Pelvic Surgical Anatomy
John L. Dalrymple, MD
CREOG & APGO Step Up to Residency Program
Précis: In this session, the fundamental anatomical structures of the female pelvis will
be reviewed with a particular focus on key surgical landmarks. Gynecologic case studies
will further illustrate why knowledge of normal anatomy is essential in the medical and
surgical care of women.
I.
Introduction
A. Objectives: At the conclusion of this session, participants will be able to:
1. Describe basic abdominal and pelvic anatomy (organs, blood supply, ligaments,
and adjacent structures) related to common gynecologic surgical procedures.
2. Name common potential pitfalls and complications that can occur during
gynecologic pelvic surgery
3. Describe the challenges related to anatomical distortions from pelvic
disease/pathology, patient body habitus, and complex procedures.
4. List the physiologic changes related to anatomical changes from pelvic surgery
(optional)
B. Relevant OBGYN Milestones
1. Gynecology Technical Skills – Patient Care
• Laparotomy (Hysterectomy, Myomectomy, Adnexectomy)
• Vaginal Surgery (Vaginal Hysterectomy, Colporrhaphy, Mid-urethral Sling)
• Endoscopy (Laparoscopy, Hysteroscopy, Cystoscopy)
Demonstrates knowledge of basic abdominal and pelvic anatomy
2. Pelvic Floor Disorders (Urinary Incontinence, Pelvic Prolapse, Anal Incontinence)
— Medical Knowledge
Demonstrates basic knowledge of normal pelvic floor anatomy
II. General Considerations
A. Preparation for the OR (PRE-OP)
1. Review basic/relevant anatomy:
• What organs are being removed/corrected/altered?
• What anatomy must be traversed to get there?
2. Understand indications for surgery:
• Why is procedure being done/what are goals of surgery?
• What alternatives are there and have they been considered?
B. In the OR (INTRA-OP)
1. 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?
2. 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?
C. After the OR (POST-OP)
1. Anticipate physiologic changes:
Pelvic Surgical Anatomy
Step Up To Residency
Dalrymple
What will the patient/you expect acutely and chronically from anatomical
changes (reproductive, GI, GU, sexually, physically, etc)?
2. Manage complications:
• What anatomic/physiologic changes will you expect from common
complications (bowel, bladder, vascular, nerve injuries)?
•
III. Case studies
A. Abdominal hysterectomy for symptomatic leiomyoma (vs Radical hysterectomy for
cervical cancer)
1. Relevant surgical anatomy:
• Abdominal and pelvic exam: abdominal wall landmarks (umbilicus, ASIS,
liver, costal margin); uterine and adnexal size, location, mobility; incision type
and positioning of patient
• Layers of the abdominal wall: Dermis, adipose, fascial layers, muscles,
peritoneum; arcuate line, blood supply
• Abdominal structures: omentum/lesser and greater sac, GI structures
(large and small bowel, appendix, stomach, liver, pancreas); GU structures
(kidneys, ureter and bladder), visceral and pelvic peritoneum,
retroperitoneum and related structures; related blood supply and ligaments
• Pelvic structures: cervix, uterus, tubes, ovaries; blood supply (uterine and
ovarian) and ligaments (round, broad, suspensory/IP, utero-ovarian, cardinal,
uterosacral); pelvic nerves; pelvic side wall and retroperitoneal structures
including iliac vascular system, course of the ureter, major/minor nerves,
lymph nodes; para-rectal and para-vesicle spaces
2. Special points of consideration – high risk areas and potential complications
• Distortion of ligaments, retroperitoneal space, course of the ureter and blood
supply to the uterus
• GU injuries: ureteral injury (IP ligament, uterine vessels, bladder flap) and
bladder injury/cystotomy
• Vascular injury/large blood loss: collateral blood supply; increased and
altered blood flow
• Nerve injury: pelvic sidewall compression; positioning; transection/crush
3. Physiologic outcomes
• Abdominal wall and pelvic floor changes; GI/GU changes; loss of
menstruation; change in sexual response
B. Laparoscopic salpingo-oophorectomy/cystectomy for severe endometriosis
1. Relevant surgical anatomy
• Abdominal and pelvic exam: same as above; port placement
• Layers of the abdominal wall: same as above
• Abdominal structures: same as above
• Pelvic structures: same as above; different field of view (c/w laparotomy);
spaces – vesicouterine fold, anterior/posterior cul de sac, focus on ligaments
and course of ureter
2. Special points of consideration – high risk areas and potential complications
• Distortion of uterosacral ligaments, ovarian fossa, and course of the ureter;
obliteration or culdesac; retroperitoneal space, blood supply to the ovary and
tube
• Ureteral injury
• Vascular injury/large blood loss
• Bowel injury
3. Physiologic outcomes
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Pelvic Surgical Anatomy
Step Up To Residency
Dalrymple
•
Improved symptoms/pain; potential loss of ovarian function/menopause
C. Vaginal hysterectomy for uterine prolapse
1. Relevant surgical anatomy
• Abdominal and pelvic exam: Vulvar, perineal and vaginal landmarks;
uterine size and mobility; vaginal wall changes (cystocele, rectocele,
enterocele)
• Pelvic structures: Vulvar, vaginal wall anatomy; urethral/bladder anatomy;
anal/rectal anatomy; cervix and uterus; blood supply, ligaments, and course
of the ureter; pelvic floor/diaphragm musculature
2. Special points of consideration – high risk areas and potential complications
• Distortion of the bladder and ureters from prolapse
• Cystotomy or ureteral injury
• Injury to rectum/anus
3. Physiologic outcomes
• Improved pelvic pressure/bulging; improved GI/GU function
IV. Conclusions
A. Pelvic anatomy is generally preserved and knowledge of key abdominal and pelvic
anatomical landmarks is essential for any pelvic surgeon
B. Complications can best be avoided by anticipating the pathologic changes that result
in anatomic alterations as a result of pelvic disease
C. Knowledge of pelvic and abdominal anatomy is crucial for successful surgical
management that will lead to improved patient outcomes
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