3d anatomical basis for transobturator surgeries
DESCRIPTION
3D ANATOMICAL BASIS FOR TRANSOBTURATOR SURGERIES. Prof. Paulo Palma. Paradigm shifts. 1. Integral Theory, 1993 (Peter Petros) Creating neoligaments using tapes Reinforcement of pubourethral ligament Midurethral tape placement. 2. Transobturator Approach, 2001 (Delorme) - PowerPoint PPT PresentationTRANSCRIPT
3D ANATOMICAL BASIS FOR TRANSOBTURATOR SURGERIES
Prof. Paulo Palma
Paradigm shifts
1. Integral Theory, 1993 (Peter Petros)– Creating neoligaments using tapes– Reinforcement of pubourethral ligament– Midurethral tape placement.
2. Transobturator Approach, 2001 (Delorme)- Reinforcement of urethropelvic ligament- Less visceral and vascular complications- Less irritative voiding symptoms
Sacro UterineSacro Uterine LigamentLigament
BladderBladder
UterusUterus
PP
Tendineous Tendineous ArcArc
PubourethralPubourethralLigamentLigament
SacruSacrumm
Urethropelvic LigamentUrethropelvic Ligament
VaginaVagina
Anterior Median PosteriorCompartimentsCompartiments
PP
Tendineous ArcTendineous Arc
SacrumSacrum
VaginaVagina
PubourethralPubourethralLigamentLigament
Urethropelvic LigamentUrethropelvic Ligament
Sacro Sacro UterineUterine LigamentLigament
LIGAMENTSLIGAMENTS
RestRest
StrainingStraining
VoidingVoiding
12 3
4
1. Superficial Transverse 1. Superficial Transverse Muscle of perineumMuscle of perineum
2. Isquiocavernosous muscle2. Isquiocavernosous muscle
3. Bulbocavernosous Muscle3. Bulbocavernosous Muscle
4. External Anal Esfincter 4. External Anal Esfincter
First muscular layer
5
5.Deep Transversal5.Deep TransversalMuscle of perineum Muscle of perineum
Second Muscular LayerSecond Muscular Layer
6677
886. Pubovaginal6. Pubovaginal7. Puborectal7. Puborectal
8. Ileococcigeous8. Ileococcigeous
White LineWhite Line
RECTOVAGINAL FASCIARECTOVAGINAL FASCIA
VESICOVAGINAL FASCIAVESICOVAGINAL FASCIA
Bony Anatomy
Ischial tuberosity
Pubic Symphysis
Ischiopubic ramus
Obturator Canal
Muscular Anatomy
Clitoris
GracilisGracilisAdductor longus
Adductor magnus
Muscular Anatomy
Muscle Function Innervation
Adductor longus Adducts & flexes thigh Obturator (L2,3)
Adductor brevis Adducts & flexes thigh
Obturator (L2, 3)
Adductor magnus
Adducts, extends, flexes & rotates
thigh
Obturator (L2, 3) & Tibial (L4,
5)
Gracilis Adducts thigh, flexes knee
Obturator (L2, 3)
Obturator internus
Lateral rotator of thigh
Obturator (L5, S1)
Obturator externus
Lateral rotator of thigh
Obturator (L3, 4)
Pectineus Flexes thigh, Adducts thigh Femoral (L2, 3)
Obturator VesselsRetroperitoneal View
Obturator vessels
Obturator nerve
Obturator canal
Obturator Vascular Anatomy
Obturator - Neuroanatomy
• From anterior division of L2-4• Innervates all muscles of the obturator region,
except pectineus• Passes through obturator canal and splits to
innervate the muscles that adduct the thigh and help with external rotation
• Small sensory area on the medial thigh
PPTendineous Arc
Tendineous Arc
UterusUterus
VaginaVagina
Anterior aginal Wall Defects
PPTendineous Arc
Tendineous Arc
UterusUterus
VaginaVagina
LateralLateralDefectDefect
Anterior aginal Wall Defects
LateralDefect
Anterior aginal Wall Defects
PPTendineous Arc
Tendineous Arc
UterusUterus
VaginaVagina Central DefectCentral Defect
Central Defect
Central Defect
Central Defect: Treatment
PPTendineous Arc
Tendineous Arc
UterusUterus
VaginaVagina
Anterior Vaginal Prolapse (AVP)
PubourethralPubourethralLigamentLigament
PP
UterusUterus
VaginaVagina Lateral DefectLateral Defect
Anterior Vaginal Prolapse (AVP)
Central DefectCentral Defect
Tendineous Arc
Tendineous Arc
PP
UterusUterus
VaginaVagina
Anterior Vaginal Prolapse (AVP)
Evaluation of pelvic floor reconstructive surgery using tridimentional helical CT
Fig 3. Notice the well supported bladder base and the TOT arms
PPTendineous Arc
Tendineous Arc
RectumRectum
UterusUterus
VaginaVagina
Levator ani
Levator aniPosterior Posterior
DefectDefect
Posterior Vaginal Prolapse (PVP)
SacrospinalSacrospinalLigamentLigament
PPTendineous Arc
Tendineous Arc
RectumRectumUterusUterus
VaginaVagina
Levator ani
Levator ani
Posterior Vaginal Prolapse Repair
Evaluation of pelvic floor reconstructive surgery using tridimentional helical CT
Fig 4. Infracoccigeal sacropexy showing indirectly the “neo rectovagianl fascia”
Posterior sling
AnchoringTails
BladderBladderRectum
MeshMesh