Pelvic Anatomy from a Laparoscopic Perspective Tommaso Falcone MD Professor & Chairman Cleveland...
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Transcript of Pelvic Anatomy from a Laparoscopic Perspective Tommaso Falcone MD Professor & Chairman Cleveland...
Pelvic Anatomy from a Laparoscopic Perspective
• Tommaso Falcone MD
• Professor & Chairman
• Cleveland Clinic Foundation
Anatomy & Advanced Laparoscopic Surgery Course
Anatomic Areas
• Anterior abdominal wall• Pelvic sidewall• Extra-peritoneal spaces
– Retropubic space– Presacral space– Pararectal space
Anterior Abdominal Wall
• Relationship of the vessels & nerves to potential entry sites for trocars
Retroperitoneal Vessels & Umbilicus
• Bifurcation of the aorta– thin patients at umbilicus– More caudad with increasing weight
• Left common iliac vein – inferior to the bifurcation of the aorta– crosses the sacrum
Left Upper Quadrant Insertion• 2-cm below the subcostal margin
mid-clavicular line• Organs
– Aorta-11 cm– Spleen-12cm– Stomach-4.4cm– Liver-4.0cm– Left kidney 13.2cm
Laparoscopic view of the spleen• Spleen is far from
the LUQ, unless splenomegaly is present
Pelvic Sidewall Anatomy
• 3 layers– Ureter– Branches of the
int.iliac artery– Muscle & nerve
Pelvic Sidewall: ureter
• Pelvic brim– over the common or external iliac– under ovarian vessels
• Courses anterior to the internal iliac– UNDER THE OVARY– 1.5 -2 CM LATERAL UTERO-SACRAL
LIGAMENTS
• Cervix– WITHIN 2CM
Pelvic Sidewall: Blood vessels• Internal iliac artery
– anterior & posterior division– Umbilical artery
• obliterated• medial umbilical ligament• relationship to the uterine artery
Pelvic Arteriogram
Pelvic & Inguinal Nerves
• Genito-femoral nerve• Femoral nerve
Retropubic Space
• Anterior– Pubic bone
• Lateral– Obturator internus
muscle, fasciae, neurovascular bundle
• Posteriorly– bladder &
pubocervical fasciae
Pelvic Diaphragm
• Sheet of muscle (Levator ani & coccygeus) covered on both sides by fasciae
• From pubis to coccyx & is attached to the lateral pelvic wall by a thickened band of obturator fascia called arcus tendineus m. levator ani
• Anogenital hiatus
Pelvic Diaphragm:Muscle• Levator Ani
– Pubococcygeus (Puborectalis & pubovaginalis)
– Iliococcygeus• Iliococcygeus portion that arises
from the obturator internus muscle (arcus tendineus m. levator ani) & ischial spine
• Arcus: spine of the ischium forward & upward.
Pelvic Diaphragm: Fasciae• Parietal fasciae on the muscles• Endopelvic fasciae on the pelvic
viscera– Attached to the parietal fasciae laterally– Connective tissue attachments stabilize
the vagina– Attachment along a line of thickened
parietal fasciae called Arcus tendineus fasciae pelvis or white line
– Mid-vagina is supported by lateral connections to the white line
Pre sacral space