Pelvic Surgical Anatomy

John L. Dalrymple, MD
Division Director, Gynecologic Oncology
Department of Obstetrics and Gynecology
UT Southwestern Austin Programs
I have nothing to disclose.
 Objectives
Describe basic abdominal and pelvic anatomy
related to common gynecologic surgical
procedures
Name common potential pitfalls and
complications that can occur during gynecologic
pelvic surgery
Describe the challenges related to anatomical
distortions from pelvic pathology, patient body
habitus, and complex procedures
List the physiologic changes related to anatomical
changes from pelvic surgery (optional)
 Why Anatomy is important
Backbone of understanding clinical
conditions
Whats normal
Whats abnormal
Why its abnormal
How to manage the problem
Surgery is all about anatomy
Obstetrics AND Gynecology is loaded
with anatomical clinical correlations
 General Considerations
Preparation for the OR (PRE-OP)
Review basic/relevant anatomy:
What organs are being removed/corrected/altered?
What anatomy must be traversed to get there?
Understand indications for surgery:
Why is procedure being done/what are goals of
surgery?
What alternatives are there and have they been
considered?
 General Considerations
In the OR (INTRA-OP)
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?
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 patients body habitus affect her anatomy?
What potential complications can you expect?
 General Considerations
After the OR (POST-OP)
Anticipate physiologic changes:
What will the patient/you expect acutely and
chronically from anatomical changes (reproductive,
GI, GU, sexually, physically, etc)?
Manage complications:
What anatomic/physiologic changes will you expect
from common complications (bowel, bladder,
vascular, nerve injuries)?
What are the expected postoperative pelvic and
abdominal anatomic changes that occur after
surgery?
 General Considerations
In the OR (INTRA-OP)
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?
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 patients body habitus affect her
anatomy?
What potential complications can you expect?
 Case Studies
Relevant surgical anatomy
Special points of consideration
danger areas and potential
complications
Physiologic outcomes
 Case Study 1
38 yo G2P2 female with symptomatic
menometrorrhagia, dysmenorrhea and
anemia. Prior cesarean section x 2.
Examination: BMI 28; Pelvic 16 wk fibroid
uterus palpable midway to the umbilicus on
abdominal exam
Ultrasound: multiple leiomyomas (>6)
measuring in size from 4 to 8 cm, located in
fundal, posterior/anterior and lateral uterus.
EMB proliferative; UPT neg; Hgb 8 mg/dL
 Surgical Approach
Preop Dx: Symptomatic
Leiomyoma
Planned Procedure: Exploratory
laparotomy, Total abdominal
hysterectomy (TAH)
Relevant Surgical Anatomy
Abdominal and pelvic examination
Layers of the abdominal wall
Abdominal structures
Pelvic structures
 The Pelvic Exam
Components
External genitalia
Lesions, ulcers, cysts
Vagina
Lesions, prolapse (cystocele,
rectocele)
Cervix
Size, shape, mobility, lesions
Uterus
Size, shape, position, mobility
Adnexa
Masses, size, shape, mobility,
laterality
 The Abdominal Exam

Components
Visual inspection
Scars
Distortions
Palpation
Masses
Liver and spleen edge
(HSM)
Ascites
Umbilicus - hernias
Panus/adipose
Percussion and
Auscultation
 Layers of the Abdominal
Wall
Ski
n External
Superficial Fascia oblique
fatty layer muscle
Internal
(Campers fascia) oblique
Superficial Fascia muscle
Transverse
membranous layer abdominis
(Scarpas fascia) muscle
Transversalis
fascia

Parietal Extraperitoneal
peritoneum fat
Layers of the Abdominal
Wall

Ext. oblique m.
Int. oblique m.

Ext. oblique m.
Int. oblique m.
 Abdominal incisions
Vertical
(midline)
Pfannenstiel
Maylard
Cherney
Abdominal Structures
Abdominal Organs Major
Female Pelvic Organs
Uterus/Ovaries
Blood Supply and Ligaments
The spaces
Fibroid Uterus Distorted Anatomy
 Special Points of
Consideration
Distortion of ligaments
Distortion of retroperitoneal spaces
Course of the ureter
Increased blood supply to uterus
---------
Urologic injury bladder, ureters
Vascular injury/large EBL collateral
blood supply and increased flow
 Special Points of
Consideration
Distortion of ligaments
Distortion of retroperitoneal spaces
Course of the ureter
Increased blood supply to uterus
---------
Urologic injury bladder, ureters
Vascular injury/large EBL collateral
blood supply and increased flow
 3 points of ureteral injury
When clamping the
IP (gonadal vessels)
When clamping the
uterine vessels
With inadequate
bladder flap
development
(clamping the
cardinal ligaments)
 Physiologic Outcomes
Abdominal wall and pelvic floor
changes
GI/GU changes
Loss of menstruation
Potential change in sexual
response
 Case Study 2
24 yo G0 female with severe chronic pelvic pain,
dysmenorrhea and dyspareunia. Healthy.
Examination: BMI 22; Pelvic NEFG, normal
sized retroverted, but slightly fixed uterus with
exquisite tenderness and uterosacral nodularity;
slight fullness of left adnexa with tenderness
Ultrasound: normal uterus with 5-6 cm left
complex adnexal cystic ovary
UPT negative; cervical cultures negative for
chlamydia and gonorrhea
 Surgical Approach
Preop Dx: Complex adnexal mass, r/o
endometriosis
Planned Procedure: Diagnostic
laparoscopy, left ovarian
cystectomy/salpingo-oophorectomy
Relevant Surgical Anatomy
Abdominal and pelvic examination
Layers of the abdominal wall
Abdominal structures
Pelvic structures
Blood Supply of the Anterior
Abdominal Wall
Laparoscopy abdominal contents
Laparoscopic view of Pelvic
Anatomy
Anatomical distortions -
Endometriosis
 Special Points of
Consideration
Distortion of uterosacral ligaments
Obliteration of posterior cul-de-sac and
ovarian fossa
Course of the ureter
Blood supply to ovary/tube
---------
Ureteral injury
Vascular injury/large EBL
Bowel injury
 Physiologic Outcomes
Improved symptoms and/or pain
Potential loss of ovarian function
and/or menopause
 Case Study 3
62 yo G4P4 female with pelvic
pressure and bulging/protruding
mass per vagina
Examination: Pelvic near complete
uterine prolapse (procidentia)
Pap smear negative/normal; U/s
atrophic ovaries; uterus with 3 mm
endometrial stripe
 Surgical Approach
Preop Dx: Uterine prolapse
Planned Procedure: Total vaginal
hysterectomy +/- Bilateral salpingo-
oophorectomy
Relevant Surgical Anatomy
Abdominal and pelvic examination
Pelvic structures
Pelvic floor anatomy
Perineum
Vaginal and pelvic examination
The Pelvic Floor
Vaginal Hysterectomy
 Special Points of
Consideration
Distortion of bladder and
ureters
Atrophic changes
---------
Bladder/ureteral injury
Anal/rectal injury
 Physiologic Outcomes
Improved pelvic
pressure/bulging
Improved GI/GU function
 Conclusions
Pelvic anatomy is generally preserved and
knowledge of key abdominal and pelvic
anatomical landmarks is essential for any
pelvic surgeon
Complications can best be avoided by
anticipating the pathologic changes that result
in anatomic alterations as a result of pelvic
disease
Knowledge of pelvic and abdominal anatomy is
crucial for successful surgical management
that will lead to improved patient outcomes
 Congratulations &
Welcome to OBGYN!