Ministry of Health of Ukraine
BUKOVINIAN STATE MEDICAL UNIVERSITY
“APPROVED”
on methodical meeting of the Department of
Anatomy, Topographical anatomy and Operative
Surgery
“………”…………………….2007 р. (Protocol №……….)
The chief of department
professor ……………………….……Yu.T.Achtemiichuk
“………”…………………….2007 р.
METHODICAL GUIDELINES
for the 3d-year foreign students of English-spoken groups of the Medical Faculty
(speciality “General medicine”)
for independent work during the preparation to practical studies
THE THEME OF STUDIES
“TOPOGRAPHICAL ANATOMY AND OPERATIVE SURGERY OF THE
PELVIS”
Module 2
“Topographical anatomy and operative surgery of the regions and organs of the
lumbar region, pelvis and extremities”
Semantic module
“Topographical anatomy and operative surgery of the walls and organs of lumbar
region and pelvis”
Chernivtsi – 2007
1. Actuality of theme:
The topographical anatomy and operative surgery of pelvis are very importance,
because without the knowledge about peculiarities and variants of structure, form,
location and mutual location of their anatomical structures, their age-specific and
sexual properties it is impossible to diagnose in a proper time and correctly and to
prescribe a necessary treatment to the patient. Surgeons of the different specialization
usually pay much attention to the topographic anatomy of the small pelvis organs.
Topography of the bladder, urethra and ureter is important for urologist, womb and
adnexa for obstetrics and gynecologists, rectum for proctologists. Small measures of the
true pelvis, availability a number of the organs, nerves and vessels causes the certain
difficulties for surgical interventions for clinical and topical diagnosis.
2. Duration of studies: 2 working hours.
3. Educational purpose (concrete purposes):
To know peculiarities and variants of structure, form, location and mutual
location of the pelvis and pelvic organs.
To be able to define the borders, skeletotopy and projectors of the pelvis.
To master practical skills to make the approaches to the pelvic organs.
4. Base knowledges, abilities, skills, that necessary for the study themes
(interdisciplinary integration):
The names of previous disciplines
1. Normal anatomy
2. Physiology
The got skills
To describe the structure and function of
the different organs of the human body, to
determine projectors and landmarks of
the anatomical structures.
5. Advices to the student.
5.1. Table of contents of the theme:
Surgeons of the different specialization usually pay much attention to the topographic anatomy of
the small pelvis organs. Topography of the bladder and ureter is important for urologist, womb and
adnexa for obstetrics and gynecologists, rectum for proctologists. Small measures of the true pelvis,
availability a number of the organs, nerves and vessels causes the certain difficulties for surgical
interventions for clinical and topical diagnosis.
There are large vessels and nervous plexes in the cellular spaces of the small pelvis that causes
a great lethality on account of traumatic shock and loss of blood. The infectiosity of the organs'
contents leads to the development of phlegmons and their increasing.
The small pelvis is a part of a human body, which is bordered by two hipbones, sacrum,
coccygeal bone the 5 lumbar vertebra and ligaments.
The skin, soft tissues, which cover hipbones, belong to other anatomo-topographical regions.
The hipbone consists of three bones these are iliac, sciatic, pubic bones and are divided by the
cartilage. The neonate may pass through the maternal passages because measures and pelvis
configuration may vary.
The three bones form a hipbone by union at the acetabular region. This let us to carry great
loading.
The bones union reflects the change of the function during phylogenesis. The pelvis of the fourfooted can't carry on a large loading because their horizontal posture.
The humans have a vertical posture and pelvis is a support for the internal organs and a place of
transferring of the load from corpus to legs, separate bones connected by the cartilage forms one
bone, and a synchondrosis becomes a synosthosis. All the pelvic bones are sturdy fixed. There are
connected by three joints two sacroiliac joints, pubic symphysis and sacrococcygeal symphysis. The
pubic symphysis connects the pubic bones by means of fibrous cartilage. The superior pubic ligament
passes along the superior edge of the joint. The arcuate pubic ligament passes along the inferior
edge of the sumphysis. It forms the urogenital diaphragm (the triangular ligament).
The pubic symphysis may be disjoined in obstetrics practice to broader the maternal passages.
The operation is called the symphysotomia. The sacroiliac articulation is paired, form by jointing of
the auricular surfaces of the sacrum and iliac bones. It is strengthened with ventral sacroiliac
ligaments from the front, with interosseal and dorsal sacroiliac ligaments from behind. The
obstetricians call this articulation "a key of pelvis". A rupture of these ligaments while delivery is
attended by the discrepancy of the pelvic ring. Women after labor can't walk for a long time with such
a complication.
The mobility in the sacroiliac articulation play an important role in delivery, the apex of the
coccygeal bone back for 2cm while fetus passes through the maternal passages. On account of this
fact conjugate of the pelvic outlet increases from 9sm to 11 cm. If the coccygeal bone in immobile
because of fusing with the sacrum, there will be a stage, called a clinically contracted pelvis.
The fixative apparatus of the pelvis consists of the ligament, between the backbone and the upper
flaring portion of the iliac bone. Two powerful ligaments link the sacrum (on both sides) with iliac and
ischiadic bones. There is sacrotuberous ligament and sacrospinous ligament. Both ligaments the sciatic
spine and two notches of the innominate bone form the greater sciatic foramen and the lesser sciatic
foramen. Muscles, vessels and nerves pass through these foramens.
The inguinal ligament and membrane obturatoria are the false ligaments of the pelvic. Small
measures of the ligaments and their tightness limit the mobility in pelvic joints. Their physiological
importance is to amortize sudden strikes and pushes and reduce the strength of the hits while
movements. The rupture one of the joints is attended with affection of the others. That's why when
the rupture of the pubic symphysis is having place; the removal of the pubic bones is possible just
with a slight tear at the sacroiliac articulation.
The walls of the pelvic bound are rather elastic, on account of the coordinated actions of the
joints. That's why the fractures occur seldom just because of a great straight power affection. The
joints of the bones influent the form of the fractures. The weakest places are situated on the anterior
and posterior bonewalls of the pelvis because these places have the spongious structure. Sacral and
obturatorium foramens are available and that's the place of union of three pelvic bones. These facts
explain us the localization of the most typical fractures. These fractures are double direct fracture,
when the posterior and anterior (straight) walls of the pelvis are fractured.
The fracture line goes through the foramen obturatorium from the front across the place if
ischiopubic symphysis and through the sacrum near the sacral foramens from behind. The bone
basement of the pelvis is divided into 2 parts: large (false) pelvis and small pelvis. The terminal line
that passes through the promontorium, arcuate line of the iliac bone, spine of the pubic bone and a
superior edge of the symphysis border them. The large pelvis belongs to the inferior portion of the
abdominal cavity. There are genitourinary system and the terminal portion of the digestive system in
the small pelvis.
The conjugate of the inlet and outlet are important in obstetrics.
The gynecoid pelvis has such measures of the inlet the anterior-posterior diameter of the pelvic
inlet (from the promontorium to the pubic symphysis) is 11 cm, the transversal diameter (the line
between the farthest points of the terminal line) is 13 cm, oblique diameter (from the pubic tuber to
sacroiliac articulation is 12 cm.
The obstetric conjugate or the outlet (the distance from the coccygeal bone to the subpubic angle)
is 11 cm; the transversal diameter (the distance between the tubes of the ischiadic bone) is 11 cm.
The small measures of the bone pelvic ring mean the contracted pelvis. There may occur pelvis
justo minor, generally contracted flat pelvis, in obstetrician pathology. An operative intervention is
necessary than.
An axes of the pelvis is the line that passes in the middle of the conjugates of the inlet and
outlet, and goes through the center of the pelvis.
Pelvis is leaned to the front that is the physiologic posture. The angle between the surface of the
inlet and horizontal surface is 54-55° in women one is called the angle of inclination.
Different diseases (rickets, pathologic curvature of the vertebral column, congenital
dislocations and inflammations in hip joint) influent the form, measures and axis of the true pelvis.
Pelvic ring differs in men and women. Masculine pelvis is narrower and longer, gynecoid pelvis
is wider and shorter. The inlet is heart-spared in men and oval in women. The subpubic angle is 7075° in men and 80-100° in women.
The muscles that cover walls and bottom of the true pelv is are parietal and visceral. The
piriformis muscle starts from the sacrum, goes through the greater obturatorium foramen and fixates
to the greater trochanter. The parietal muscles are the next.
The piriformis muscle while passing through the greater obturatorium foramen forms two slits:
foramen suprapiriformis and infrapiriformis. Vessels and nerves bounds pass there. The second parietal
muscle is the internal obtutatorium muscle. It starts from fixes to the fosse intertrochanterica.
There is ma fissure in a lesser sciatic foramen. The pudendal neurovascular bound goes through
the fissure into the ischiorectal fosse. Those three foramens connect the pelvic cavity with the ischiac
region.
The pelvic outlet covered with the visceral muscles those are forming the diaphragm of the
pelvis. These muscles are:
1) The levator ani muscle. It consists of the two portions (the pubococcygeal and
iliococcygeal muscle) those muscles start from the pubic bone and the tendinous arch formed by the
strengthened pelvic fascia that goes around the rectum. It fastens to the coccygeal bone.
2) The coccygeal muscles those pass from the coccygeal bone to the sciatic spine.
3) The external sphincter of anus.
The pelvic cavity is divided into three portions (stores).
1) The peritoneal portion. That is the inferior part of the peritoneal cavity that is limited by the
horizontal surface that passes across the pelvic inlet and contain the pelvic organs those are covered
by the peritoneum.
2) The subperitoneal portion. That is a space between the peritoneum and levator ani muscle.
3) The subcutaneous portion. That is a space between the diaphragm of the pelvis and skin. The
portion belongs to the perineum and contains the ischiorectal fosse.
The peritoneum goes from the anterior abdominal wall and covers the lateral parts and the
posterior wall o the bladder, the internal edges of the deferens duct and apexes of the seminal vesicles
at the first portion of the pelvic cavity in man.
There are two recesses in women' anatomy. The peritoneum goes from the bladder on to the
uterine and forms the vesicouterine pouch. It passes then from the uterine on to the rectum and is
forming the rectourine) pouch (Douglas' pouch). That is the most inferior point of the abdominal
cavity. The pathologic fluid accumulates there while there is an inflammation in the abdominal
cavity or blood (while the oviduct breaks because of the extrauterine pregnancy).
There will be a sharp pain if a doctor presses at the posterior vault of the vagina and takes away
his hand suddenly. The symptom is called the Douglas' scream. One can have a fluid while puncture
of the posterior vault of the vagina. That helps to precise the diagnosis.
The walls and organs of the true pelvis are covered with the pelvic fascia. The parietal layer
covers the pelvic walls and the visceral one is fused with the organs.
The parietal layer goes down to the border of the superior and inferior portions of the internal
obturator muscle and forms the enlargement that is called the tendinous arch. The levator ani
muscle starts from it.
The pelvic fascia covers that muscle, piriformis muscle, it reaches then the pelvic organs and
goes upwards and becomes the visceral fascia.
The pelvic organs are inside the space that is bordered by the pubic bones from the front, by
sacrum from the behind and sagital plates of the visceral fascia from sides.
The peritoneperineal aponeurosis (Salyshcheva-Denonvilley), which is formed from the
primary peritoneal duplicature, divides the space into the anterior and posterior portions.
There are urogenital organs at the anterior portion and rectum at the posterior portion. So all
the pelvic organs have the fascial sheathes (coverings). The prostatic sheath is called PyrogovReticiy' sheath and the rectal sheath is the Amus's sheath. The fascia is much like ligaments at the
places of the organs fastening to the pelvis.
There are muscular fascicles as well as collagenic and elastic fascicles. Those are the pubovesical
ligament and the puboprostatic ligament in men and the pubouterine and sacrouterine ligaments in
women.
The spaces between the fascial layers are filled with the pelvic fat.
The space between the pubic symphysis and bladder.
The triangle fascial plate (the antevesical fascia) is strained between the obliterated umbilical
arteries and ring and divides the space into two portions. These are the antevesical fat (between the
transversal and antevesical fascias and anteperitoneal space (between the antervesical fascia and
peritoneum). The antervesical fat goes to the paravesical fat from sides where the internal ilium
vessels are passing.
The retrovesical space is between the posterior wall of the bladder and peritoneoperineal
aponeurosis. It borders with the sagittal parts of the visceral fascia from sides.
The recto rectal space is between rectum and sacrum. The fat that lies around the rectum is
called the pararectal fat.
The parametric fat is around the neck of the womb. It is of a great importance.
The lateral space is bordered by fascias of the obturator and piriformis muscles from sides by
ligaments those are straitened between the pubic bones and sacrum from medial. The internal ilium
vessels pass there. The fascia of the piriformis muscle gives a segment that separates the parietal space
from the lateral one. There are branches of the sacral plexus and the great sciatic nerve there.
The internal iliac artery is the main artery at the lateral space. It goes more medial than
transverse muscle and divides into the anterior and posterior trunks. The anterior trunk goes superficially and gives visceral and parietal branches. These are the umbilical artery, superior uterine
artery (or the deferens duct in men), inferior vesicle artery, middle rectal artery, obturator artery and
internal pudenda artery from which the inferior rectal artery starts away. The posterior parietal trunk lies
more profoundly. The lateral sacral, iliolumbar, and inferior sciatic arteries go from it.
Nerves start from the sacral plexus that is formed by 4-5 lumbar and 1-3 sacral nerves. The
sacral plexus lies on the anterior surface of the piriformis muscle and gives branches. These are the
superior and anterior nerves of the sciatic part, the greater sciatic, posterior femoral cutaneus,
obturator and pudendal nerves.
The ligature of the ilium artery is performed when the parietal branches of the internal ilium artery
are damaged and bleeding can't be stopped. An access is performed according to Shevkunenko.The
skin, fat and fascia should be cut along the line, which starts from the edge of the 12 rib above the
anterior superior ilium spine and turns to the external body of the rectus abdominal muscle. An access
according to Pirogov is performed above the Poupart's ligament higher 2-3 cm and in parallels to this
ligament. Then the abdominal muscles and transverse fascia are cut. The peritoneum with the attached
urethra on it should be exfoliated by the gauze tourunde. The internal ilium artery may be ligatured on
the psoas muscle.
The blood supply of the pelvic organs the opposite side artery will supply.
The suppurative processes of the perineal spaces.
The suppuration may spread in different ways. The pus spread along the vessels into the visceral
spaces from the lateral space; into the ischiac fat through the suprapiriformis foramens; into the
medial surface of the hip through the obturator foramen.
The pus spreads hip and into the anterior abdominal wall through the obturator and femoral
canals from the antervesical space. The pus spreads into the retroperitoneal space along the urethra
from the paravesical space or from the retrovesical space.
The pus spreads from the parauterine space by two ways:
1) Along the round ligament of the uterus through the internal inguinal ring to the anterior
abdominal wall.
2) To the inguinal fosse and to the retroperitoneal space then. There are such accesses for the
abscesses draining:
1) The antevesical space is drained from the Cooprianov's access. The inferior median cut is
performed; the packer passes between the bladder and the levator ani muscle. Urogenital diaphragm
and run through the skin under the inferior border of the pubic.
2) The Buyalskiy-Mack-Woters' access is put into practice for antervesical space draining.
The skin should be cut at the anterior surface of the hip 4-cm Jower than the femoralperineal fold,
the packer passes through the abductor muscles to the obturator membrane and breaks it in its lower
portions, (there is a neurovascular canal in its upper portion).
3) The Pyrogov's access is applied for the operations at the ureter (its lower 1/3) and for the
antervesical space draining. The incision goes in parallels to the Poupart's ligament. The purulent
parametritis may be drained from the same access. If the process spreads towards the vagina the posterior
vault of the vagina would be drained. The semilunar incision between the anal orifice and the sacrum
is performed to access the retrorectal space.
The abscess should be evacuated in the rectum opening by its wall incision if it lies directly
near the rectum.
The urinary bladder.
It is situated in the true pelvis cavity. It borders with the posterior surface of the pubic
symphysis in men. The seminal vesicles, ampulles of the deferent duct and rectum lay from the
behind. The prostata and the perineal muscles are lower. The bladder borders with the uterine and the
superior portion of the vagine in women. The levators ani muscles are from sides. The bladder lies
higher than symphysis in infants.
There are apex, corpus, fundus and cervix that prolongs to the uterine in the bladder. The
peritoneum goes from the abdominal wall on to the anterior wall of the bladder, forms the
transversal fold and covers its superior, posterior and partially lateral wall. The peritoneum is
attached to the bladder with a loose connective tissue, so slips lightly, accept the apex where it is
jointed tightly with the muscular layer. The full bladder juts out the symphysis. Its anterior wall isn't
covered with the peritoneum. In this case that gives a possibility to punctate the bladder without injuring
the peritoneum.
The fixative apparatus of the bladder is rather important in surgery. It is attached to the pubic
symphysis with the pubovesical and puboprostatic ligaments from the front; the rectovesical ligaments
are from the behind. The urethra is fastened to prostata from below. The apex is attached to the navel
by the obliterated cystic duct. There are the vesicouterine ligaments in women instead of the prostatical
component. There are 4 layers in the bladder. These are the connective tissue, muscular, submucous and
mucous layer.
There are external longitudinal, medial, circular and internal transverse oblique layers in the
muscle layer of the bladder. The circular layer is the most powerful and forms the internal vesicle
sphincter at the cervix of the bladder. The main sphincter of the bladder is the external sphincter that is
formed by the striated muscle around the membranous part of the urethra. The mucous layer slips on
the submucous base and forms in the empty bladder accept the Letto triangle where the submocus
base is absent and there are no folds. The base of the triangle are the interureter fold. Its apex is the
cervix of the bladder with the internal opening of the ureter. The triangle is the orientative point for
finding of the ureter openings while the chromocystscopiy.
The blood supplying is providing by the superior (a portion of the umbilic artery) and inferior
vesical arteries (those are the branches of the internal ilium artery). The additional blood supply is
providing from the medial rectal and uterine arteries. The venous outflow is providing by the vesical
plexus that is attached with the antevesical and rectal plexuses.
The sensitive innervating and voluntary regulation of the external sphincter goes from the
sacral plexus by the pudenda nerve. The para-sympathic splanchnic nerves (2-4 sacral segments)
innervate the involuntary muscles of the walls and internal sphincter.
There is bladder's constriction and sphincter's relaxation while those nerves irritation. The
sympathic innervating goes from the sympathic trunk. and nerves of the hypogastric plexus. There is a
bladder relaxation and sphincter constriction while those nerves irritation.
he lymph flows off the into the ilium and hypogastrical lymphatic nodes those are along the
iliac artery and aorta.
Prostata.
It is situated between the bladder and urogenital diaphragm. It is cone shaped. Its width is 4 cm,
its length is 2 cm, height is 4 cm, and weight is 20 gr. The sulcus divides it into right and left parts on
its posterior surface. The prostata borders with the levator ani muscle from sides, rectum that is
separated by the fascia from behind. That's why it may be palpated through the rectum. It is smooth
and elastic in normal, with its sulcus and parts. The prostata is the conglomerate of the alveolitubular
glands
in
the
musculous-connective
tissue
stroma.
The urethra passes oblique through it. The urination is difficult while prostata enlargening.
Its blood supply is providing by the inferior vesical, medial rectal and internal pudendal arteries.
These arteries form the organic plexus (Santorini plexus) that is injuring easily while adenectomia and
may be a cause of the pulmonal artery's thrombembolism.
The paracentesis of the bladder.
The intervention is performing while the acute parauria and the cathetrization is impossible.
The stippling is carrying out on 2 cm higher the pubic symphysis perpendicularly to the abdomen
strictly on the median line. When gap feeling appears and the urine starts to drop from the end of the
cannula the bladder will empty. The needle must be quickly brought out after the procedure.
The high incision of the urine bladder.
The incision is carrying out to extract stones, foreign objects, tumors, and adenoma by means of
the catheter. The bladder should be filled with a sterile physiologic salt solution to lift the bladder
apex above the symphysis.
An access is a suprapubic median longitudinal incision. The bladder walls are fixating with 2
ligatures through its muscular layer. The bladder empties by means of the catheter and the surgeon
incises its wall between the ligatures. The wall of the vesicle should be sutured hermetically after the
manipulation. The first interrupted suture involves the adventicia, muscular and the submucous
layers. There is no reason to suture the mucous layer because salt may crystallize on the threads.
The external suture involves just the adventitia and muscular layer.
The uterine.
It is the muscular cavitary organ that is situated between the bladder and rectum. It consists of
the corpus, fundus and cervix. There are orifices of the oviduct at the borders of the fundus (base).
The end of the uterine cavity has it opening in the canal of the cervix. The isthmus of the uterine is
between the corpus and cervix. The obstetricians call it the superior segment of the uterine. The inferior
part o the cervix is in the vagine and may be palpated. That's why the cervix is divided into the
supravaginal and vaginal J parts. The wall of the uterine consists of 3 layers. These are serosal
(perimetrium) with the subserosal basement, muscular (myometrium) and mucous layers
(endometrium) (without the submucouse basement).
The peritoneum covers the uterine mostly. The lateral borders have no covering. There is a
layer of fat between the anterior and posterior layers of the peritoneum where the vessels and nerves
pass.
The pelvic fundus is a fixative apparatus more important as the ligaments are.
The ligaments are:
1) The broad ligament of the uterine. It is the peritoneal duplicature that passes from the lateral
borders of the uterine (uterine ribs to the lateral pelvic walls). There is the uterine tube in it from
above.
2) The cardinal ligaments. These are the fibrous muscular bands those are passing at the inferior
parts of the broad ligaments.
3) The round ligament. It is the anologic to the Hunter's gubernaculum. It starts from the
angles of the uterine and goes to the deep inguinal ring. It may pull the peritoneum into the inguinal
canal like the vaginal process in men. It is called Nukke's diverticulum and may be the pace of the
cystogenesis. The ligament diverges to Emlakh bunch in the large pudendal lip after the leaving
of the inguinal canal.
4) The sacrouterine ligaments. They go in the lateral folds of the peritoneum from the
sacrum to the uterine. There are muscular fascicles in it sometimes.
5) The vesicouterine ligament. It is the extension of pubovesical ligament and is formed by
the bulge of the sagital plate of the visceral layer of the pelvic fascia.
The main blood supply is providing by the uterine artery, which is the branch of the internal
artery. The uterine artery crosses with the ureter for two times. The ureter passes from the front of the
uterine artery at start. The artery passes from the front of the ureter at the middle of the uterine artery
level. The artery turns around the ureter semicirculary. They are equal at the diameter. There is a
danger of the ureter incision or dressing instead of the artery. The pulsation may help differ them.
The uterine artery goes within the broad ligament and comes to the uterine ribs and divides into
the ascending and descending branches there. The branches go in parallels to the uterine axe. The
terminal arteries come horizontally directly to the uterine from these branches.
The isthmus has lesser vessels than the corpus. The isthmus portion ought to be incised while
the Caesarian section according to the architecture of the vessels net. There would be the lesser
traumatisation and bleeding.
The ovarian artery provides the additional blood supply. It starts from the aorta and forms the
anasthomose with the uterine artery.
The uterine arteries are straight in infants. They become sinuous in pubertates that gives a
reserve for the uterine enlarging while pregnancy. The arteries are the most sinuous after the delivery.
The uterine involution is of a great meaning in this process after the delivery. That is the symptom of
labor in past of a women at the medicolegal investigation.
The venous outlet is providing by the uterovaginal plexus and ovarian veins partially. The
ovarian veins confluent into the inferior Cava vein from right side and renal vein from the left.
The parasympathic innervation is providing by the pelvic nerves those form the uterovaginal
plexus (Frankengeiser's plexus). The sympathic innervation is providing by the hypogastrical
plexus.
The corpus has sympathic innervation dominant, the cervix has the parasympathic innervation
dominant. That explains the chronic contraction of the corpus and relaxation of the cervix while
delivery. The nervous plexuses are mostly in the parametriums from sides that should be
mentioned while the novocaine anesthesia.
The ovary.
It is lying in the fosse between the internal and external ilium arteries on the internal obturator
muscle. It is covered with a germinal epithelium
that makes a mat surface.
There is a residue of the peritoneum like a thin border that is called
Farae-Waldeyer's ring.
The ligamentous apparatus.
1) The infundibulopelvic ligament is a suspensory ligament of the ovary. The ovarian vessels
pass there.
2) The own ligament. It goes from the lateral angle of the uterine to the uterine end of the
ovary.
3) The mesoovarium. It goes from the broad ligament of the uterine to its posterior layer.
The blood supply is providing by ovary and uterine arteries.
The surgery interventions are carrying out because of the cysts, tumors or breakups of the ovary.
An access is the inferior median laparotomy. When the cyst is too large it should be punctate and
empty previously.
There is performing the exposure of cyst. There are two forceps on its peduncle between them the
dicision is carrying out. The sero-serous suture is applied. The abdominal cavity must be closed in
layers. There is the uterine tube along the superior border of the broad ligament of the uterine. There
are the interstitial tube, tubal isthmus, ampullar tube and infundibulum. There are fimbriae on the
infundibulum those embrace the ovary.
Mesosalpinx is the part of the broad ligament of the uterine between the uterine tube and
mesovarium. The operations are carrying out while the extrauterine pregnancy.
Four accesses may be applied.
1) The inferior median laparotomy from the umbilic to pubic.
2) Pfanenstile's access. This is the arched incision along the suprapubic fold. The blunt
dissection of the straight abdominal muscles is applied after white line section.
3) Cherny's access. This is a transverse incision 5-6 cm higher than pubic symphysis. All the
layers are dissected. The access is applying when the pelvic and abdominal organs revision is
necessary.
4) The oblique incisions are in parallels to the Poupart's ligament. There are such moments of
the operation because of the interrupted tubal pregnancy.
1) The lips of the wound are pulled away with the retractor.
2) The exposure of the tube with the ooblast.
3) The dissection of the tubal part after the mesosalpinx clipping by Bilrot’s clamp and dressing
of it catgut suturing of the angle of the uterine.
4) The peritonization.
5) Clots of blood exposure from the abdominal cavity.
6) The revision of the pelvic organs.
7) The suturing of the wound.
The rectum intestine.
It is the terminal portion of the large intestine. It starts at the level of the third sacral vertebra.
It looses its mesentery there. There is a longitudinal layer of the smooth muscle along the rectum
in contrast to other intestines. The pelvic part of the rectum is higher than the pelvic diaphragm. The
lower portion is called the perineal part.
There is the ampoule and supraampullar portion in the pelvic part. Rectum turns for two times
in a sagital plane
The first curvature is from the behind and responds to the curvature of the sacrococcygeal
symphysis. The second curvature is from the front, where the ampoule of the rectum goes onto anus.
These curvatures are of a great meaning while rectoromanoscvopia and endoscopia. When they are
not mentioned there is a risk of trauma.
The rectum curves to the left in the frontal plane. That's why the patient lies on his left side
while administration of the enema. The length of the rectum grows for 5-6 cm after straightening.
That's why the mobilization of the rectum is possible while the intestinal obstruction.
The supraampular parts are covered by the peritoneum wholly. The posterior side looses lower
the peritoneal cover and then the lateral sides loose it. The inferior part of the ampoule lies
retroperitonealy.
There is the mesorectum at the supraampoular part sometimes. These patients have the rectal
prolapse more often.
There is prostata in front of the rectum in men or uterus in women. The sacrum and coccygeum
are from behind. There are ischiorectal fosses from sides.
The mucous layer forms the circular folds in the pelvic part and longitudinal folds in the
perineal part. The longitudinal folds (Morgany's columns) end with the tubercles with the semilunaris
valves. They form sinuses. The circular space between the sinuses and anus is called the hemorrhoid
zone. The structure of the mucous layer plays role in the pathogenesis of the rectal diseases. Every
rectal abscess and fistula grows from the anal crypts. The infection spreads into the anal submucous
glands from there and goes into the rounding tissues through the glands' wall.
The muscular layer consists of the longitudinal and circular fascicles. The longitudinal muscles
are distributed evenly.
The circular muscles form sphincters those are the constrictive system of the rectum. Its damage
means the failure of the main rectal function.
The external sphincter is around the anus. The subcutaneous part is the most superficial. The
superficial part of the external muscular sphincter starts from the coccygeal bone. The most powerful
part of the anus is its deep part of the striated muscles. The pudendal nerve gives the voluntary
innervation.
The smooth muscles thicken 3-4 cm higher than anus and form the internal sphincter. The third
sphincter (or Hepher's muscle) is 10 cm higher than anus. There is the vegetative innervation. The both
sphincters are involuntary.
The sympathic innervation goes from the mesenteric and aortal plexuses; the parasympathic
innervation goes from the pelvic nerves. The mucous and muscular layers are connected by means of
vessels. The separation of the mucous layer is possible after the complete dicision of the vessels. But
the mucous layer is rather mobile. The prolapse of the mucous layer may occur if the vessels are too
long.
The blood supply is providing by:
1) the superior rectal artery that goes from the inferior mesenteric artery
2) Twinned medial rectal artery that goes from the internal ilium artery.
3) Twinned inferior rectal artery that goes from the internal pudendal artery (the brunch of the
internal ilium artery).
When the superior and medial arteries are too long they may be the factor of the rectal
prolapse.
The venous outflow is providing by the subcutaneous, submucous and subfascial plexes. The
subcutaneous plexus is situated around the external rectal sphincter. The submucuos plexus is the
mostly developed. The subfascial plexus is between the longitudinal muscular layer and rectal fascia.
The venous blood flows out into the rectal veins. The superior one is the start of the inferior
mesenteric vein and belongs to the portal vein system. The inferior and medial veins belong to the
inferior Cava vein system. The medial veins flows into the internal ilium veins. The inferior veins
flows into, the internal pudendal veins. That is the way of the portacaval anastomoses formation.
These anasthomoses may enlarge and imitate the hemorrhoid while the portal system block.
That is rather possible because there are no valves in the hemorrhoid veins.
The submucous plexus is rather special. Its structure is much like the cavernous corpuses that
means a lot of anasthomoses with arteries and arterioles. The bleeding will be with a bright red color of
the blood because of a high containing of the arterial blood. The hemorrhoid bleeding may be
significant and leads to anemia. That fact ought to be mentioned while the differential diagnosis of
the intestinal bleeding.
There are 3 zones of the lymph outflow. These are the inferior, medial and superior zones. The
lymph flows into the inguinal lymphatic nodes from the perineal part; into the sacral and internal
ilium lymphatic nodes from the ampoule and into the inferior mesenteric lymphatic nodes from the
supraampular part.
The sensitiveness of the rectum differs in various parts. The pelvic part is of law sensitiveness.
The anus is of a great pain sensitiveness because of the various innervation. The pelvic part has the
sympathic and parasympathic innervation; the anus is innervated by the spinal nerves. That should be
mentioned while anesthesia.
The sacrum should be dicised lower than the third sacral foramen while the access to the
rectum. The 3rd, 4th and sometimes the 5th sacral nerves may innervate the rectum. Don't let these
nerves to damage. That leads to the functional break of the rectum, anal sphincter and other pelvic
organs.
There are three accesses for the operative interventions at the rectum. These are the perineal,
abdominal and perineo-abdominal a sacral access.
The perineal access is applied when low localization of the tumor. But a great trauma is
possible if there is a need to broaden the wound by means of the coccygeal bone or even the part of
the sacrum extraction, (the operation by Kraske).
The combined perineoabdominal access is much better. The rectum is extracted both with the
tumor through the laparotomy incision.
The operative treatment of the hemorrhoids.
There are 3 groups of the operations
1) the dressing of hemorrhoids
2) Cutting off the piles.
3) Cutting off the mucous layer and piles by Widenhead.
4) The method has been founded by Hippocrates. The local type of the anesthesia is applied.
When the sphincter is rasped the fenestrated Luer's forceps should be placed on the piles. Then
the mucous layer is dissected. The hemorrhoid dressing is performing with silk ligatures on both
sides. The residue-free diet should be prescribed. The knots necrotize and falloff at the 6-7 day.
1) The operation by Rockytsky.
a) The local type of the anesthesia is employed. The piles are exposed with Luers forceps; the
denticulate Rockytsky forceps are applied lower. The piles are cutting off and interrupted catgut suture
is placed. The mucous layer is sewed with between the denticles of forceps.
b) The operation by Meligane-Morgan. The idea is that the piles are situated according the 3, 7
and 11 figures of the clock-face.
3) The operation by Widehead. It is the dicision of the mucous layer together with the
hemorrhoids as a cylinder of 5 cm height. The mucous layer is pulling down and sewing to the
skin.
4) The constriction of the anal canal may occur as a complication.
The perineum.
This is a system of the soft tissues that closes the pelvic outlet. It is bordered by the pubic and
sciatic bones in front, by sciatic tubers from sides and by the sacrum from the behind. It is a
diamond-shaped.
The obstetrical perineum is the tissue between the posterior comissure and anus. The perineum
divides into urogenital and anal triangles by the arch line between the sciatic tubers.
There is a suture on the skin in man. It is the prolongation of the scrotal suture. There are
branches of the pudendal nerves and internal pudendal vessels in the subcutaneous fat.
The superficial fascia covers the superficial muscles of the perineum. These are the superficial
transverse perineal muscle, ischiocavernosus and bulbospongious muscles. The profound layers of the
urogenital triangle are called the urogenital diaphragm. It consists of the inferior fascia of the
urugenital diaphragm that covers the deep transverse perineal muscle and arcuate pubic ligament
from the side of the pelvic surface.
The diaphragm is stretched between the arcuate pubic ligament and transverse perineal
ligament.
The urethra passes through the urogenital diaphragm. The vagine passes through it in women.
The muscular fascicles those are strengthening the sphincter of the urethra are starting off the
deep transverse muscle.
There are three parts in the urethra in men. These are the prostatic, membranous and
spongious parts. The urethra turns twice. The first retropubic flexure is formed by the spongious part
and curves to the behind and down. The membranous part is fixed the best. These facts have to be
mentioned while the cathetrization of the bladder.
The skin, subcutaneous fat and superficial perineal fascia are the layers of the anal triangle. The
profound layers are the ischiorectal fossa that is filled with the fat tissue. It is located around the
rectum and anus. The internal obturator muscle with its fascia borders from the exterior ad the
levator ani muscle borders it from the middle.
It is bordered from the perineal side too. The inferior end of the great ischiadic muscle is from
the behind, the sciatic tubers are from the exterior and the external anal sphincter is from the middle, the
superficial perineal muscle is from the front.
The levator ani muscle is covered with the inferior pelvic fascia from the surface of the
ischiorectal fossa.
The pudendal nerve and internal pudendal vessels pass from the ischiac region through the minor
obturator foramen. The nerve and vessels are lying on the internal obturator muscle. The end of the
fascia forms a canal for them. (Olkock's canal).
The inflammation of the ischiorectal fat is called the paraproctitis.
There are the subcutaneous, submucosal ischiorecal and pelvirectal paraproctitis.
1) The semilunar incisions arc applied while the subcutaneous parapro ctitis. The radial incisions
are atraumatic for the branches of the pudendal nerve those converge radial to the externa! anal
sphincter. But the incisions concur with the anal folds. That's why the incisions collapse soon. The
semilunar incisions are expanded that lets the deep access. But the damage of the pudendal nerve is
rather possible. That's why just the skin is incised semilunary. The blunt dissection of the deeper
tissues is employed.
2) The submucosal paraproctitis is incised through the mucous layer and drained through the
anus.
3) The ischiorectal paraproctitis is incised in the middle between the external sphincter and
sciatic tuber to avoid the damage of the sphincter and neurovascular bound.
4)The pelvirectal paraproctitis is incised semilunary between the coccygeus and anus. The
blunt dissection of the tissues is employed then between the levator ani muscle and the coccygeal
muscle.
The operative anatomy of the testicles.
The embryogenesis o the testicle goes at the 4th month both with the primary ren retroperitoneally.
It descends to the internal inguinal ring at the 7th month of the embryogenesis. It passes through all the
layers of the abdominal wall and forms all the coverings (sheathes) with itself. The testicle has own
albugineal envelope. The testicles are intime attached to the peritoneum and pull into the scrotum
like a vaginal process that obliterate to the moment of birth. The serous envelope of the testis forms
just to the moment of birth too. Th internal spermatic fascia is formed of the transverse abdominal fascia.
The cremaster muscle is formed by the oblique and straight abdominal muscles. The external spermatic
fascia is formed by Tompson's plate; tunica dartos is formed by the subcutaneous fat.
The testicular arteries provide blood supply. The venous blood outflows from the right testicle into
the inferior Cava vein and from the left one to the left renal vein. That explains more frequent dilatation
of the veins of the left testicle and spermatic cord.
The operation by Ivanisevich is performed then. That is the dressing of the left testicular vein or
both vein and artery (operation by Yerohin).
Hydrocele occurs frequently. This is the accumulation of the fluid in the serous envelope while
the inflammatory, posttraumatic fluid production dominates its absorbtion.
The parietal layer of the own envelope is incised and the fluid has to flow to the tunica dartos.
1) The operation by Wincelmann (the incision and turning inside out of the envelope).
2) The operation by Bergmans-Israel (cutting off the segment of the parietal layer).
3) The operation by Alferov (fenestration).
5.2. Theoretical questions to studies:
1. Put the definishen of the landmarks and borders of the pelvis.
2. The walls of the pelvis.
3. Vessels and nevs of the pelvis.
4. Fascial structure and cellular tissue of pelvis.
5. Lymphatic drainage of the pelvis.
6. The topographical anatomy and operative surgery of the uterus.
7. The topographical anatomy and operative surgery of the urinary bladder.
8. The topographical anatomy and operative surgery of the rectum.
9. The topographical anatomy and operative surgery of the urethra.
10. The topographical anatomy and operative surgery of the prostata.
5.3. Practical tasks which are executed on studies:
1. Localize the main landmarks of pelvis.
2. Realize the approaches to pelvic organs.
5.4. Materials for self-control:
А. Questions for self-control:
Select the best response:
1. The following statements concerning the uterus are correct except:
A. The fundus is part of the uterus above the openings of the uterine tubes.
B. The long axis of the uterus is usually bent anteriorly on the long axis of the vagina (anteversion).
C. The nerve supply of the uterus is from the inferior hypogastric plexuses.
D. The anterior surface of the cervix is completely covered with peritoneum.
E. The uterine veins drain into the internal iliac veins.
2. Concerning the vas deferens, all of the following statements are true except:
A. It emerges from the deep inguinal ring and passes around the lateral margin of the inferior
epigastric artery.
B. It crosses the ureter in the region of the ischial spine.
C. The terminal part is dilated to form the ampulla.
D. It lies on the posterior surface of the prostate but is separated from it by the peritoneum.
E. It joins the duct of the seminal vesicle to form the ejaculatory duct.
3. Concerning the pelvic part of the ureter, the following statements are true except:
A. It enters the pelvis in front of the bifurcation of the common iliac artery.
B. The ureter enters the bladder by passing directly through its wall, there being no valvular
mechanism at its entrance.
C. It has a close relationship to the ischial spine before it turns medially toward the bladder.
D. The blood supply of the distal part of the ureter is from the superior vesical artery.
E. It enters the bladder at the upper lateral angle of the trigone.
4. Concerning the seminal vesicle, the following statements are true except:
A. The seminal vesicles are related posteriorly to the rectum and can be palpated through the rectal
wall.
B. The seminal vesicles are two lobulated organs that store spermatozoa.
C. The upper ends of the seminal vesicles are covered by peritoneum.
D. The function of the seminal vesicles is to produce a secretion that is added to the seminal fluid.
E. The seminal vesicles are related anteriorly to the bladder, and no peritoneum separates these
structures.
5. Concerning the ovary, the following statements are true except:
A. The lymph drainage is into the para-aortic (lumbar) lymph nodes at the level of the first lumbar
vertebra.
B. The round ligament of the ovary extends from the ovary to the upper end of the lateral wall of the
body of the uterus.
C. The ovarian fossa is bounded above by the external iliac vessels and behind by the internal iliac
vessels.
D. The left ovarian artery is a branch of the left internal iliac artery.
E. The obturator nerve lies lateral to the ovary.
6. Concerning the nerve supply to the urinary bladder, the following statements are true except:
A. The sympathetic postganglionic fibers originate in the first and second lumbar ganglia.
B. The parasympathetic postganglionic fibers originate in the inferior hypogastric plexuses.
C. The afferent sensory fibers arising in the bladder wall reach the spinal cord via the pelvic
splanchnic nerves and also travel with the sympathetic nerves.
D. The parasympathetic preganglionic fibers arise from the second, third, and fourth sacral segments
of the spinal cord.
E. The parasympathetic postganglionic fibers are responsible for closing the vesical sphincter during
ejaculation.
7. Concerning the vagina, the following statements are true except:
A. The area of the vaginal lumen around the cervix is divided into four fornices.
B. The upper part of the vagina is supported by the levator ani muscles and the transverse cervical
ligaments.
C. The perineal body lies posterior to and supports the lower part of the vagina.
D. The upper part of the vagina is not covered with peritoneum.
E. The vaginal wall receives a branch of the uterine artery.
8. Concerning the visceral layer of pelvic fascia in the female, the following statements are true
except:
A. In the region of the cervix of the uterus, it is called the parametrium.
B. It is condensed to form the pubocervical, transverse cervical, and sacrocervical ligaments of the
uterus.
C. It covers the obturator internus muscle.
D. It does not become continuous above with the fascia transversalis.
E. On the lateral wall of the pelvis, it fuses with the parietal layer of pelvic fascia.
Match the structures listed below with the most likely route of lymphatic drainage:
9. Cervix of uterus
10. Prostate gland
11. Posterior fornix of vagina
A. Internal iliac lymph nodes
B. Internal and external iliac lymph nodes
C. Superficial inguinal lymph nodes
D. Para-aortic (lumbar) lymph nodes
E. None of the above
Match the structures listed below with the appropriate main venous drainage:
12. Left ovary
13. Prostate
14. Urinary bladder
15. Mucous membrane of the rectum
A. External iliac vein
B. Internal iliac vein
C. Inferior vena cava
D. Common iliac vein
E. None of the above
Answers to Questions
1. D
2. D
3. B
4. B
5. D
6. E
7. D
8. C
9. B
10. A
11. B
12. E
13. B
14. B
15. E
В. Test tasks for self-control:
1.
The lesser sciatic foramen is associated with all the following structures EXCEPT the
A external pudendal artery and vein
B pudendal nerve
C sacrospinous ligament
D sacrotuberous ligament
E tendon of the obturator internus muscle
2.
Which of the following is a characteristic of the female (as compared with the male) pelvis?
A A heart-shaped (as opposed to oval) pelvic inlet
B A relatively deep (as opposed to shallow) false pelvis with ilia that are more vertical
C A pelvic outlet of smaller diameter
D A narrow subpubic angle between the pubic rami
E None of the above
3.
Structures normally found within the internal spermatic fascia of the spermatic cord include all the
following EXCEPT the
A deferential artery
B ilioinguinal nerve
C pampiniform plexus
D testicular artery
E testicular nerve
4.
The gubernaculum is a continuous mesenchymal condensation extending from the caudal pole of each
testis through the inguinal canal to the scrotal swelling, inferiorly. In the female it becomes
A the canal of Nuck
B the ligament of the ovary
C the round ligament of the uterus
D the round ligament of the uterus and the ligament of the ovary
E none of the above
5.
An extension of the abdominal cavity is present in the scrotum. It is represented in the adult male by
A the cremaster muscle
B the gubernaculum
C the spermatic cord
D the tunica vaginalis
E none of the above
6.
Factors that should be considered by the physician at this point include the fact that varicocele of the
pampiniform plexus on the right side
A is very uncommon
B occurs about as often as that on the left side
C may be the result of testicular torsion
D may be associated with a long, redundant mesorchium
7.
It was decided that the testicular vein would be ligated just cranial to the deep inguinal ring to
eliminate venous back pressure proximal to the varicocele. In an incision parallel and one fingerbreadth cranial to the inguinal ligament, the surgeon encountered all the following structures EXCEPT
the
A external oblique aponeurosis
B transverse abdominis muscle
C internal oblique muscle
D genitofemoral nerve
E ilioinguinal or iliohypogastric nerve
8.
Upon gaining access to the peritoneal cavity and locating the testicular vein, it was noted that the vein
was inexplicably dilated. Further exploration revealed a large ret-roperitoneal mass in the vicinity of
the lower pole of the kidney that encroached upon the vein so that it did not drain freely into the
A hepatic portal vein
B inferior vena cava
C internal iliac vein
D right renal vein
E right suprarenal vein
9.
Since the tumor appeared to be of renal origin, it was decided that a CT scan, arteriogram, and
intravenous pyelogram were needed before removal of the tumor could be considered. The testicular
vein was ligated as planned. After ligation, blood returns from the testes by all the following collateral
pathways EXCEPT
A deep dorsal vein of the penis
B
C
D
E
external pudendal veins
posterior scrotal veins
veins associated with the cremaster muscle
veins of the vas deferens
10.
The ischioanal fossa is characterized by all the following EXCEPT
A adipose tissue that is continuous with the superficial layer of superficial fascia found in the
urogenital triangle
B anterior projections between the urogenital diaphragm and pelvic floor
C a voluntary sphincter innervated directly by twigs from the sacral E plexus
D inferior rectal arteries derived from an artery that passes along the pudendal canal
E lymphatic drainage largely to ward the inguinal nodes
11.
Which of the following statements correctly pertains to the dartos tunic of the scrotum?
A It is formed by the fusion of the two layers of superficial fascia of the perineum
B It is invested with adipose tissue
C It participates in the cremaster reflex
D It receives innervation from the genital branch of the genitofemoral nerve
E It responds to cold temperatures by lowering the testes away from the body
12.
Laceration of the male urethra just inferior to the urogenital diaphragm would likely result in
extravasation of urine into all the following regions EXCEPT
A the abdominal wall between the deep layer of superficial fascia and deep fascia
B the anal triangle between the superficial (ischioanal) fat and the deep fascia
C the penis between the superficial fascia and the deep (Buck’s) fascia
D the scrotum deep to the dartos layer
E the urogenital triangle between the deep layer of superficial (Colles’) fascia and deep fascia
13.
Which of the following structures is found in the superficial perineal space of the male?
A Bulbourethral glands
B Deep dorsal vein of the penis
C External urethral sphincter
D Membranous urethra
E Prostatic urethra
14.
Which of the following structures is found in the deep perineal space of the female?
A Deep dorsal vein of the clitoris
B Deep transverse perineal muscle
C Greater vestibular glands
D Paraurethral glands
E Vestibular bulb
15.
Regions that drain to the inguinal lymph nodes include all the following EXCEPT the
A anal triangle
B lower abdominal wall
C lower extremity
D scrotum
E testis
16.
Fructose, a source of energy for spermatozoa, is found primarily in secretions from the
A bulbourethral glands
B epididymis
C prostate
D seminal vesicles
E testis
17.
Benign prostatic hypertrophy results in obstruction of the urinary tract. This specific condition is
associated with enlargement of
A the lateral lobes
B the median lobe
C the posterior lobes
D none of the above
18.
The external urethral sphincter in the female is
A a modified portion of the pelvic diaphragm
B continuous completely around the urethra
C innervated by the pudendal nerve
D subject to involuntary control
E none of the above
19.
All the following statements concerning female sexual function are correct EXCEPT
A erection is a parasympathetic event
B erection is the result of muscle contraction
C uterine spasm accompanying orgasm is a sympathetic event
D loss of tumescence is the result of sympathetic activity
20.
All the following structures are contained within or are a part of the broad ligament of the uterus
EXCEPT the
A mesometrium
B mesosalpinx
C mesovarium
D round ligament of the uterus
E ureter
21.
All the following statements correctly characterize the pelvic diaphragm, which forms the floor of the
abdominopelvic cavity, EXCEPT
A it comprises the levator ani and coccygeus muscles with their fascia
B it functions to support the pelvic organs
C it is innervated by twigs from the sacral plexus
D it lies in the same plane as the urogenital diaphragm
E it originates in part from a condensation of fascia across the obturator internus muscle
22.
All the following statements apply to the uterine artery EXCEPT that it
A anastomoses with branches of the ovarian and internal pudendal arteries
B is the homologue of the artery of the vas deferens (deferential artery) in the male
C is a branch of the anterior division of the internal iliac artery
D passes immediately inferior to the ipsilateral ureter at one point
E runs in the transverse cervical ligament
23.
On digital examination of the apical region of the vagina, the structure presented first to the examining
finger is the posterior lip of the cervix. This observation precludes which of the following uterine
postures?
A Antiflexion
B Anteversion
C Retroflexion
D Retroversion
E None of the above
24.
The ovaries are palpable and appear normal on pelvic examination. Other structures that could be
palpated on pelvic examination include all the following EXCEPT the
A aorta
B coccyx
C ischial spines
D sacral promontory
E
sacrospinous ligament
25.
The uterus is indirectly supported by all the following pelvic structures EXCEPT the
A obturator internus muscle
B pubovaginalis and puborectalis portions of the levator ani muscle
C rectum
D urinary bladder
E vagina
26.
Structures that contribute to the direct support of the uterus include all the following EXCEPT the
A lateral or transverse cervical ligaments
B pubocervical ligaments
C round ligaments of the uterus
D suspensory ligaments
E uterosacral ligaments
27.
Which of
ligament?
A
B
C
D
E
the following would be found immediately inferior to the left cardinal (lateral cervical)
Ovarian neurovascular bundle
Uterine tube
Round ligament of the uterus
Ureter
Uterine artery and vein
28.
The patient is scheduled for a hysterosalpingogram, in which radiopaque material is injected into the
uterus and uterine tubes. Examination of subsequent radiographs discloses spillage of the contrast
medium into the peritoneal cavity, an indication that
A the uterine tube is normal
B the mesonephric ducts failed to form properly
C the paramesonephric ducts failed to form properly
D there is a rectouterine fistula
E there is a vesicovaginal fistula
29.
After receiving counseling as to both the best time in the ovula-tory cycle and the most favorable coital
position for conception, the patient becomes pregnant. She is observed closely throughout the
pregnancy. At delivery, caudal analgesia is induced by administration of anesthetic into the epidural
space in the sacral region. The needle is introduced via the
A anterior sacral foramina
B dural sac
C intervertebral foramina
D posterior sacral foramina
E sacral hiatus
30.
Properly administered caudal analgesia accomplishes all the following EXCEPT
A blockage of pain fibers arising from the cervix
B blockage of pain fibers arising from the perineum
C elimination of uterine contraction
D paralysis of perineal musculature
31.
As delivery begins, a midline episiotomy is performed to the external anal sphincter. An incision that
is precise will sever all the following structures EXCEPT the
A central tendon of the perineum
B fourchette (frenulum of the labia)
C posterior vaginal wall
D superficial transverse perineal muscle
32.
The delivery, which is a difficult one requiring extensive use of forceps, produces tearing of the
external anal sphincter and anal canal. A normal boy is delivered. Both the sphincteric tear and
episiotomy incision are sutured. In retrospect, a posterolateral (mediolateral) episiotomy may have
been preferable to a midline incision in this case. A posterolateral episiotomy would involve sectioning
all the following structures EXCEPT the
A central tendon of the perineum
B deep transverse perineal muscle
C superficial transverse perineal muscle
D perineal branches of the pudendal nerve
E perineal branches of the internal pudendal artery
33.
Which of the following arteries may occasionally arise as a branch of the external iliac artery or
inferior epigastric artery instead of as a branch of the internal iliac artery?
A Internal pudendal artery
B Obturator artery
C Superior gluteal artery
D Umbilical artery
E Uterine artery
34.
Bilateral lumbar sympathectomy does not affect autonomic control of the descending colon because
A the descending colon receives its parasympathetic innervation from the pelvic splanchnics
B the descending colon receives its parasympathetic innervation from the vagus nerve
C the descending colon receives its sympathetic innervation from thoracic splanchnic nerves
D lumbar splanchnics innervate the pelvic viscera via the hypo-gastric nerve
E only presynaptic sympathetic fibers have been severed
35.
Sympathetic and parasympathetic nerves reach the pelvic plexus by different pathways. If during
surgical resection of the rectum, the sympathetic nerves were excised bilaterally, which of the
following complications would ensue?
A A dilated and neurogenic bladder
B Loss of control of the external urethral sphincter
C Impotence (inability to obtain erection)
D Inability to ejaculate (E) None of the above
36.
The following pelvic structures are correctly linked to the somatic regions to which they refer pain
EXCEPT
A the cervix to the perineum, leg. and foot
B the epididymis to the lumbar and umbilical regions
C the mid-ureter to the inguinal region, pubic region, and medial thigh
D the ovary to the umbilical region, lumbar region, and medial thigh
E the uterine body to the inguinal region, hypogastric region, and medial thigh
C. Clinical Problem Solving
Study the following case histories and select the best answers to the questions following them.
A 30-year-old man involved in a barroom brawl was seen in the emergency department. He was found
to have a blood-stained tear on the seat of his trousers and lacerations of the anal margin. During the fight he
was knocked down and fell in the sitting position on the leg of an upturned bar stool. While under
observation he developed the signs and symptoms of peritonitis.
1. The signs and symptoms displayed by this patient could be explained by the following anatomic
facts except
A. The patient had impaled his rectum on the leg of the upturned bar stool.
B. At operation, a laceration of the anterior wall of the middle of the rectum was found.
C. The leg of the bar stool had entered the rectovesical pouch.
D. The rectal contents had contaminated the peritoneal cavity and was responsible for the
development of peritonitis.
E. The anterior surface of the middle third of the rectum has no peritoneal covering.
A 46-year-old man had been treating himself for hemorrhoids for the past 3 years. He had noticed that
his feces were often slightly blood stained. For the past 12 months, he had noticed that when he had his
bowels open, he always felt that more was to come. Sometimes he went to the toilet several times a day but
was only able to pass flatus and blood-stained mucus. Recently, pain had developed down the outside of his
right leg. Digital examination of the rectum revealed a large, hard-based ulcer on the posterior wall of the
rectum with extensive induration of the pararectal tissues. A diagnosis of advanced carcinoma of the rectum
was made.
2. The following facts about this patient are probably correct except:
A. Some of the bleeding was from the carcinomatous ulcer of the rectum as well as from the
hemorrhoids.
B. The lymphatic drainage of the rectum takes place first into the pararectal lymph nodes.
C. Carcinoma of the rectum never metastasizes to the liver.
D. Examination of the right leg revealed some weakness of the muscles supplied by the sciatic nerve.
E. The carcinoma had extended posteriorly to involve the sacral plexus.
F. The patient indicated that the leg pain was felt in skin areas supplied by branches of the sciatic
nerve.
An inebriated 40-year-old man was involved in a fight over a woman. The woman's husband gave the
man a severe blow on the lower part of the anterior abdominal wall, whereupon he doubled up with pain and
collapsed on the floor. On admission to the emergency department of the local hospital the man was in a
state of shock and complaining of severe pain in the lower abdominal region. He was unable to pass urine
since the fight. A diagnosis of ruptured urinary bladder was made.
3. The following facts concerning this patient are correct except:
A. Rectal examination revealed a bulging backward of the rectovesical fossa.
B. Although the patient had consumed a considerable volume of liquor, dullness was not present on
percussion of the anterior abdominal wall above the symphysis pubis.
C. The urine accumulated in the rectovesical pouch. D. A full bladder is more likely to be ruptured by
a blow on the anterior abdominal wall than an empty bladder.
E. In the adult as the normal bladder fills, its superior wall extends upward into the abdomen, leaving
the covering of parietal peritoneum behind.
A 56-year-old woman was seen by her obstetrician and gynecologist complaining of a "bearing-down"
feeling in the pelvis and of a low backache. On vaginal examination, the external os of the cervix was found
to be located just within the vaginal orifice. A diagnosis of uterine prolapse was made.
4. The following anatomic facts concerning uterine prolapse are correct except:
A. The most important support to the uterus is the tone of the levator ani muscles.
B. The transverse cervical, pubocervical, and sacrocervical ligaments play an important role in
supporting the uterus.
C. Damage to the levator ani and the cervical ligaments during childbirth can be responsible for
prolapse of the uterus.
D. Prolapse most commonly reveals itself before menopause.
E. Prolapse of the uterus is always accompanied by some prolapse of the vagina.
A 25-year-old woman was seen in the emergency department complaining of severe pain in the right
iliac region. Just before admission she had fainted. On physical examination, her abdominal wall was
extremely tender on palpation in the lower right quadrant, and some rigidity and guarding of the lower
abdominal muscles were noticed. A vaginal examination revealed a fairly firm cervix with a closed external
os. A tender "doughlike mass" could be felt through the posterior fornix. The patient had missed her last
period.
5. The following facts concerning this patient are correct except:
A. A diagnosis of ruptured ectopic pregnancy was made.
B. Tubal pregnancies commonly occur where the infundibulum narrows to join the isthmus.
C. Each uterine tube is situated in the base of the broad ligament.
D. An ectopic tubal pregnancy almost invariably results in rupture of the tube with severe
intraperitoneal hemorrhage.
E. Tubal rupture occurs as a result of the eroding action of the trophoblast.
F. Once a tubal pregnancy dies the decidual lining of the uterus begins to be shed because of lack of
hormonal support, and this causes vaginal bleeding.
G. The doughlike mass is produced by the accumulation of blood in the pouch of Douglas.
A 39-year-old woman was admitted to the local hospital after experiencing a gunshot wound to the
lower part of her back. Radiographic examination revealed that the bullet was lodged in the vertebral canal at
the level of the third lumbar vertebra. A comprehensive neurologic examination indicated that a complete
lesion of the cauda equina had occurred.
6. The following facts concerning this patient are likely to be true except:
A. The cauda equina, which consists of anterior and posterior nerve roots below the level of the first
lumbar segment, was sectioned at the level of the third lumbar vertebra.
B. The preganglionic sympathetic nerve fibers to the vesical sphincter that descend in the anterior
roots of the fourth and fifth lumbar nerves were sectioned.
C. The preganglionic parasympathetic fibers to the detrusor muscle that descend in the anterior roots
of the second, third, and fourth sacral nerves were sectioned.
D. The patient would have an autonomous bladder.
E. The bladder would fill to capacity and then overflow.
F. Micturition could be activated by powerful contraction of the abdominal muscles and manual
pressure on the anterior abdominal wall in the suprapubic region.
A 65-year-old man with a history of prostatic disease was found on radiologic examination of his
skeleton to have extensive carcinomatous metastases in the skull and lumbar vertebrae. The PSA level in his
blood was found to be excessively high.
7. The following facts concerning this patient are correct except:
A. The patient has advanced carcinoma of the prostate that has spread some distance from the primary
site.
B. The prostate is surrounded by the prostatic venous plexus, which drains into the internal iliac veins.
C. Large veins with valves connect the prostatic venous plexus to the vertebral veins.
D. Coughing, sneezing, or straining at stool can force the blood from the prostatic plexus into the
vertebral veins.
E. Dislodged cancer cells can be dislodged and carried with the blood to the vertebral column and
skull.
A 72-year-old woman was suspected of having a tumor of the sigmoid colon. The physician decided
to confirm the diagnosis by performing a sigmoidoscopy.
8. The following anatomic facts are correct concerning the procedure of sigmoidoscopy except:
A. After inserting the instrument into the anus, the lighted end enters the ampulla of the rectum after a
distance of about 1 1/2 inches (4 cm).
B. Some side-to-side movement may be necessary to avoid the transverse rectal folds.
C. The rectosigmoid junction will be reached approximately 6 1/2 inches (16.25 cm) from the anal
margin.
D. To negotiate the rectosigmoid junction, the tip of the sigmoidoscope should be directed anteriorly
and to the patient's left.
E. Stretching of the colonic wall may give rise to colicky pain in the upper part of the abdomen in the
region of the xiphoid process.
Answers to Clinical Problems
1. The upper third of the rectum has peritoneum on its anterior and lateral surfaces; the middle third
has peritoneum on its anterior surface; and the lower third has no peritoneal covering.
2. Advanced carcinoma of the rectum not only extends to the pararectal and inferior mesenteric nodes
but may also spread via the superior rectal, inferior mesenteric, splenic, and portal veins to the liver.
3. In the adult, as the normal bladder fills its superior wall bulges upward into the abdomen, peeling
off the peritoneum from the posterior surface of the anterior abdominal wall.
4. Prolapse of the uterus most often reveals itself after menopause, when the pelvic fascia tends to
atrophy.
5. C. Each uterine tube is situated in the upper free margin of the broad ligament.
6. B. The preganglionic sympathetic nerve fibers to the vesical sphincter descend in the anterior roots
of the first and second lumbar nerves and were left intact.
7. C. The large veins that connect the prostatic venous plexus to the valveless vertebral veins are also
devoid of valves.
8. E. Colicky pain from the colon is referred to the lower part of the anterior abdominal wall above the
symphysis pubis.
Literature
1. Snell R.S. Clinical Anatomy for medical students. – Lippincott Williams &
Wilkins, 2000. – 898 p.
2. Skandalakis J.E., Skandalakis P.N., Skandalakis L.J. Surgical Anatomy and
Technique. – Springer, 1995. – 674 p.
3. Netter F.H. Atlas of human anatomy. – Ciba-Geigy Co., 1994. – 514 p.