Surgical Core Curriculum
- Gyn Onc
Amreen Husain, M.D.
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
Abdomen
• Landmarks to note
– Costal margins
– Xiphoid process
– Umbilicus
– Anterior superior iliac spines
– Inguinal creases
– Pubis
Layers of abdominal wall
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•
•
•
Skin
Superficial fascia
External and internal obliques
Transversus abdominis muscles,
Aponeurosis and fascia
• Rectus muscles and sheaths
• Preperitoneal fat
• Parietal peritoneum
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
The Pelvis
• Surrounded by bony structures:
– Sacrum, ischium, ilium and pubic bones
• Floor is composed of muscles:
– Piriformis, coccygeus and levator ani
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
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
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
Avascular Tissue Planes
• Paired Spaces:
– Paravesical/paravaginal spaces
– Pararectal spaces
• Unpaired spaces:
– Prevesical (retropubic) space of Retzius
– Vesicovginal space
– Rectovaginal space
– Presacral (retrorectal) space
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
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
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
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
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
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
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
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
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
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
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
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.
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
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
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
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
Embryology
• Close proximity to reproductive
organs due to proximity of
mesonephric ducts and mullerian
system
• Congenital anomalies occur
concomitantly 35- 40% of the time
• Most common is ureteral duplication
– 1% of women
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
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
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
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
Types of injuries
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•
•
•
Crushing from a clamp
Ligation
Transection
Angulation with secondary
obstruction
• Ischemia due to thermal injury
• Resection
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
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
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
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)
Signs and Symptoms
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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
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%
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
Ureteroneocystotomy
• Ureteral injuries 5-6cm from bladder
• Non-tunneled reimplantation into
bladder
• Mobilize proximal ureter
• Mobilize bladder
• Perform cystotomy in tranverse
fashion
Additional length
• Psoas hitch – bladder stretched to
reach Psoas and attached to the
muscle
• Boari flap – segment of bladder made
into a tunnel
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
Other Techniques
• Transureterouretrostomy
• Transposition of segment of ileum
• Mobilization of kidney
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
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
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
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