1. Pelvic Surgical Anatomy
John L. Dalrymple, MD
Division Director, Gynecologic Oncology
Department of Obstetrics and Gynecology
UT Southwestern Austin Programs

2. I have nothing to disclose.

3. Objectives
Describe basic abdominal and pelvic anatomy related to common gynecologic surgical procedures
Name common potential pitfalls and complications that can occur during gynecologic pelvic surgery
Describe the challenges related to anatomical distortions from pelvic pathology, patient body habitus, and complex procedures
List the physiologic changes related to anatomical changes from pelvic surgery (optional)

4. Why Anatomy is important
Backbone of understanding clinical conditions
What’s normal
What’s abnormal
Why it’s abnormal
How to manage the problem
Surgery is all about anatomy
Obstetrics AND Gynecology is loaded with anatomical clinical correlations

5. General 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?

6. General 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?

7. General 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?

8. General 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?

9. Case Studies Relevant surgical anatomy Special points of consideration
danger areas and potential complications
Physiologic outcomes

10. Case Study 1
38 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 exam
Ultrasound: 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

11. Surgical Approach Preop Dx: Symptomatic Leiomyoma
Planned Procedure: Exploratory laparotomy, Total abdominal hysterectomy (TAH)
Relevant Surgical Anatomy
Abdominal and pelvic examination
Layers of the abdominal wall
Abdominal structures
Pelvic structures

12. The Pelvic Exam Components External genitalia Vagina Cervix Uterus
Lesions, ulcers, cysts
Vagina
Lesions, prolapse (cystocele, rectocele)
Cervix
Size, shape, mobility, lesions
Uterus
Size, shape, position, mobility
Adnexa
Masses, size, shape, mobility, laterality

13. The Abdominal Exam Components Visual inspection Palpation
Scars
Distortions
Palpation
Masses
Liver and spleen edge (HSM)
Ascites
Umbilicus - hernias
Panus/adipose
Percussion and Auscultation
Xiphoid process - marks upper boundary of abdomen 
Symphysis pubis - marks lower boundary 
Abdomen divided into four quadrants - RUQ, RLQ, LUQ, LLQ
Normal findings: Tympany over stomach and intestines; dullness over liver, spleen, pancreas, kidneys and distended (>150 cc) bladder
Liver border:
usually noted in the 5th, 6th or 7th intercostal space
distance between upper and lower borders should range between 6 to 12 cm at right midclavicular line
Spleen:
Left posterior midaxillary line - dullness at 6th to 10th rib
Left intercostal space in anterior axillary line - tympany

14. Layers of the Abdominal Wall
Skin
Superficial Fascia – fatty layer
(Camper’s fascia)
Superficial Fascia – membranous layer
(Scarpa’s fascia)
Extraperitoneal fat
External oblique muscle
Internal oblique muscle
Transverse abdominis muscle
Transversalis fascia
Parietal peritoneum
Two 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 THIGH
Muscles of Anterior-Lateral Abdominal Wall
1)External Oblique Muscle 2)Internal Oblique Muscle 3)Transversalis Muscle

15. Layers 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.

16. Abdominal incisions
Vertical (midline)
Pfannenstiel
Maylard
Cherney

17. Abdominal Structures

18. Abdominal Organs – Major

19. Female Pelvic Organs

20. Uterus/Ovaries

21. Blood Supply and Ligaments

22. The spaces

23. Fibroid Uterus – Distorted Anatomy

24. Special Points of Consideration
Distortion of ligaments
Distortion of retroperitoneal spaces
Course of the ureter
Increased blood supply to uterus
Urologic injury – bladder, ureters
Vascular injury/large EBL – collateral blood supply and increased flow

25. Special Points of Consideration
Distortion of ligaments
Distortion of retroperitoneal spaces
Course of the ureter
Increased blood supply to uterus
Urologic injury – bladder, ureters
Vascular injury/large EBL – collateral blood supply and increased flow

26. 3 points of ureteral injury
When clamping the IP (gonadal vessels)
When clamping the uterine vessels
With inadequate bladder flap development (clamping the cardinal ligaments)

27. Physiologic Outcomes Abdominal wall and pelvic floor changes
GI/GU changes
Loss of menstruation
Potential change in sexual response

28. Case Study 2
24 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 tenderness
Ultrasound: normal uterus with 5-6 cm left complex adnexal cystic ovary
UPT – negative; cervical cultures – negative for chlamydia and gonorrhea

29. Surgical Approach Preop Dx: Complex adnexal mass, r/o endometriosis
Planned Procedure: Diagnostic laparoscopy, left ovarian cystectomy/salpingo-oophorectomy
Relevant Surgical Anatomy
Abdominal and pelvic examination
Layers of the abdominal wall
Abdominal structures
Pelvic structures

30. Blood Supply of the Anterior Abdominal Wall

31. Laparoscopy – abdominal contents

32. Laparoscopic view of Pelvic Anatomy

33. Anatomical distortions - Endometriosis

34. Special Points of Consideration
Distortion of uterosacral ligaments
Obliteration of posterior cul-de-sac and ovarian fossa
Course of the ureter
Blood supply to ovary/tube
Ureteral injury
Vascular injury/large EBL
Bowel injury

35. Physiologic Outcomes Improved symptoms and/or pain
Potential loss of ovarian function and/or menopause

36. Case Study 3
62 yo G4P4 female with pelvic pressure and bulging/protruding mass per vagina
Examination: Pelvic – near complete uterine prolapse (procidentia)
Pap smear – negative/normal; U/s – atrophic ovaries; uterus with 3 mm endometrial stripe

37. Surgical Approach Preop Dx: Uterine prolapse
Planned Procedure: Total vaginal hysterectomy +/- Bilateral salpingo-oophorectomy
Relevant Surgical Anatomy
Abdominal and pelvic examination
Pelvic structures
Pelvic floor anatomy

38. Perineum

39. Vaginal and pelvic examination

40. The Pelvic Floor

41. Vaginal Hysterectomy

42. Special Points of Consideration
Distortion of bladder and ureters
Atrophic changes
Bladder/ureteral injury
Anal/rectal injury

43. Physiologic Outcomes Improved pelvic pressure/bulging
Improved GI/GU function

44. Conclusions
Pelvic anatomy is generally preserved and knowledge of key abdominal and pelvic anatomical landmarks is essential for any pelvic surgeon
Complications can best be avoided by anticipating the pathologic changes that result in anatomic alterations as a result of pelvic disease
Knowledge of pelvic and abdominal anatomy is crucial for successful surgical management that will lead to improved patient outcomes

45. Congratulations & Welcome to OBGYN!

46. L&D