Clinical reference for the ob/gyn: Surgical anatomy of the pelvis

Minimally Invasive Gynecologic Surgery: Evidence-Based Laparoscopic, Hysteroscopic & Robotic Surgeries

Jon Ivar Einarsson, MD, PhD, MPH, and Arnaud Wattiez, MD, eds; JP Medical Publishers

This textbook describes the full range of minimally invasive procedures in current gynecologic practice. It opens with a section that describes instrumentation, electrosurgery, how to avoid and manage complications, and single-port surgery. Subsequent sections cover procedures for benign and malignant conditions and relevant robotically assisted surgeries. Highly structured chapters provide practical guidance about key steps of each procedure, alternative management options, contraindications, and available evidence. Contributors from international centers ensure that coverage reflects global best practice.

Chapter 1: Surgical Anatomy of the Pelvis

Authors: Marcello Ceccaroni, Roberto Clarizia, Giovanni Roviglione, and Alfredo Ercoli

Synopsis: In this chapter, Ceccaroni and colleagues set the stage for performing minimally invasive procedures by focusing on the anatomy of the pelvis. Sections include: Muscles, Fasciae, Pelvic Spaces (retropubic, retroinguinal, paravesical, pararectal, retrorectal, iliolumbar, vesicovaginal, rectovaginal), Ovaries, Fallopian tubes, Uterus, Parametrium (Lateral parametrium, anterior parametrium, posterior parametrium), Urinary bladder, Ureter, Sigmoid colon, Rectum, Pelvic lymph nodes, and Pelvic visceral nerves.

Ten figures (photographs of cadaver specimens and in vivo examples) with the anatomic features labeled aid the reader.

Key messages

• Covered by a double layer of fascial sheet that forms the parietal pelvic fascia (PPF), the pelvis forms the caudad portion of the abdomen.

• The levator ani and coccygeus muscles covered by the PPF make up the main portion of the muscular layer of the pelvis.

• Two different fascial systems-the PPF and the visceral pelvic fascia (VPF)-can be identified in the pelvis.

• Surgical dissection of connective tissue from surrounding viscera creates virtual or potential space in the pelvis. Each pelvic space is part of the retroperitoneum and its caudad limit is represented by the pelvic floor.

• The paravesical space is one of the most important spaces in the pelvis because it affords initial access to the anterolateral compartment of the pelvis for procedures such as pelvic lymphadenectomy and radical hysterectomy.

• Injury to the rectum is more likely when dissection is carried out in the rectal fascia than in the rectovaginal space proper.

• The endometrium is the most shape-varying and hormone-responsive mucosa in the human body and anatomic landmarks for it are fundamental for benign and oncologic surgery.

• In 60% of cases, the uterine trunk comes directly from the anterior branch of the internal iliac artery and the obliterated umbilical artery from a separated trunk. In the other 40% of cases, the uterine artery is a branch of the umbilical artery itself.

• To clearly identify the hypogastric nerves’ course toward the inferior hypogastric plexus, it is mandatory to access the lower mesorectum and bluntly dissect into the pararectal fossae down along the so-called holy plane of Heald on the midline.

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