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

I have nothing to disclose.

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)

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

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?

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?

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?

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?

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

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

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

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

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

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

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.

Abdominal incisions Vertical (midline) Pfannenstiel Maylard Cherney

Abdominal Structures

Abdominal Organs – Major

Female Pelvic Organs

Uterus/Ovaries

Blood Supply and Ligaments

The spaces

Fibroid Uterus – Distorted Anatomy

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

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

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)

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

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

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

Blood Supply of the Anterior Abdominal Wall

Laparoscopy – abdominal contents

Laparoscopic view of Pelvic Anatomy

Anatomical distortions - Endometriosis

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

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

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

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

Perineum

Vaginal and pelvic examination

The Pelvic Floor

Vaginal Hysterectomy

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

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

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

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