1. Surgical Core Curriculum - Gyn Onc
Amreen Husain, M.D.

2. Abdominal Wall Determine best incision for planned surgery
Several layers depending on the orientation of incision
Course of vessels in abdominal wall.
Potential need for preservation of epigastric vessels
Potential placement of stoma

3. Abdomen Landmarks to note Costal margins Xiphoid process Umbilicus
Anterior superior iliac spines
Inguinal creases
Pubis

4. Layers of abdominal wall
Skin
Superficial fascia
External and internal obliques
Transversus abdominis muscles, Aponeurosis and fascia
Rectus muscles and sheaths
Preperitoneal fat
Parietal peritoneum

5. Rectus muscle
Blood supply derived from sup epigastric artery (branch of int mammary or thoracic artery) and inf epigastric artery (branch of external iliac artery.
Nerve supply from anterior rami of thoracic nerves from T6-T12 which enter posteriorly then divide ant, medial and lateral. Denervation occurs if muslce is divided longitudinally or freed laterally

11. The Pelvis Surrounded by bony structures:
Sacrum, ischium, ilium and pubic bones
Floor is composed of muscles:
Piriformis, coccygeus and levator ani

12. The Pelvis
Divided into an anterior and posterior component by the transversely oriented broad ligament in the center of which is the uterus
Broad ligament has two layers : anterior and posterior leaves, round ligament runs anterolateral in the broad ligament to the pelvic wall

13. The Pelvis
Ovaries attached to posterior leaf of the broad ligament by meso-ovarium, to the uterus by the ovarian ligament and to the pelvic wall by the infidibulo-pelvic ligament which contains the ovarian vessels and lymphatics
Adnexal triangle an important landmark – bounded ant by round ligament, post by IP ligament and laterally by peritoneal reflection over psoas. Allows easy access to the retroperitoneum

15. Surgical Anatomy of the Pelvis
Pelvic organs include the uterus, cervix and vagina, ovaries and Fallopian tubes, bladder, pelvic ureters, rectum and portion of the sigmoid
Eight tissue planes which are avascular two dimensional potential spaces until developed by the surgeon
Three pairs of fibrovascular ligaments

16. Avascular Tissue Planes
Paired Spaces:
Paravesical/paravaginal spaces
Pararectal spaces
Unpaired spaces:
Prevesical (retropubic) space of Retzius
Vesicovginal space
Rectovaginal space
Presacral (retrorectal) space

18. Fibrovascular ligaments
Cardinal ligaments
Constitute the thickened posterior most portion of broad ligament
Arises from endopelvic fascia of the lateral cervix and extends to pelvic sidewall where it inserts into the endopelvic fascia
Posterior portion contains a major component of the autonomic nerve supply to the bladder and rectum
Contains the uterine, vaginal, inferior vesical and middle rectal arteries and veins as well as lymphatics
Ureter penetrates upper portion just below uterine artery 1-2 cm lateral to the isthmus of the uterus

19. Fibrovascular ligaments
Uterosacral ligaments with rectal pillars
Posterolateral thickenings which originate from posterolateral aspect of the cervix and run to anterolateral aspect of the rectum
they straddle the posterior cul-de-sac
Rectal pillars are longitudinal fibrovasuclar bundle btwn vagina and rectum, run the length of the vagina

20. Fibrovascular ligaments
Bladder pillars
Paired longitudinal fibrovascular bundles that run the length of the vagina anteriorly and form the lateral limits of the vesicovaginal space
Upper end connects to the lower half of the cervix forming the vesico-uterine ligament

22. The Ureter
Crossing Retroperitoneal during its entire passage from the kidney to the bladder.
Enters the pelvis by crossing over the vessels at or just proximal to the bifurcation of the common iliac artery
On the left it passes under the proximal sigmoid colon and on the right passes under the cecum and terminal ileum

23. The Ureter
As the ureter enters the pelvis it becomes attached to the lateral pelvic wall peritoneum and continues till it reaches the level of the uterosacral ligament and the posterior leaf of the broad ligament
Ureter then contiunues through the cardinal ligament to the bladder going under the uterine artery

26. Arteries and Veins Ovarian vessels
Ovarian arteries arise from the abdominal aorta 2-3 cm below the renal arteries
Ovarian vein on the right enters the vena cava below the right renal vein; the ovarian vein on the left enters the renal vein lateral to the vena cava

27. Arteries and Veins Common iliac vessels
Common iliac artery begins at the lower end of L4 and follows the pelvic brim laterally terminating over the sacroiliac joint by dividing into the external iliac and hypogastric (internal) iliac arteries
Ureter crosses both common iliac arteries near their bifurcation
Common iliac veins lie posterior to the artery, the left common iliac vein passes under the proximal part of the right common iliac artery

28. Arteries and Veins External iliac vessels
External iliac vein arises at lumbosacral joint and ends by passing under the inguinal ligament to become the femoral artery
Main branches are the deep circumflex and inferior epigastric vessels
External iliac veins are positioned inferiomedial to the arteries

29. Arteries and Veins Hypogastric Arteries
Posterior and Anterior divisions at 4 cm from its origin
Anterior Trunk : Six primary branches in order
Common branch giving rise to the uterine, umbilical, superior vesical and sometimes vagina
Obturator, Inferior vesical, middle Rectal, internal pudendal and inferior gluteal
Posterior Trunk
Four branches none of which supply pelvic viscera
Iliolumbar, superior and inferior lateral sacral, superior gluteal

33. The Groin Femoral Triangle
Bounded superiorly by the inguinal ligament, laterally by the medial border of the sartorius muscle and medially by the adductor longus muscle
Structures passing via the subinguinal space from the pelvis to the leg from lateral to medial are the lateral femoral cutaneous nerve, iliopsoas muscle, femoral nerve, then the femoral artery, femoral vein, femoral canal w/ lymphatics and femoral branch of the genitofemoral nerve

35. The Small Intestine
Jejunum and Ileum combined average 22 ft in length of which the jejunum accounts for 40%.
Jejunum and ileum differ in that the jejunum is thicker, has thicker mucosal folds, the mesenteric fat extends onto the wall of the ileum but not the jejunum, the vasa recta are shorter in the ileum

36. The Small Intestine Arterial Supply
Entire blood supply derived from the superior mesenteric artery (SMA) a ventral midline branch of the aorta.
SMA enters the base of the mesentery as it emerges from between the duodenum and pancreas
Branches are : Common inferior pancreaticoduodenal a., the middle and right colic a., ileocolic a., series of jejunal and ileal branches which anastomose with each other forming arcades.

37. The Large Intestine
4-6ft in length from ileocecal junction to the anus.
Divisible into the cecum and appendix; the ascending, transverse, descending and sigmoid colon; Rectum and anus
Ascending and descending colon are retroperitoneal while transverse and sigmoid colons have distinct mesenteries

39. The Large Intestine Arterial Supply
Derived from superior and inferior mesenteric arteries
Marginal artery of Drummond is a scalloped continuous vessel formed by anastomosing arcades of the ileo-colic, right, middle, left colic and sigmoidal arteries
Inferior mesenteric artery (IMA) arises from the aorta at L# about 3-4 cm from bifurcation,
Branches to the left colic artery, sigmoidal arteries (2-4), becomes the superior rectal artery in the pelvis

41. Ureteral Injuries Incidence is 0.1% - 1.5% in pelvic surgery
75% during gynecologic surgery
¾ during abd surgery
¼ during laparoscopic surgery
Most common causes of litigations against gyn surgeons

42. Anatomy of the Ureter Retroperitoneal
25-30cm in length : divided into abdominal and pelvic segments by the pelvic brim
Three layers :
mucosa lined with transitional epithelium
muscularis made up of interweaving smooth muscle fibers
Adventitia containing intercommunicating
network of blood vessels

43. Embryology
Close proximity to reproductive organs due to proximity of mesonephric ducts and mullerian system
Congenital anomalies occur concomitantly % of the time
Most common is ureteral duplication – 1% of women

44. Blood supply Segmental with much anastomising
Cephalad – supplied by branches of renal and ovarian arteries
Middle – form aortic and common iliac branches
Pelvic – from hypogastric, rectal and vaginal arteries

46. Path of the ureter
Abdominal ureter : runs along anterior surface of the psoas muscle and posterior to the ovarian vessels
Crosses pelvic brim anterior to common iliac at its bifurcation

47. Path of the Ureter
Pelvic ureter: travels along the pelvic sidewall lateral to the sacrum and anterior to the hypogastric. Veers medial as it passes beneath the uterine artery approx 1.5cm lateral to the internal os then passes into the tunnel of the cardinal ligament and travels medially and anteriorly over the vaginal fornix to enter the bladder.
Travels 2cm within bladder wall before exiting

48. Location of ureteral injuries
Cardinal ligaments where uterine artery and ureter cross or at the ureteral tunnel
Infundibulopelvic ligament
Lateral pelvic sidewall along the uterosacral ligaments
Intramural portion of ureter

49. Types of injuries Crushing from a clamp Ligation Transection
Angulation with secondary obstruction
Ischemia due to thermal injury
Resection

50. Prevention Identification and visualization
After dividing round ligament enter broad ligament along psoas muscle and dissect retroperitoneal space, ureter is attached to the medial leaf of the broad ligament
No benefit to preop IVP or stenting
Can also be palpated (with experience!!)
Can also be identified as it crosses iliac

52. Basic steps - TAH Routine identification before clamping IP
Mobilize bladder from vaginal cuff for at least 1cm
Clamp uterine artery at the internal os and at right angles to the uterus
Clamp inside prior pedicles once the uterine artery has been clamped

53. Basic steps - TVH
Develop vesico-vaginal space with retraction of the bladder anteriorly
Palpation of the ureter
Small pedicle bites medial to where ureter is palpated

54. Recognition of uerteral injury
70% not identified until post –op
Morbidity due to :
Necrosis w/ extravasation
Fistula formation
Stenosis w/ hydronephrosis and renal loss
Uremia and death with bilat obstruction (rare)

55. Signs and Symptoms Flank pain Fever Persistent Ileus
Ascites or retroperitoneal fluid collection
Rise by 0.8 in Creatinine
Fistula formation 8-10 days post-op
Usually subtle – high index of suspicion
U/S normal in 20% - CT-IVP is standard test

56. Management of ureteral injury
Antegrade or retrograde stent placement
If stent placement unsuccessful decide between immediate repair vs PCN and delayed repair
< 72hrs – immediate repair
>2wks – PCN and repair in 6-8 wks, obtain IVP prior to repair as spontaneous healing can occur in upto 80%

57. Principles of Repair Atraumatic handling
Healthy mucosa-to-mucosa approximation
Minimal mobilization and dissection
Tension free
Stent placement
Epithelial healing in 2 weeks
Normal peristalsis in 4 weeks

58. Ureteroneocystotomy Ureteral injuries 5-6cm from bladder
Non-tunneled reimplantation into bladder
Mobilize proximal ureter
Mobilize bladder
Perform cystotomy in tranverse fashion

60. Additional length
Psoas hitch – bladder stretched to reach Psoas and attached to the muscle
Boari flap – segment of bladder made into a tunnel

62. Ureterouretorostomy Injuries above the pelvic brim Freshen edges
Cheatle incision on either end
Reapproxiamte with 5-6 stitches using
4-0 Vicryl, place all stitches then tie
Stent

65. Other Techniques Transureterouretrostomy
Transposition of segment of ileum
Mobilization of kidney

67. Laparoscopy and ureteral injuries
Incidence about 0.5%
Usually due to electrocautery and eqaully divided between mono and bipolar
Also commonly due to stapling device when used on uterine arteries or IP as width of device is 1.2cm
Particular care when anatomy is distorted

69. Cystotomy and Repair
Most common urinary tract injury during hysterectomy
Avoid by sharply dissecting bladder of cervix and anterior vagina
Trigone is only part that is fixed and not easily distensible, adjacent to upper vagina in the anterior vgainal fornuix
Injury near vaginal cuff or cervix is always close to or at trigone

70. Repair of bladder dome injury
Identify entire length and ends of defect
Use 3-0 or 4-0 Vicryl as 3weeks required for complete healing and chromic only maintains strength for 4-5days
Running suture through mucosa and muscularis, important to invert and reapproximate mucosa
2nd layer of imbricating interrupteds
Can be closed in any direction
Drain for 5-7 days in healthy tissue

71. Repair of trigone injury
Visulize ureteral orifices
Keep in mind ureters travel within bladder wall 2cm laterally, can be palpated
Two layer closure, maintain suture lines in direction away from ureters and trigone
Retrograde filling and Cystoscopy at end
Drain for min10-14 days