Pelvic Anatomy from the Laparoscopic Perspective

A Review and Some Tips

One of the confusing things about pelvic anatomy is that most pelvic structures cannot be seen from the laparoscopic perspective. We know that the pelvis contains all of these structures:

But, what you see in the OR appears very different. This is because:1) The pelvic structures are covered by peritoneum2) Many patients have scar tissue or other findings that distort their anatomy

Medical students play a critical role in the gynecologic OR. This is why it is very important for you to understand the anatomy of what you are seeing. In every gynecologic laparoscopic surgery, you should be able to identify:1) The uterus2) The fallopian tubes3) The ovaries4) The round ligaments5) The broad ligaments6) The infundibulopelvic ligaments7) The utero-ovarian ligaments8) The bladder9) The rectum and sigmoid colon

More advanced students should also strive to identify:1) The ureters2) The junction of the cervix and the vagina3) The inferior hypogastric vessels4) The uterine arteries

Remember that many of the ligaments in the pelvis are composed of endopelvic fascia. Endopelvic fascia cannot be seen laparoscopically, because it is retro-peritonealized. However, the ligaments that it forms can be seen. Review your endopelvic fascia. Pay attention to the following: vesicovaginal space, ureter, rectovaginal space, uterosacral ligaments, cardinal ligaments.

Now imagine where all of these endopelvic/retroperitoneal structures are when the pevic organs are in place (remember that in this view, the peritoneum is shown as very thin and translucent. In reality, the peritoneum is thicker and obscures the retroperitoneal structures):

Now review the ligaments formed by folds of the peritoneum:

Another good image.

The sagittal view helps you remember which structures are “intra-peritoneal” (uterus, broad ligament, ovaries, fallopian tubes, round ligaments, utero-ovarian ligaments) and which are “retro-peritoneal” (bladder, cervix, rectum, ureters):

So how do you find these structures in the OR? One easy method is:1) Identify the uterus and ovaries (ovaries are usually white). 2) There are three major structures that originate from the superior portion of the uterus. These are:

a) The utero-ovarian ligament (connects to the ovary).b) The falloipan tubes (find the fimbriae)c) The round ligaments (the most anterior structure).

3) Trace the ovaries back to the abdominal wall to identify the infundibulopelvic ligament. This contains the ovarian vessels, which originate from/insert into the aorta/IVC/left renal vein.

These should be the basic steps you should take to orient yourself in every gynecologic surgery. Once you have identified these structures, the rest should fall into place.

Ovary (white)

Tube (fimbriae)

Round ligament (anterior)

There is one more key point to remember. All of the prior photos show the uterus as a structure that is elevated out of the pelvis. In reality, the uterus usually flops forward on top of the bladder and sinks down into the true pelvis. This makes it hard to identify any structures at all! This shows the uterus as it rests normally:

Uterus

Bowel

One of the jobs of a medical student is to elevate the uterus out of the pelvis using a uterine manipulator. This allows the surgeons to see all of the important anatomic structures.

Please watch the following videos so that you are prepared to use the uterine manipulator in the gynecologic OR:

How a uterine manipulator works (watch until 1:30):https://www.youtube.com/watch?v=VMB42641H9I

Different type of manipulators used in our hospital (watch until 3:30):http://www.youtube.com/watch?v=PwXEteyts8w

The uterine manipulator also helps protect the ureters:https://www.youtube.com/watch?v=BsAj4F_bBS0