Anatomy for the Gynecologic Oncologist

Chris DeSimone, M.D. Assistant Professor Division of Gynecologic Oncology

Overview
Abdominal wall anatomy Upper abdomen organs, vessels, innervation Pelvic anatomy Vulvar anatomy

Abdominal wall anatomy

Best to comprehend the anatomy as it relates to incision types Midline, Pfannenstiel, Maylard & Cherney What dermatomes are affected by a midline incision? What are affected by a pfannenstiel? Name all the layers of the abdominal wall above and below the arcuate line? Describe the relationship between the incision type and the inferior epigastric artery?

Innervation of the abdominal wall

Musculature

Rectus sheath

Rectus sheath

Course of the epigastric artery

Veins of the abdominal wall

Upper abdominal anatomy

Adequate debulking of ovarian carcinoma requires dissection of several key organs What vessels supply the omentum, spleen, stomach, small bowel, colon and liver? What are their functions? How do you manage these organs postoperatively if they are injured or removed?

Omentum
Functions as a filter for lymphatic fluid Lymph fluid flow in a clock-wise pattern secondary to peristalsis of the ascending, transverse and descending colon Brings lymph fluid to the cisterna chyli, the thoracic duct and then the left brachiocephalic vein Right sided lymphatic drainage is directed through lymphatic channels of the diaphragm to the azygos system and then the IVC and SVC

Omentum

Stomach
Second organ involved with digestion Innervated by the vagus nerve Blood supply from the celiac trunk: left and right gastric arteries, right and left gastroepiploic arteries and the short gastric arteries Produces hydrochloric acid and pepsin to digest food Produces 1 to 1.5 liters of fluid each day Injury can be controlled by primary closure Continuous NG suctioning causes a hyponatremic, hypokalemic metabolic alkalosis

Stomach

Spleen
Filter for senescent erythrocytes and circulating pathogens Major producer of opsonins (properdin/ tuftsin) Hilum contains the splenic artery and vein Extremely vascular Splenocolic ligament must be mobilized to free the splenic flexure of the colon Posterior aspect of this ligament in close proximity to the tail of the pancreas Splenectomies patients are at risk for pneumonia, bacteremia, pancreatic injuries and splenic abcesses MUST BE VACCINATED POST OPERATIVELY FOR:
Streptococcus pneumoniae Haemophilus influenzae Nisseria meningitidis

Spleen

Small Bowel
On average 270 to 290 cm in length Consists of the duodenum ( 20cm), jejunum (100 to 110cm) and ileum (150 to 160 cm) Entire blood supply from the superior mesenteric artery Both parasympathetic and sympathetic innervation Parasympathetic innervation is from the vagus nerve which stems from the celiac ganglion Parasympathetic innervation controls motility and secretion of enzymes Sympathetic innervation from three sets of splanchnic nerves oriented around the base of the SMA Sympathetic innervation responsible for pain sensation and blood vessel motility

Small Bowel
Majority of nutritional uptake is responsible within the jejunum and ileum 80% to 90% of proteins reabsorbed in the jejunum 95% of lipid reabsorbed within the jejunum and ileum 8 to 10 liters of water are reabsorbed, perhaps only 500 ml actually enter the cecum Fat soluble vitamins are reabsorbed in the terminal ileum (A, D, E and K) Vitamin B12 also reabsorbed in the terminal ileum KEY POINT: the more small bowel removed expect problems with digestion, nutrition and diarrhea

Small Bowel
Enzymes of the small bowel
Gastrin (D) promotes gastric acid and pepsinogen production CCK (D) promotes pancreatic enzyme secretion and gall bladder contraction Secretin (D,J) causes water release, secretion of bile salts and inhibition of gastrin Somatostatin (P) universal off switch Gastrin releasing peptide (D,J,I) universal on switch Motilin (D,J) stimulates upper GI motility

Small Bowel
Small Bowel Obstruction
Adhesions 60% Malignancy 20% Hernias 10% Crohns disease 5% Miscellaneous 5%

Duodenum

Small Bowel

Small Bowel

Colon
6 segments cecum and appendix, ascending, transverse, descending, sigmoid and rectum On average 130 to 150 cm in length Blood supply from the superior mesenteric and inferior mesenteric arteries (SMA & IMA)

Segments of the colon

Blood supply to the colon

Colonic function
Absorption
1000 to 1500ml of ileal effluent crosses the ileocecal valve Stool has 100 to 150 ml of water Descending colon mainly responsible

Recycling of nutrients
Nonstarch polysaccharides Short chain fatty acids Urea Ascending colon responsible

Colonic innervation
Parasympathetic innervation from the vagus nerve and the pelvic autonomic center S2-S4 Nerves are centered in plexuses along the subserosal and muscular components of the colon: Auerbach and Meissner plexuses Controls colonic motility Sympathetic innervation is from the superior and inferior mesenteric ganglia (found by the SMA and IMA) Controls pain and vascular tonicity

Cecal anatomy

Appendix
No appreciable utility Associated with carcinoid and primary appendiceal carcinomas Must be taken for mucinous ovarian tumors Appendiceal artery arises from the ileocolic artery and MUST be ligated Primary appendiceal tumors often diagnosed by gynecologic oncologists as a right ovarian tumor

Appendix

Portal circulation
Not essential for gynecologic malignancies; however must understand the different source of venous drainage Splenic vein, SMV, IMV, gastric veins involved in the portal system Portal hypertension can therefore cause, gastroesophageal varices, rectal varices and medusae caput Acute bleeding has 25-30% mortality rate Patients with cirrhosis have a 50% mortality rate

Portal circulation

Pelvic Anatomy
The home of the gynecologic oncologist Focus on blood supply, nerves of the pelvis, musculature and rectal anatomy Must understand the boundaries of pelvic lymph node dissection
Lateral: genitofemoral nerve Medial: ureter Inferior: deep iliac circumflex vein Superior: inferior mesenteric artery

Pelvic blood supply

Aorta
Middle sacral artery

Common iliac artery External iliac artery

Inferior epigastric artery Deep circumflex iliac artery

Posterior division of internal iliac artery

Superior gluteal artery Iliolumbar artery Lateral sacral

Anterior division of internal iliac artery

Obturator artery Uterine artery Superior vesical artery Inferior vesical artery Umbilical ligament Middle rectal artery Internal pudendal artery
Inferior rectal artery Labial arteries Dorsal artery of the clitoris

Pelvic blood supply

Pelvic blood supply

Common iliac artery

External iliac artery & vein

Superior vesical artery

Obturator space

Obturator nerve

Obturator artery

Obturator venous plexus

Pelvic nerves
Femoral nerve
Nerve roots L2, L3, L4 Provides motor function to the extensor muscles Provides sensation to the thigh

Sciatic nerve
Nerve roots L4, L5, S1, S2, S3 Largest nerve in the body It divides into the tibial and peroneal nerves Provides motor function to the distal extremity

Obturator nerve
Nerve roots L2, L3, L4 Provides motor function to the adductor muscles

Pudendal nerve
Nerve roots S2, S3, S4 Provides motor functions to the muscles of the pelvis and extern al anal sphincter Provides sensation to the vulva and clitoris

Genitofemoral nerve
Nerve roots L1, L2 Provides sensation to the thigh and vulva

Pelvic nerves

Pelvic nerves

Muscles of the pelvis

Psoas
L2, L3, L4 flexes thigh

Piriformis
S1, S2 rotates thigh laterally

Obturator internus
L5, S1, S2 rotates thigh laterally

Levator Ani
Pubococcygeus Iliococcygeus Puborectalis S3, S4 raise pelvic floor

Coccygeus
S4, S5 raise pelvic floor

Muscles of the pelvis

Muscles of the pelvis

Bladder
Muscular structure which functions as a reservoir for urine Can hold 1000 ml however most females have a strong urge to void at 400 ml Supplied by the superior vesical and inferior vesical arteries Innervation is both parasympathetic and sympathetic Parasympathetic (S2, S3, S4) controls detrusor contraction while inhibiting the internal sphincter Sympathetic (T11, T12, L1, L2) transmit sensation

Bladder innervation

Rectum
Last portion of the colon, rich blood supply, relatively mobile below the peritoneum Multiple layers which control continence
1st it follows the contour of the sacrum 2nd the valves of houston produce sharp turns for the feces to navigate 3rd the puborectalis muscles forms a sling around the rectum called the anorectal angle All these layers close off the lumen with valsalva

The pectinate line marks the transformation from squamous epithelium to columnar epithelium Blood supply stems from both the IMA and the internal iliac arteries (superior, middle, inferior rectal arteries)

Rectum

Rectum

Vulvar anatomy
Layers of support to the pelvic floor Blood supply to the vulva
Internal pudendal artery
Inferior rectal artery Labial/ perineal arteries Dorsal artery of the clitoris

External pudendal artery

Nervous supply to the vulva

Ilioinguinal nerve Pudendal nerve
Labial/ perineal nerves Dorsal nerve of the clitoris

Posterior femoral cutaneous nerve

Points of interest with a inguinal lymphadenectomy

Vulva: deep to superficial

Vulva: deep to superficial

Vulva: deep to superficial

Vulva: deep to superficial

Vulva: deep to superficial

Vulvar blood supply

Vulvar blood supply

Vulvar blood supply

Lymphatic drainage of the vulva

Innervation of the vulva

Femoral Triangle
Borders: Inguinal ligament superiorly, sartorius muscle laterally and adductor longus medially Superficial inguinal lymph nodes above the cribriform fascia (6-8) Femoral nerve, artery, and vein are found below the cribriform fascia Deep inguinal lymph nodes (2-3) Cloquets node deepest most superior lymph node before crossing inguinal ligament and thereby external iliac lymph nodes

Femoral Triangle

Muscles of the thigh

Sartorius
L2, L3 (F) Flexes, abducts and laterally rotates thigh

Gracilus
L2, L3 (O) Flexes, adducts and medially rotates thigh

Adductor longus
L2, L3 (O) Adducts thigh

Femoral and Obturator Nerves