Female Pelvic Applied Anatomy

Dr. SHASHWAT JANIM.S. ( GYNEC )

DIPLOMA IN ADVANCED ENDOSCOPY.

Assistant Professor Smt. N.H.L. MUNICIPAL MEDICAL COLLEGE , AHMEDABAD.

Mob : +91 99099 44160.

E-mail : drshashwatjani@gmail.com

Basic Facts of Anatomy

do not Change

But our understanding does…

Exploration of specific anatomic relationships and the development of new clinical and surgical correlation

continue to evolve….

Comprehensive understanding of Anatomy is essential for ..

Avoiding visceral injuries : About 75 % iatrogenic injuries to ureter result from Gynecological surgeries….

Understanding of interrelation ship of Bony pelvis, ligaments , muscles, fasciae , nerves , blood vessels and pelvic viscera for safe and effective management of Pelvic floor Disorders.

Understanding and managing the normal and abnormal Obstetric conditions.

Bony Pelvis

Organ anatomy

Spaces

Vascular anatomy

Neuroanatomy

Topics Covered..

Nomenclature used here reflects current slandered

nomenclature according to

the Nomina Anatomica*.

*International Anatomical Nomenclature Committee: Edinburg, Scotland.

(founded in 1989)

Female Pelvis : Evolvement

•Forms a bony ring through with body weight is transmitted to lower

extremities.

•Adopts to child bearing.

Pelvic Structure

Sacrum

Coccyx

Paired Hip Bones ( Os Coxae, innominate )

Sacrum and CoccyxExtension of Vertebral Column:

Fused 5 sacral and 4 coccygeal vertebrae

Os Coxae ( Hip Bones )

Pelvic Bone Articulation

Sacro-illiac Joint :

Synchondroses

Symphysis pubis

Sacrococcygial joint

Cartilaginous symphyseal joint

Important Landmarks

Symphysis Pubis and Pubic Tubercle: Pelvimetry, Symphysotomy etc…

Sacral Promontory: Landmark in Laparoscopy, Bifurcation of Major Vessels, Prolapse repair

Sacral hiatus Iliac Crest Anterior Superior iliac Spine: Surgical Landmark

Ischial Spine: Pudendal Block , Clinical Pelvimetry

Ischial Tuberosity

Sacral Promotory Fixation

Pudendal Nerve Block

Pelvic Inlet

False Pelvis

True Pelvis

Linea T

erminalis

Boundaries of False Pelvis Posterior : Lumber Vertebrae Anterior: Lower portion of Anterior abdominal wall Laterally: iliac Fossa

Upper: Pelvic Inlet Lower : Pelvic Outlet

Boundaries of True Pelvis

SPSP ASAS

LTLT

Pubic BonePubic Bone

•Obliquely Truncated

•Bent Cylinder

•Greatest Height Posteriorly

Pelvic Planes and Axis

Conjugates

Outlet

Symphisis pubis

Coccyx

Four Ligaments Inguinal Ligament

• Important for repair of Inguial Hernia

Cooper’s Ligament

• Frequently used in Bladder suspension

procedures.

Sacrospinous Ligament

• For Vaginal Suspension

Sacrotubourous Ligament

Sacrospinous fixation

Bladder Suspension Procedureon cooper’s Ligament

Normal Variants

Pelvic Viscera

Peritoneal Orientation

Hystero Laparo Scopy

Pelvic Floor

Levator Ani muscle

Pelv

ic F

loor

Vascular anatomyThe common iliac bifurcation is at the level of

sacral promontory.

Ext Iliac Artery

2 branches :

Inf Epigastric

Deep Circumflex iliac A.

Inferior Epigastric

The external iliac artery lies lateral to external iliac

vein.

The inferior epigastric artery is the only branch of

external iliac artery.

The inferior epigastric vein drains into the external

iliac vein.

Vasclar Anatomy : Internal Iliac

The internal iliac ( Hypogastric )artery divides into anterior and posterior divisions.

Internal iliac (Hypogastric) artery

10 branches

Internal Iliac Ligation

Uterine Artery

The uterine artery is the first branch of anterior division of internal iliac artery. It originates about 6”(six inches) distal to the bifurcation of common iliac artery

Internal Iliac & Uterine A. Thus, there is sufficient length of internal artery

available for ligation. After giving out uterine artery, the internal iliac artery continues further as obliterated hypogastric artery.

The uterine artery traverses through the Para rectal space and crosses above the ureter from lateral to medial side to enter the uterus.

Uterine Artery

Uterine Artery & Vein

The Uterine vein, contrary to popular belief, comes from below the ureter to join the internal iliac vein.

Thus, the ureter lies in the fork with the uterine artery above and the uterine vein below.

SPACES

There are four important spaces:

Retro pubic space

Para vesical space

Pouch of Douglas

Para rectal space

Para rectal space

The Para rectal space lies…

lateral to the ureter

medial to the internal iliac vessels.

It continues downwards upto the levator ani muscle.

The only structures crossing this space are

Uterine artery

Uterine vein.

Pararectal space

ureter

Internal Iliac A.

Obliterate umbilical A.

Uterine A

Exterrnal Iliac vs.

Paravesical space

The paravesical space lies medial to the obliterated hypogastric artery and is bounded caudally by the pubic bone.

The retro pubic space can be entered through this space.

Pararectal & Paravesical spaces

Retro pubic space

The retro pubic space is bounded by the obliterated hypogastric artery on either side, the pubic symphysis anteriorly and the urinary bladder posteriorly.

Pouch of DouglasThe pouch of Douglas is bounded by cardinal and

uterosacral ligaments on either side, the uterus anteriorly and rectum posteriorly.

The veins run in the uterosacral and cardinal

ligaments. Likewise, the lymphatics also run in these

ligaments along the veins. Hence, the ligaments are

cut as laterally as possible in cancer surgery.

The small veins run in the paracolpos.

The circumflex iliac vein, which drains into external iliac vein from medially, is very liable to get damaged during nodal dissection.

The obturator artery and vein run parallel to the obturator nerve.

The obturator nerve originates at the bifurcation of common iliac vessels and then runs caudally between the external and internal iliac vessels.

Lymphatic Drainage

The lymphaticsThe lymphatics from the uterus travel along the infundibulopelvic from the uterus travel along the infundibulopelvic

ligament and drain into the ligament and drain into the para-aortic group of nodespara-aortic group of nodes. .

Lymphatics

Lymphatics from cervix and upper vagina go along

the paracolpos and cardinal ligament and drain into

the ileo-obturator nodes. The obturator node is the

first echelon of spread from the cervical cancers.

Lymphatics from the ovaries go along the infundibulo-

pelvic ligaments and drain into the Para-aortic group

of nodes.

Innervations of Reproductive Organs

Innervation ofPelvic Viscera

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