3ObjectivesDescribe basic abdominal and pelvic anatomy related to common gynecologic surgical proceduresName common potential pitfalls and complications that can occur during gynecologic pelvic surgeryDescribe the challenges related to anatomical distortions from pelvic pathology, patient body habitus, and complex proceduresList the physiologic changes related to anatomical changes from pelvic surgery (optional)
4Why Anatomy is important Backbone of understanding clinical conditionsWhat’s normalWhat’s abnormalWhy it’s abnormalHow to manage the problemSurgery is all about anatomyObstetrics AND Gynecology is loaded with anatomical clinical correlations
5General Considerations Preparation for the OR (PRE-OP)Review basic/relevant anatomy:What organs are being removed/corrected/altered?What anatomy must be traversed to get there?Understand indications for surgery:Why is procedure being done/what are goals of surgery?What alternatives are there and have they been considered?
6General Considerations In the OR (INTRA-OP)Perform the EUA (pelvic AND abdominal exam)What anatomical distortions are present?Does this affect the route of surgery?How will you position the patient?Performing the procedure:What are the abdominal wall and pelvic floor anatomical landmarks?Is the anatomy distorted by the disease process or prior procedures?Does the patient’s body habitus affect her anatomy?What potential complications can you expect?
7General Considerations After the OR (POST-OP)Anticipate physiologic changes:What will the patient/you expect acutely and chronically from anatomical changes (reproductive, GI, GU, sexually, physically, etc)?Manage complications:What anatomic/physiologic changes will you expect from common complications (bowel, bladder, vascular, nerve injuries)?What are the expected postoperative pelvic and abdominal anatomic changes that occur after surgery?
8General Considerations In the OR (INTRA-OP)Perform the EUA (pelvic AND abdominal exam)What anatomical distortions are present?Does this affect the route of surgery?How will you position the patient?Performing the procedure:What are the abdominal wall and pelvic floor anatomical landmarks?Is the anatomy distorted by the disease process or prior procedures?Does the patient’s body habitus affect her anatomy?What potential complications can you expect?
9Case Studies Relevant surgical anatomy Special points of consideration danger areas and potential complicationsPhysiologic outcomes
10Case Study 138 yo G2P2 female with symptomatic menometrorrhagia, dysmenorrhea and anemia. Prior cesarean section x 2.Examination: BMI – 28; Pelvic – 16 wk fibroid uterus – palpable midway to the umbilicus on abdominal examUltrasound: multiple leiomyomas (>6) measuring in size from 4 to 8 cm, located in fundal, posterior/anterior and lateral uterus.EMB – proliferative; UPT – neg; Hgb – 8 mg/dL
11Surgical Approach Preop Dx: Symptomatic Leiomyoma Planned Procedure: Exploratory laparotomy, Total abdominal hysterectomy (TAH)Relevant Surgical AnatomyAbdominal and pelvic examinationLayers of the abdominal wallAbdominal structuresPelvic structures
13The Abdominal Exam Components Visual inspection Palpation ScarsDistortionsPalpationMassesLiver and spleen edge (HSM)AscitesUmbilicus - herniasPanus/adiposePercussion and AuscultationXiphoid process - marks upper boundary of abdomen Symphysis pubis - marks lower boundary Abdomen divided into four quadrants - RUQ, RLQ, LUQ, LLQNormal findings: Tympany over stomach and intestines; dullness over liver, spleen, pancreas, kidneys and distended (>150 cc) bladderLiver border:usually noted in the 5th, 6th or 7th intercostal spacedistance between upper and lower borders should range between 6 to 12 cm at right midclavicular lineSpleen:Left posterior midaxillary line - dullness at 6th to 10th ribLeft intercostal space in anterior axillary line - tympany
14Layers of the Abdominal Wall SkinSuperficial Fascia – fatty layer(Camper’s fascia)Superficial Fascia – membranous layer(Scarpa’s fascia)Extraperitoneal fatExternal oblique muscleInternal oblique muscleTransverse abdominis muscleTransversalis fasciaParietal peritoneumTwo important surgical landmarks are formed by the aponeuroses of the abdominal wall muscles. The linea alba is in the midline between the 2 rectus muscles. Formed by the fusion of the aponeuroses of the external oblique, internal oblique, and transversus abdominis, identifying this structure during a midline incision is important. A second surgical landmark is the arcuate line that is found below the rectus muscle, approximately halfway between the umbilicus and the symphysis pubis. Above the arcuate line, the aponeuroses of the internal oblique and transversus abdominis fuse to form the posterior rectus sheath. Below the arcuate line, the posterior rectus sheath is absent. This anatomic finding occurs as the aponeuroses of the oblique muscles and the transversus pass in front of the rectus muscle.Features of Camper's Fascia-->Major site of fat storage -->CONTINOUS with the superficial fascia of the thorax, thigh, & pubis ("Superficial layer of superficial perineal fascia")Features of Scarpa's (membranous) Fascia-->Continous with the **membranous layer of Superficial Perineal Fascia (COLLES Fascia)** -->Contains NO FAT -->Fuses with the FASCIA LATA OF THE THIGHMuscles of Anterior-Lateral Abdominal Wall1)External Oblique Muscle 2)Internal Oblique Muscle 3)Transversalis Muscle
15Layers of the Abdominal Wall Ext. oblique m.Int. oblique m.The arcuate line marks the lower limit of the posterior layer of the rectus sheath. Superior to the line, the rectus sheath splits into a anterior and posterior section, with the rectus abdominus muscles lying between the 2 sections. The external oblique and part (1/2) of the internal oblique form the anterior sheath; the other part (1/2) of the internal oblique and the transversus form the posterior sheath.
24Special Points of Consideration Distortion of ligamentsDistortion of retroperitoneal spacesCourse of the ureterIncreased blood supply to uterusUrologic injury – bladder, uretersVascular injury/large EBL – collateral blood supply and increased flow
25Special Points of Consideration Distortion of ligamentsDistortion of retroperitoneal spacesCourse of the ureterIncreased blood supply to uterusUrologic injury – bladder, uretersVascular injury/large EBL – collateral blood supply and increased flow
263 points of ureteral injury When clamping the IP (gonadal vessels)When clamping the uterine vesselsWith inadequate bladder flap development (clamping the cardinal ligaments)
27Physiologic Outcomes Abdominal wall and pelvic floor changes GI/GU changesLoss of menstruationPotential change in sexual response
28Case Study 224 yo G0 female with severe chronic pelvic pain, dysmenorrhea and dyspareunia. Healthy.Examination: BMI – 22; Pelvic – NEFG, normal sized retroverted, but slightly fixed uterus with exquisite tenderness and uterosacral nodularity; slight fullness of left adnexa with tendernessUltrasound: normal uterus with 5-6 cm left complex adnexal cystic ovaryUPT – negative; cervical cultures – negative for chlamydia and gonorrhea
29Surgical Approach Preop Dx: Complex adnexal mass, r/o endometriosis Planned Procedure: Diagnostic laparoscopy, left ovarian cystectomy/salpingo-oophorectomyRelevant Surgical AnatomyAbdominal and pelvic examinationLayers of the abdominal wallAbdominal structuresPelvic structures
34Special Points of Consideration Distortion of uterosacral ligamentsObliteration of posterior cul-de-sac and ovarian fossaCourse of the ureterBlood supply to ovary/tubeUreteral injuryVascular injury/large EBLBowel injury
35Physiologic Outcomes Improved symptoms and/or pain Potential loss of ovarian function and/or menopause
36Case Study 362 yo G4P4 female with pelvic pressure and bulging/protruding mass per vaginaExamination: Pelvic – near complete uterine prolapse (procidentia)Pap smear – negative/normal; U/s – atrophic ovaries; uterus with 3 mm endometrial stripe
42Special Points of Consideration Distortion of bladder and uretersAtrophic changesBladder/ureteral injuryAnal/rectal injury
43Physiologic Outcomes Improved pelvic pressure/bulging Improved GI/GU function
44ConclusionsPelvic anatomy is generally preserved and knowledge of key abdominal and pelvic anatomical landmarks is essential for any pelvic surgeonComplications can best be avoided by anticipating the pathologic changes that result in anatomic alterations as a result of pelvic diseaseKnowledge of pelvic and abdominal anatomy is crucial for successful surgical management that will lead to improved patient outcomes