pelvic anatomy from a laparoscopic perspective tommaso falcone md professor & chairman cleveland...

Pelvic Anatomy from a Laparoscopic Perspective

• Tommaso Falcone MD

• Professor & Chairman

• Cleveland Clinic Foundation

Anatomy & Advanced Laparoscopic Surgery Course

Anatomic Areas

• Anterior abdominal wall• Pelvic sidewall• Extra-peritoneal spaces

– Retropubic space– Presacral space– Pararectal space

Anterior Abdominal Wall

• Relationship of the vessels & nerves to potential entry sites for trocars

Retroperitoneal Vessels & Umbilicus

• Bifurcation of the aorta– thin patients at umbilicus– More caudad with increasing weight

• Left common iliac vein – inferior to the bifurcation of the aorta– crosses the sacrum

Left Upper Quadrant Insertion• 2-cm below the subcostal margin

mid-clavicular line• Organs

– Aorta-11 cm– Spleen-12cm– Stomach-4.4cm– Liver-4.0cm– Left kidney 13.2cm

Laparoscopic view of the spleen• Spleen is far from

the LUQ, unless splenomegaly is present

Pelvic Sidewall Anatomy

• 3 layers– Ureter– Branches of the

int.iliac artery– Muscle & nerve

Pelvic Sidewall: ureter

• Pelvic brim– over the common or external iliac– under ovarian vessels

• Courses anterior to the internal iliac– UNDER THE OVARY– 1.5 -2 CM LATERAL UTERO-SACRAL

LIGAMENTS

• Cervix– WITHIN 2CM

Pelvic Sidewall: Blood vessels• Internal iliac artery

– anterior & posterior division– Umbilical artery

• obliterated• medial umbilical ligament• relationship to the uterine artery

Pelvic Arteriogram

Pelvic & Inguinal Nerves

• Genito-femoral nerve• Femoral nerve

Retropubic Space

• Anterior– Pubic bone

• Lateral– Obturator internus

muscle, fasciae, neurovascular bundle

• Posteriorly– bladder &

pubocervical fasciae

Pelvic Diaphragm

• Sheet of muscle (Levator ani & coccygeus) covered on both sides by fasciae

• From pubis to coccyx & is attached to the lateral pelvic wall by a thickened band of obturator fascia called arcus tendineus m. levator ani

• Anogenital hiatus

Pelvic Diaphragm:Muscle• Levator Ani

– Pubococcygeus (Puborectalis & pubovaginalis)

– Iliococcygeus• Iliococcygeus portion that arises

from the obturator internus muscle (arcus tendineus m. levator ani) & ischial spine

• Arcus: spine of the ischium forward & upward.

Pelvic Diaphragm: Fasciae• Parietal fasciae on the muscles• Endopelvic fasciae on the pelvic

viscera– Attached to the parietal fasciae laterally– Connective tissue attachments stabilize

the vagina– Attachment along a line of thickened

parietal fasciae called Arcus tendineus fasciae pelvis or white line

– Mid-vagina is supported by lateral connections to the white line

Pre sacral space