preven4ve
measures:
1-­‐
Pre
operaLve
intravenous
urography
2-­‐Placement
of
ureteric
catheters.
3-­‐
Uriglow
–
ureteric
catheters
with
incorporated
light
source.
O
Warda

55. THE
PELVIC
URETER
PrevenVon
of
ureteric
injuries
Abdomino
pelvic
surgery
•
Adequate
exposure
•
Most
important
axiom
of
surgery:
(Any
imp
structure
at
risk
of
inadvertent
injury
must
be
carefully
dissected
&
adequately
exposed).
•
To
avoid
blind
clamping
of
blood
vessels.
•
To
not
damage
the
sheath
of
ureter;
longitudinal
vessels
•
Recognized
by
Pale
glistening
appearance,
longitudinal
vessels
on
surface,
peristalsis.
O
Warda

56. THE
PELVIC
URETER
PrevenVon
of
ureteric
injuries
1-­‐
Divide
the
round
ligament
near
the
lateral
pelvic
side
wall,
then
open
the
lateral
peritoneum
10-­‐15
cm
in
a
cephalad
direcLon.
2.
Place
an
index
finger
on
the
external
iliac
artery,
3.
By
moving
the
finger
upward
(cephalad),
the
first
structure
to
be
exposed,
crossing
&
in
contact
with
the
iliac
artery,
will
be
the
ureter.
4.
As
the
index
finger
is
placed
on
the
ureter,
the
infundibulopelvic
lig.
should
be
behind
the
middle
phalanx,
can
be
safely
clamped
with
the
ureter
clearly
visible.
5.
Followed
towards
the
cardinal
lig.
Where
it
passes
under
the
uterine
artery;
Push
laterally
&
downward
moving
it
away
from
cervix.
O
Warda

57. THE
PELVIC
URETER
PrevenVon
of
ureteric
injuries
Vaginal
surgery
-­‐
To
develop
an
adequate
vesico-­‐uterine
space
•
To
clamp,
cut
&
ligate
only
small
bites
of
paracervical
&
parametrial
Lssue
•
In
post.
culdoplasty
ligaLon
of
uterosacrals
to
support
vaginal
apex
aner
the
uterus
is
removed
can
kink
or
obstruct
the
ureters
if
not
done
carefully.
•
Ant.
colporrhaphy:
Not
to
start
too
laterally
or
to
insert
deep
sutures;
distance
between
needle
&
ureter
in
upper
third
of
vagina
is
only
0.9
cm
(Hofmeister’s
fluroscopic
findings)
O
Warda

58. THE
PELVIC
URETER
PrevenVon
of
ureteric
injuries
Laparoscopic
surgery
•
Retroperitoneal
dissecLon
to
locate
ureters
•
ElectrocoagulaLon
of
bleeding
points
around
the
uterosacral
ligaments
is
risky,
might
beTer
done
with
clips,
sutures.
•
SomeLmes
width
&
length
of
the
stapler
makes
safe
applicaLon
difficult;
uterines,
cardinals
pedicles
are
beTer
ligated
vaginally.
O
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59. KEY
POINTS
FOR
CLINICAL
PRACTICE
•
Thorough
knowledge
of
the
anatomy
of
the
ureter
is
must
&
to
be
aware
of
the
sites
where
it
is
liable
to
be
injured.
• PreoperaLve
IVU
or
stent
placement
has
not
been
shown
to
decrease
the
incidence
of
ureteric
injuries.
• •
A
high
index
of
suspician
&
early
invesLgaLons
are
necessary
for
diagnosis.
• •
Early
diagnosis
&
management
will
reduce
postoperaLve
morbidity
&
save
renal
loss.
• •
Timings
of
repair
should
be
individualized,
as
no
difference
in
outcome
in
early
&
late
repair.
O
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60. PELVIC
SPACES
O
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61. IntroducVon
• An
exact
knowledge
of
the
anatomy
of
the
firm
pelvic
connecLve
Lssue
is
necessary
for
the
gynecologic
surgeon
to
avoid
blood
vessels
running
within
these
Lssues
during
dissecLon,
especially
when
anatomy
is
pathologically
disturbed,
thereby
save
the
paLent’s
blood
during
surgery.
•
Three
pairs
of
ligaments
divide
the
pelvis
into
eight
potenCal
spaces
filled
with
loose
areolar
connecLve
Lssue
and
are
usually
devoid
of
blood
vessels
and
nerves.
• These
ligaments
are
pubocervicals,
mackenrodt’s
(cardinal
or
transverse
cervicals,
and
uterosacrals.
O
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62. O
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63. O
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64. O
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65. O
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66. IntroducVon
These spaces are:
• Prevesical space (Retzius),
• Two paravesical spaces……(Bilateral)
• Vesicovaginal space,
• Rectovaginal space,
• Two Pararectal spaces……..(bilat.)
• Retrorectal space, and Presacral space
O
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67. I -Prevesical space (of
Retzius)
O
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PVS

68. • Is
a
fat-­‐
Filled
space
;
boundaries:
It
is
separated
from
the
undersurface
of
the
rectus
abdominis
muscle
by
the
transversalis
fascia
and
can
be
entered
by
perfora4ng
this
layer.
-­‐
Anterior:
by
the
pubic
bone
covered
by
the
transveralis
fascia
and
extending
to
the
umbilicus
between
the
lateral
umbilical
ligaments
(obliterated
umbilical
arteries).
-­‐Posterior:
the
anterior
wall
of
the
bladder.
-­‐The
floor
of
this
space
=
urethra,
the
paraurethral
(pubourethral)
ligaments,
and
the
urethrovesical
juncLon
(bladder
neck)
.
-­‐
The
inferior
=
pubic
symphysis
and
the
adjacent
superior
pubic
rami
with
Cooper's
ligament
represent.
-­‐It
separated
from
the
para-­‐vesical
space
by
the
ascending
bladder
septum
(bladder
pillars)
O
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69. Prevesical space (of Retzius)
O
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IMPORTANT
STRUCTURES
LYING
WITHIN
PVS:
1-­‐
Dorsal
vein
of
the
clitoris
2-­‐Obturator
nerve
3-­‐Branch
to
obturator
canal
from
external
iliac
artery
4-­‐Dense
plexus
of
vessels
near
bladder
neck
5-­‐Nerves
to
lower
urinary
tract
6-­‐
iliopecVneal
line
(ridge-­‐like
fold
of
periosteum
used
to
anchor
sutures
during
urethral
suspension
operaVons

70. Prevesical
space
(of
Retzius)
O
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• Clinical
importance
1-­‐Upon
entering
the
space,
the
pubo-­‐uretheral
ligaments
may
be
seen
inserLng
in
the
posterior
aspect
of
the
symphysis
pubis
as
a
thickened
prolongaLon
of
the
arcus
tendinous
fascia
2-­‐
Combined
abdominal
and
vaginal
bladder
neck
suspension
procedures
usually
enter
the
Retzius
space
between
the
arcus
tendinus
and
the
pubo-­‐uretheral
ligament.
• Access
to
PVSp:
1-­‐
Open
access:
cusng
the
rectus
muscle
in
the
midline
&
dissecLon
between
the
muscle
superficially
&
the
peritoneum
deep
towards
the
symphysis
pubis.
2-­‐
Laparoscopic
access:
intra-­‐peritoneal
approach,
insufflaLon
helps
dissecLon.

71. O
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PREVESICAL
SPACE
OF
RETZIUS

72. II- Vesicovaginal and
vesicocervical space
O
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• The
space
between
the
lower
urinary
tract
and
the
genital
tract
is
separated
into
the
vesicovaginal
and
the
vesicocervical
spaces
by
a
thin
septum,
the
supravaginal
septum
.
• The
lower
extent
of
the
space
is
the
juncLon
of
the
proximal
⅓
and
the
distal
⅔
of
the
urethra,
where
it
fuses
with
the
vagina,
and
extends
to
lie
under
the
peritoneum
at
the
vesicocervical
peritoneal
reflecLon.
• It
extends
laterally
to
the
pelvic
sidewalls,
separaLng
the
vesical
and
genital
aspects
of
the
cardinal
ligaments.

73. Vesico-­‐vaginal
space
(VVSp)
• Lies
in
the
midline
and
is
bounded
by:
-­‐Anterior:
the
bladder
advenLLa
-­‐Posterior:
the
anterior
vaginal
wall
advenLLa
-­‐Laterally:
the
bladder
septa
or
pillars
-­‐Superior:
by
the
point
of
fusion
between
the
bladder
advenLLa
and
the
vaginal
advenLLa.
This
point
is
called
the
supravaginal
septum
or
vesico-­‐vaginal
ligament
-­‐Inferiorly:
the
vesicovaginal
space
is
limited
by
the
fusion
of
the
uretheral
and
vaginal
advenLLa
• Clinical
importance:
Tear
of
the
fascial
investments
and
thickenings
medially,
transversely
or
laterally
allow
herniaLon
and
development
of
a
cystocele
O
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74. Vesico-­‐cervical
space:
• Is
a
conLnuaLon
of
the
vesicovaginal
space
superiorly
above
the
supravaginal
septum:
• Boundaries:
Posterior:
the
advenLLa
of
the
cervix
and
vagina
Anterior:
the
bladder
advenLLa
Superior:
the
vesicouterine
peritoneal
pouch
Inferior:
the
supravaginal
septum
• Cusng
the
supravaginal
septum
establishes
communicaLon
between
the
vesicovaginal
space
and
vesico-­‐cervical
space
O
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75. O
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VESICO-­‐VAGINAL
SPACE

76. VESICO-­‐CERVICAL
SPACE
O
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77. III- RECTOVAGINAL SPACE
O
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78. Recto-­‐vaginal
space:
• Extends
between
the
vagina
and
rectum.
It
is
bounded
by:
-­‐Anterior:
the
recto-­‐vaginal
septum
-­‐Posterior:
the
anterior
rectal
wall
-­‐Lateral:
the
descending
rectal
pillars
separaVng
the
recto-­‐vaginal
space
from
the
para-­‐rectal
space
on
each
side
-­‐Superior:
peritoneum
of
Douglas
pouch
-­‐Inferior:
the
perineal
body
2
to
3
cm
above
the
hymenal
ring
O
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79. Recto-­‐vaginal
space:
cont.,
O
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• Clinical
importance:
1-It divides the pelvis into rectal and urogenital
compartments allowing the independent
function of the vagina and rectum.
2-An anterior rectocele results from a defect or
an avulsion of the septum from the perineal
body.
3- Reconstruction of the perineum is critical for
the restoration of this important compartment
separation as well as for support of the
anterior vaginal wall

80. O
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Cervix
uteri
Posterior
vaginal
wall

81. IV- PRESACRAL & RETRORECTAL SPACES
O
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• The
pre-­‐sacral/retro-­‐rectal
space
begins
below
the
biforcaLon
of
the
aorta
and
bounded
laterally
by
the
internal
iliac
arteries

82. Retro-­‐rectal
space:
• It
is
the
space
posterior
to
the
rectum.
• Boundaries:
-­‐Anteriorly:
by
the
advenLLa
of
the
rectum
-­‐Posteriorly:
by
the
anterior
aspect
of
the
sacrum
-­‐Laterally:
it
communicates
with
paraectal
spaces,
laterally
above
the
uterosacral
ligament
and
extends
superiorly
into
the
presacral
space
O
Warda

83. Pre-­‐sacral
space
• Is
the
superior
extension
of
the
retrorectal
space
and
is
bounded:
-­‐
Anteriorly:
by
the
deep
parietal
peritoneum
-­‐
Posteriorly:
by
the
anterior
aspect
of
the
sacrum
• Clinical
importance
-­‐
This
space
contains
the
middle
sacral
vessels
and
the
hypogastric
plexus
between
the
bifurcaVon
of
the
aorta.
-­‐
Presacral
neurectomy
requires
a
good
familiarity
and
knowledge
of
this
space
O
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84. O
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85. O
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86. V- PARAVESICAL SPACES
O
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UTERUS

87. Para-­‐vesical
spaces
• Right
and
Led
spaces
• Lie
above
the
cardinal
ligament
and
its
prolongaVon
• Boundaries:
ü Medially:
by
the
bladder
pillars
ü Laterally:
by
the
pelvic
walls
(the
fascia
of
obturator
internus
and
levator
ani)
ü Superiorly:
by
the
lateral
umbilical
Ligament.
O
Warda

88. O
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89. VI- PARA-RECTAL SPACES
• Right
and
Len
spaces
• Boundaries:
-­‐Medially:
by
the
rectal
pillars
-­‐Laterally:
by
the
levator
ani.
-­‐
Posteriorly:
above
the
ischial
spine
by
the
antero-­‐lateral
aspect
of
the
sacrum
• It
is
separated
from
the
retro-­‐rectal
space
by
the
posterior
extending
descending
rectal
pillars.
O
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90. O
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91. O
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92. THE
CONNECTIVE TISSUE
SEPTA
O
Warda

93. The
supra-­‐vaginal
septum
• Represents
the
point
of
fusion
between
the
connecLve
Lssue
support
of
the
bladder
and
that
of
the
upper
vagina
and
cervix
O
Warda

94. Supra-­‐vaginal
septum
(cont.)
O
Warda
• Clinical
importance
1-­‐
Cervical
cancer
may
directly
invade
the
wall
of
the
bladder
along
this
septum
2-­‐
The
connecLve
Lssue
of
the
septum
may
be
sonened
considerably
in
pregnancy
with
the
increase
in
elasLcity
that
occur
to
accommodate
the
necessary
stretching
as
the
uterus
enlarges
as
well
as
the
contracLon
of
the
uterus
in
labor
with
minimal
alteraLon
in
bladder
funcLon.

95. Supra-­‐vaginal
septum
(cont.)
O
Warda
3-­‐This
sonening
accounts
for
the
ease
with
which
the
bladder
may
be
bluntly
separated
from
the
LUS.
and
cervix
at
CS
in
contrast
to
need
for
sharper
surgical
division
of
these
organs
in
the
non
pregnant
state.
4-­‐
The
vaginal
operator
may
incise
directly
through
the
point
of
fusion
between
the
bladder
and
vagina
providing
access
to
the
vesico-­‐uterine
peritoneal
fold
5-­‐The
abdominal
operator
will
first
enter
the
anterior
peritoneum
conLnuing
the
dissecLon
beneath
the
connecLve
Lssue
capsule
of
the
uterus
beneath
or
through
the
supra-­‐vaginal
septum
which
is
the
principle
of
the
so
called
endo-­‐fascial
(=intra-­‐fascial)
abdominal
hysterectomy.

96. The
recto-­‐vaginal
septum:
• This
septum
represent
fusion
of
the
walls
of
the
fetal
peritoneal
pouch
• It
extends
from
the
caudal
margin
of
the
cul-­‐
de-­‐
sac
to
the
proximal
edge
of
the
perineal
body.
• It
consists
of
dense
collagen,
abundant
smooth
muscle
fibers,
coarse
elasLc
fibers
demonstrated
by
special
stain
(Orcien)
• Clinical
importance
-­‐ Avulsion
of
septum
→
rectocele
,
consLpaLon
-­‐ Failure
of
normal
fusion
early
in
life
may
→
congenital
enterocele
due
to
deep
cul-­‐
de-­‐
sac
O
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97. THANKS
O
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