5. Skin & subcutaneous tissue
Fibers in dermal layer of abdominal skin-
transversely oriented →more tension on
the skin of a vertical incision and in a wide
scar.
Subcutaneous tissues -2 layers
Superficial- Camper fascia – fatty layer
Deep- Scarpa fascia – membranous layer
Scarpa fascia -best developed laterally, not
seen well-defined in midline vertical
inscision
6. Musculo-aponeurotic layer
Two groups of muscles:
1.vertical muscles – rectus abdominis, pyramidalis
2.oblique flank muscles- external oblique, internal oblique,
and transversus abdominis.
Broad, sheet like tendons of these muscles form aponeurosis that
unite with their corresponding member of other side, forming the
rectus sheath
7. Vertical muscles
Rectus abdominis muscle-
-originates from sternum and
cartilages of ribs 5 to 7
-inserts into anterior surface of the pubic bone.
Fibrous interruptions within the muscle firmly
attach it to the rectus abdominis sheath.
Rectus sheath is attached to the rectus muscle
and these two structures become difficult to
separate during Pfannenstiel incision.
Pyramidalis muscle arises from the
pubic bones and insert into the linea alba
8. Flank Muscles
External oblique- fibers run
obliquely anteriorly and inferiorly
origin - lower 8 ribs
Aponeurotic insertion- iliac crest
pubic tubercle n linea alba.
Inferior margin thickened to form
inguinal lig
Internal oblique muscle-fibres
perpendicular to the fibers of the
external oblique ms
origin - anterior 2/3rd of iliac crest,
lateral part of the inguinal ligament, and
thoracolumbar fascia
Insertion- 10-12th ribs ,pecten pubis
and linea alba
9. Flank Muscles
• Transversus abdominis
Origin- 7-12 costal cartilages,
thoracolumbar fascia, anterior 3/4th of
iliac crest, lateral inguinal ligament.
Insertion- pubic crest, pecten pubis via
cojoint tendon linea alba
caudally fused with internal oblique ms
form conjoint tendon
• Weakening of conjoint tendon- direct
inguinal hernia
• Transverse orientation and transverse
pull of muscular fibers place vertical
suture lines in the rectus sheath under
more tension -more prone to
dehiscence
10. Rectus sheath
• Broad, sheet like tendons of these muscles form aponeurosis that unite with their
corresponding member of other side, forming the rectus sheath
• Neurovascular plane -between internal oblique and transverse abdominis
A:above arcuate line-
anterior sheath - external oblique and split aponeurosis of internal oblique
posterior sheath -aponeurosis of transverse abdominal muscle and
split aponeurosis of the internal oblique muscle.
B: below arcuate line (linea semicircularis) -all of the fascial aponeuroses form
ant rectus sheath
11. • Low transverse incisions should not
exceed lateral margin of rectus
muscles to avoid nerve and inferior
epigastric vessel injury
• Sutures extending lateral to edges of
inscision avoided as they entrap
illiohypogastric and iilioinguinal nerve
causing denervation injury and pain
• Lateral border of the rectus muscle is
marked by the semilunar line of the
rectus sheath- hernia through lenia
semilunaris – spigelian hernia
12. • Inguinal canal lies at lower edge of
musculofascial layer of abdominal wall.
• Through the inguinal canal, the round
ligament terminate in labium majus,
ilioinguinal nerve and genital branch of
the genitofemoral nerve passes.
• Midinguinal point –halfway between
ASIS & pubic symphysis- femoral pulse
palpated
• Canal is lined by processus vaginalis-
failure to regress- indirect inguinal
hernia
13. Transversalis Fascia, Peritoneum and
Bladder Reflection
• Transversalis fascia-a layer of fibrous
tissue that lines the abdomino-pelvic
cavity.
• Peritoneum -single layer of serosa-
thrown into 5 vertical folds converging
toward the umbilicus.
• Single median umbilical fold -
presence of the urachus (median
umbilical ligament).
• Paired medial umbilical folds -
obliterated umbilical arteries
• Lateral umbilical folds- inferior
epigastric arteries and veins.
14. Umbilical area
• Important surgical landmark
• Mc point of entry during
endoscopic surgery
• All layers of anterolateral
abd wall fuse here
• Level- L3 L4
• T10 dermatome
• Illiac vein join to form venacava
• Abdominal aorta bifurcates
• Contains umbilical ring –defect in
linea alba, window for umbilical
hernia- round lig of liver, median n
medial umbilical lig attached
15. Vascular supply of abdominal wall
Superficial vessels-skin & sc tissue
1.Superficial epigastric vessels
from femoral vessels toward umbilicus,
position- between skin and musculofascial
layer
2.External pudendal artery –
from femoral artery medially
supply mons pubis.
many midline branches lead to heavy
bleeding in its territory of distribution
3.Superficial circumflex iliac vessels -
laterally from femoral vessels toward flank.
16. Vascular supply of abdominal wall
Deep vessels-supply musculofascial
layer
1. Deep circumflex illiac artery –
Branch of iiliac artery
Between internal oblique and transverse
abdominal muscle.
2.inferior epigastric artery and its two veins -
Originate lateral to the rectus muscle.
Run towards umbilicus and intersect the
muscle's lateral border midway between pubis
and umbilicus.
17. Angle between vessel and border of rectus muscle forms apex of Hesselbach
triangle
Base -inguinal ligament.
Lateral laparoscopic trocars placed where injury to inferior epigastric and
superficial epigastric vessels can occur easily.
Just above pubic symphysis vessels lie 5.5 cm from the midline,at umbilicus- 4.5
cm from the midline
Placement either lateral or medial to the line connecting these points minimizes
potential vascular injury.
Location of inferior epigastric vessels seen by following round ligament to its point
of entry into deep inguinal ring-vessel lies just medial to this point.
Round ligament
19. Nerves of abdominal wall
1.Intercostal nerves 7 through 11
2. subcostal nerve (T12)
• pierces lateral border of rectus sheath to supply
rectus muscle- Incisions along lateral border of
rectus - denervation of the muscle - atrophic and
weaken abdominal wall.
• rectus sheath elevation during Pfannenstiel
incision stretches perforating nerve- sometimes
ligated for hemostasis from accompanying artery
- cutaneous anesthesia.
3. Iliohypogastric (L1)- suprapubic area skin
4. Ilioinguinal nerves L1-lower abdominal wall labia
majora and medial thigh
• pass medial to ASIS,entrapped in lateral closure
of transverse incision- chronic pain syndrome
• minimised if trocar placed superior to ASIS
• low transverse inscision not extend beyond
rectus ms
20. 5.Genitofemoral nerve(L1,L2)
-Lies on the psoas muscle ,retractor can
damage it
-anesthesia in medial thigh and lateral labia.
-Injured during pelvic lymphadenectomy
6.Lateralcutaneous nerve(L2,L3)
-Compressed by a retractor blade lateral to
psoas or by too much flexion of the hip in
lithotomy position
- anesthesia over anterior thigh-meralgia
parasthetica
21. 7.Femoral nerves (L2-L4)
• Pass under inguinal lig
• Nerve compress by lateral blade of retractor
• In lithotomy compress against ingunal lig d/t
thigh hyperflexion >90 degree excess hip
abduction lateral rotation-
• c/f inability to flex thigh extend knee absent
patellar reflex sensory loss ant thigh medial
leg
8.Obturator nerve (L2-L4)
• Exit obturator canal supplies adductor muscles
skin over medial thigh
• Injured during pelvic lymphadenectomy
incontinence, pelvic support procedure
• C/F-inability to adduct thigh , sensory loss over
inner thigh
22. VULVA & ERECTILE STRUCTURES
• Pudendum or vulva – part of female
external genitalia found on superficial
pouch of ant perineal triangle
• Ant triangle (urogenital)
Anterolaterally -pubic arch ,ischiopubic ramii
• Post triangle (anal )
Posterolaterally-sacrotuberous lig coccyx
• Both share a common base i.e line
between ischial tuberosities
23. Layers and pouches of the Anterior Triangle of
the Perineum
1.Skin
2.Subcutaneous perineal pouch
Fatty layer-Camper fascia
Membranous layer-Colles fascia
3.Superficial space
Superficial fascia of perineal muscle
Clitoris and its crura
Bulb of vestibule
Bartholin gland
Ischiocavernous muscle
Bulbocavernous muscle
Superficial transverse perineal muscle
4.Deep space-
Perineal membrane
External urethral spincter
Compressor urethrae
Urethrovaginal sphincter
24. Subcutaneous tissues of vulva
Consist of mons, labia, clitoris, vestibule, and erectile structures.
1.Mons -hair-bearing skin over a cushion of adipose tissue on pubic bone
2.Labia majora
• hair-bearing skin and adipose tissue
• Homologous with scrotum
• Join medially below mons -ant commissure
infront of anus -posterior commissure
• contain the termination of the round ligaments and obliterated processus
vaginalis (canal of Nuck).
• round ligament can give rise to leiomyomas in this region
• Rich venous plexus – injury – hematoma formation
25. Subcutaneous tissues of vulva
3.Labia minora
• hairless skin folds devoid of fats and hair follicles
• Homologous to ventral aspect of penis
• Anteriorly divide to enclose clitoris ant- prepuce/hood n post-frenulum
• Posteriorly unite-fourchette
• Fossa navicularis – between fourchette and vaginal orifice
26. Subcutaneous tissues of vulva
3.Labia minora
• Cutaneous structures of labia minora and vestibule lie on a loossely
organised connective tissue stratum that permits mobility of the skin during
intercourse and allows the skin to be easily dissected off the underlying
fascia during skinning vulvectomy
• Highly sensitive d/t vast sensory inervations- surgical reduction done for
dysparenuia is a/w complication hypoasthesia
• Chronic derma disease like lichen sclerosis – atrophy of labia minora
• Surgery for removal of prepuce /adjacent skin – injury to dorsal nerve of
the clitoris
27. • Bartholin gland duct –2cm
Opens at junction of ant. 2/3rd and
post.1/3rd in groove between
hymen and labium minor-
posterior lateral vestibule 3-4 mm
outside the hymenal ring
• Minor vestibular gland
openings- along a line extending
anteriorly from this point, parallel
to hymenal ring and extending
toward the urethral orrifice
• Skene ducts open into the inner
aspect of these labia in
paraurethral area
28. • Holocrine sebaceous glands of labia majora are a/w hair shafts, and in labia
minora, they are freestanding.
• Apocrine sweat glands -lateral to introitus and anus - undergo change with
menstrual cycle with increased secretory activity in premenstrual period
• Chronic infection- hidradenitis suppurativa
• Neoplasia-hidradenomas =require surgical therapy
• Eccrine sweat glands - form palpable masses as syringomas.
Interlacing fibrous septa of subcutaneous tissue attach laterally to ischiopubic
rami and fuse posteriorly with posterior edge of perineal membrane
Anteriorly -no connection to pubic rami, and this permits communication between
area deep to this layer and abdominal wall.
Fibrous attachments to the ischiopubic rami and the posterior aspect of the
perineal membrane limit the spread of hematomas or infection in this
compartment posterolaterally but allow spread into the abdomen and vice versa
29. Superficial perineal pouch/ Compartment
• Space between fascia of perineal muscle and perineal membrane
• Contains clitoris, crura, vestibular bulbs, and ischiocavernous and
bulbospongiosus muscle
30. 1.Clitoris – complex
erectile highly sensitive
organ
• Parts- glans ,body and 2
crura
• homologous to male
penis derived from
genital tubercle
• dorsal nerve n vessels
of clitoris lie outside
tunica albuginea but
inside clitoral fascia
31. 2. Ischiocavernous muscles- originate at
ischial tuberosities and insert on crura and
body of clitoris.
3.Superficial transverse perineal muscles,
originate at ischial tuberosity and insert to
perineal body.
4.Vestibular bulbs richly vascular spongy
erectile tissue
-Homologus to bulb of penis n corpus
spongiosum
-lie below vestibular skin covered by
bulbospongiosus muscles
-Cover bartholin glands
5.bulbospongiosus muscles -originate in
perineal body and insert into body of clitoris
All muscles in superficial perineal pouch are covered by fascia –perineal fascia
continuous with clitoral fascia
32. 6. Bartholin gland
• at post end of vestibule bulb
• Homologus to bulbourethral gland of
male
• connected to vestibular mucosa by duct
lined with squamous epithelium linning.
• lies on perineal membrane and beneath
bulbospongiosus muscle whose
contraction results in secretion
• Enormously vascular erectile tissue of
the vestibular bulb and the Bartholin
gland is responsible for the hemorrhage
associated with its removal
33. VESTIBULE
• Triangular space-
ant clitoris
post- fourchette
lateral- labia minora
• 4 openings-
ext. urethral meatus
vaginal orifice
2 bartholin gland openings
• Vagina incompletely closed by a
septum of mucous membrane- hymen
• carunculae myritiformis during child
birth hymen lacerated as cicatrised
nodule
34. VULVA
BLOOD SUPPLY OF VULVA
Artery
- Branches of internal pudental
artery
- Branches of Femoral artery
Superficial and deep pudental.
Vein
- internal pudental vein
- vesical and vaginal venous plexus
- long saphenous vein
NERVE SUPPLY OF VULVA
Anterosuperior - Cut.br. of Ilioinguinal N
Genital br. of Genitofemural N.(L1,2)
Middle part Labial and perineal br. Of
Pudental N. (S2,3,4 )
Posteroinferior Pudental br. of posterior
cut. Nerve of thigh (S2,3,4 )
LYMPHATIC DRAINAGE OF VULVA
Inguinal and Femoral LN.
Ext. Iliac
Common iliac
Aortic group of LN.
35. Pudendal nerves and vessels
• Pudendal nerve - sensory and motor
nerve of the perineum.
• Arises from sacral plexus (S2-S4)
• Pudendal nerves & vessels leave the
pelvis through greater sciatic foramen
by hooking around the ischial spine and
sacrospinous ligament to enter the
pudendal (Alcock) canal through the
lesser sciatic foramen.
38. 1.Dorsal nerve of clitoris-supply
clitoris.
2. Perineal nerve-supply
bulbocavernosus, ischiocavernous,
and transverse perineal muscles.skin
of the inner portions of labia majora,
labia minora, and vestibule.
3. Inferior rectal nerve- external anal
sphincter and perianal skin
Pudendal nerve have three branches:
39. Autonomic innervation to
erectile structures
• Cavernous nerve of clitoris
i.e from uterovaginal plexus
component of inferior
hypogastric plexus
• Consists of sympathetic n
parasympathetic
components
• Injury during radical
hysterectomy, pelvic &
perineal surgery- voiding
sexual defeacatory
dysfunction
40. Lymphatic drainage
• Inguinal lymph nodes
• 2 groups- superficial and deep
nodes.
• 1. superficial-12 to 20 superficial
nodes lie in a T-shaped distribution
parallel to and 1 cm below the
inguinal ligament, with stem
extending down along saphenous
vein.
lie superficial to fascia lata.
.
• 2.Deep-Lymphatics from superficial
nodes enter fossa ovalis (3 cm below
the inguinal ligament)and drain into
1-3 deep inguinal nodes, which lie in
femoral canal of femoral triangle.
41. Femoral triangle –
• space of the upper one third of
thigh.
• Bounded by the inguinal ligament,
sartorius muscle, and adductor
longus muscle.
• floor by the pectineal, adductor
longus, and iliopsoas muscles.
• lateral to medial – NAVEL:
femoral Nerve, Artery, Vein, Empty
space Lymph nodes.
43. PELVIC FLOOR
Muscular partition separating the pelvic cavity from anatomical
perineum
1.perineal membrane
2.perineal body
3.posterior triangle – ischioanal fossa
4. anal spincters
5.Levator ani muscles
44. 1.Perineal membrane
Triangular sheet of dense, fibromuscular tissue over
anterior half of pelvic outlet
previously called urogenital diaphragm
Separate superficial and deep perineal pouch
origin- ischiopubic rami and crura of clitoris.
Medial - urethra, walls of the vagina
Anteriorly - compressor urethrae ms and
urethrovaginal sphincters
Posteriorly - transverse vaginal muscle & smooth ms
• Dorsal and deep nerve and vessels of clitoris
found within this membrane
• Provide support for posterior vaginal wall by
attaching perineal body and vagina to ischiopubic
rami and preventing downward descent
• downward descent can be assessed by EUA by
placing a finger in the rectum, hooking it forward,
and gently pulling the perineal body downward
45. 2. Perineal body
• Mass of connective tissue bounded
by- lower vagina, perineal skin, and
anus
• central tendon of perineum
• Attached to inferior pubic rami and
ischial tuberosities through perineal
membrane and superficial transverse
perineal muscles.
• Ant- insertion of bulbocavernosus
muscles.
• lateral- fibers of pelvic diaphragm.
• Posteriorly - attached to coccyx by
external anal sphincter
• Anchor perineal body to bony pelvis
and help to keep it in place.
46. 3.Posterior triangle- ischioanal fossa
Posterior triangle / anal triangle
• formed by coccyx, sacrotuberous
ligaments, and an imaginary line
between ischial tuberosities.
• contains anal canal and two ischiorectal
(ischioanal) fossae lie on either side
• Ischioanal fossa
• lies between pelvic walls and levator ani
muscles
• Bounded
medially - levator ani muscles, external anal
sphincters
anterolaterally -obturator internus muscle.
posterior portion -extends above the
gluteus maximus.
• Pudendal canal with neurovascular
bundle lie on lateral wall
47. 4.Anal sphincters
External sphincter lies in posterior triangle of
perineum
Divided into 3 portions.
1.subcutaneous portion -attached to perianal skin
and forms ring around anal canal - characteristic
radially oriented folds in the perianal skin
2.superficial part- attaches to coccyx posteriorly and
perineal body anteriorly forms bulk of anal sphincter
3.deep part -encircle rectum and blend with
puborectalis
Internal anal sphincter - thickened circular smooth
muscle of anal wall.
• involuntary
• lies inside external anal sphincter separated by
intersphincteric groove containing longitudinal
smooth ms fibres of bowel and levator ani fibres
48. 5.Levator ani muscles
Bony pelvis is spanned by levator muscles of pelvic
diaphragm.
Pelvic diaphragm consists of two components
(a) thin horizontal shelf-like layer formed by
iliococcygeal muscle
(b) thicker “U”-shaped sling of muscles that
surround levator hiatus (medial pubococcygeal and
lateral puborectal muscles)
• Levator hiatus-open area within the U through
which urethra, vagina, and rectum pass
• Urogenital hiatus- portion of hiatus anterior to
perineal body
• Levator muscles are Strong fatigue resistrant
striated ms with three components on each
side
1.pubococcygeous
2.illiococcygeous
3.ischiococcygeous
49. 1.pubococcygeal muscle
Origin- pubic rami
Insertion -lateral vagina, perineal body, anus
coccyx
• pubovisceral muscle as majority of
attachments to vagina and anus,
• puborectal muscle is distinct from
pubococcygeal muscle and lies lateral to it.
originate from lower pubis and perineal
membrane.
2. Iliococcygeal muscle
Origin- from tendinous arc of levator anii
Insertion- into anococcygeal body(illiococygeal
raphe n coccyx)
3.Ischiococcygeus(coccygeous) muscle
Origin- ischial spine and sacrospinous ligament
Insertion- into coccyx and sacrum.
50. Pelvic diaphragm- levator ani and
ischiococcygeous muscles and their fasciae
together
• normal tone of the muscles of the pelvic
diaphragm keep the base of the U
pressed against the backs of the pubic
bones, keeping the vagina and rectum
closed.
levator plate- region of the levator ani
between the anus and coccyx formed by the
anococcygeal body and illiococcygeal raphe
• forms supportive shelf on which rectum,
upper vagina, and uterus can rest.
• horizontal position of levator plate due to
anterior traction by the pubococcygeal
and puborectal muscles is important to
vaginal and uterine support.
• levator ani muscles receive their
innervation from nerve to levator ani.i.e
an anterior branch of the ventral ramus of
the third and fourth sacral nerves .
53. 1.Vagina
• Pliable hollow viscus organ - fibromusculomembranous
• Lower portion of the vagina is constricted - passes through the urogenital hiatus
in the levator ani.
• 45˚ with horizontal,Long. Axis - right angle with uterus.cervix typically lies within
anterior vaginal wall, making it shorter than posterior wall by about 3 cm.
• Anterior and Posterior columns- anterior and posterior walls have a midline
ridge, caused by the impression of the urethra and bladder and rectum on
vaginal lumen.
• Urethral carina-caudal portion of anterior column
• Anterior ,Posterior and Lateral fornices- recesses in front ,behind and lateral to
the cervix
54. Relations
1. Lower third -
Anteriorly fused with urethra
Posteriorly with perineal body
Laterally to each levator ani by “fibers of
Luschka., bulbocavernosus, vestibular bulb,
bartholine glands
Portion of pubococcygeous attached to
vagina- pubovaginalis
2.Middle third
Anteriorly - vesical neck and trigone
Posteriorly- rectum
Laterally-levators.
3. Upper third
Anteriorly bladder
Posteriorly- cul-de-sac
Laterally- cardinal ligaments
55. • vaginal wall - mucosa, submucosa, muscularis,
and adventitia
• It has no serosa, except area covered by cul-de-
sac,
• mucosa - nonkeratinized stratified squamous
without any glands
• Submucosa- vascular tissue
• Muscularis –inner circular outer longitudinal
• Adventitia- portion of endopelvic fascia
• When it is dissected the muscularis is adherent
to it, and this combination of specialized
adventitia and muscularis is the surgeon's
“fascia,” called fibromuscular layer of vagina
56. 2. Uterus
• Hollow pyriform fibromuscular organ
• shape, weight, and dimensions vary depending
on both estrogenic stimulation and previous
parturition.
• 2 portions -upper muscular body and lower
fibrous cervix
• reproductive age- body larger than cervix
• before menarche, and after menopause body =
cervix
• triangular shaped endometrial cavity
surrounded by a thick muscular wall.
• portion of uterus that extends above the top of
the endometrial cavity i.e., above the
insertions of the fallopian tubes is called the
fundus.
57. Normal position of uterus- Anteversion- 90degree axis of cx to vx
Anteflexion- 120 degree axis of body to cx
58. 1. muscular corpus
A)Perimetrium – serous coat invests the entire
organ except on lateral borders
B)Myometrium - complex pattern of uterine
musculature due to the origin of the uterus
from paired paramesonephric primordia, with
the fibers from each half crisscrossing
diagonally with those of the opposite side.
C)Endometrium- columnar epithelium that
forms glands and a specialized stroma.
no submucosa
• Superficial portion- undergoes cyclic
change with the menstrual cycle. Spasm of
hormonally sensitive spiral arterioles that
lie within the endometrium causes
shedding of this layer after each cycle
Deeper basal layer of the endometrium
remains to regenerate a new lining. Separate
arteries supply basal endometrium, explains
its preservation at the time of menses.
59. 2.Cervix
2 portions: a)vaginal part b)supravaginal
Dense fibrous connective tissue n about 10% smooth muscle.
Smooth muscle in periphery easily dissected off fibrous cervix and form layer
reflected during intrafascial hysterectomy.
Circularly arranged around fibrous cervix into which cardinal and uterosacral
ligament
• Vaginal part - covered by nonkeratinizing squamous epithelium
• Supravaginal -canal is lined by a columnar mucus secreting epithelium
• Internal os - widens out into endometrial cavity
• External os - contains transition from squamous epithelium to columnar
epithelium of the endocervical canal- changes with hormonal variation most
susceptible to malignant transformation, infection
60. 3.Adenexal structure and broad ligament
• Ovaries and tubes constitute uterine adnexa
• Fallopian tubes -paired tubular structures 7 to
12 cm in length
• 4 portions
1.interstitial/intramural - passes through cornu
2.isthmic portion- emerging from corpus
3. ampulla- expanding lumen and convoluted
mucosa.
4. infundibulum-fimbriated end - frondlike
projections for ovum pickup.
• Distal end of fallopian tube attached to ovary
by ovarian fimbria, which is a smooth muscle
band responsible for bringing fimbria and
ovary close to one another at the time of
ovulation
• Tube's muscularis - composed of outer
longitudinal fibers & inner circular fibres
61. Ovaries
• Lateraly- attached to pelvic wall by
infundibulopelvic ligament(suspensary lig of ovary)
containing ovarian artery, vein ,lymphatics nerve
plexuxes
• Medially - uterus through utero-ovarian ligament
• Posteriorly – broad lig by mesovarium
• Reproductive life- measures 2.5 to 5 cm long, 1.5
to 3 cm thick, and 0.7 to 1.5 cm wide, Cuboidal to
columnar covering
• Consists of a cortex and medulla
• Medulla- fibromuscular, with blood vessels and
connective tissue.
• Cortex - composed of stroma, punctuated with
follicles, corpora lutea, and corpora albicantia.
62. Ovarian fossa
Depression on lateral wall of pelvis,
where in ovary lies.
• superiorly: external iliac artery and
vein
• anteriorly and inferiorly: broad
ligament
• posteriorly: ureter, internal iliac
artery and vein
• inferiorly: obturator nerve, artery
and vein
63. Round ligament –
Extensions of the uterine musculature
Homolog of the gubernaculum testis
Arise on each lateral aspect of the anterior
corpus.
Enter the retroperitoneal tissue, pass
lateral to the deep inferior epigastric
vessels
Enter each internal inguinal ring exit the
external ring and enter the subcutaneous
tissue of the labia majora.
64. Broad ligament
• Paired müllerian ducts and ovaries arise
from lateral abdominopelvic walls and
migrate toward midline pulling a
mesentery of peritoneum is pulled out
from pelvic wall. This leaves midline
uterus connected on either side to pelvic
wall by a double layer of peritoneum
called broad lig.
• Superior margin of broad lig lie fallopian
tubes, round ligaments, and ovaries
• Lower margin of broad ligament lies
cardinal and uterosacral ligaments
• Ovary, tube, and round ligament each
have their own separate mesentery,
called mesovarium, mesosalpinx and
mesoteres,
• Arrangement-
Round ligament placed ventrally ,exits pelvis
through inguinal ligament
Ovary placed dorsally
Tube is in middle and most cephalic
At the lateral end of fallopian tube and
ovary, the broad ligament ends where
infundibulopelvic ligament blends with
pelvic wall.
65. 4.Blood supply and lymphatics of genital
tract
1.ovarian arteries
2. internal iliac arteries-uterine and vaginal br
3.continuous arterial arcade connects these
vessels on the lateral border of the adnexa,
uterus, and vagina
1. ovarian arteries -
From aorta supplies adenexa.
Accompanying plexus of veins drains into vena
cava on right and renal vein on left.
Small branch through mesosalpinx supply
fallopian tube, including a prominent fimbrial
branch at lateral end of tube.
66. 2.Uterine artery
From internal iliac artery
Joins near junction of body and cervix
Uterine veins accompany uterine artery
-drain corpus and cervix.
At lateral border of the uterus (after
passing over the ureter and giving off
branch) uterine artery flows into the
side of marginal artery that runs along
the side of the uterus.Through this, it
sends blood both upward to corpus and
downward to cervix.
Descending branch of uterine artery
crosses over the cervicovaginal junction
and lies on side of vagina.
67. • vagina – from vaginal branch of uterine artery and vaginal branch of internal iliac
artery.
• Anastomotic arcade along the lateral aspect of the vagina at 3- and 9-o'clock
positions
• Branch from these vessels merge along anterior and posterior vaginal walls.
• Distal vagina also receives a supply from pudendal vessels
• Posterior wall - from the middle and inferior rectal vessels.
68. Fallopian tube
Arterial supply-Uterine and Ovarian A.
Veinous drainage-
Pampiniform plexus--Ovarian veins.
Ovaries
Arterial supply-ovarian A
Venous-pampiniform plexus –
ovarian veins
Uterus
Arterial-uterine A vaginal A & ovarian A
Venous- uterine vein –Int illiac vein
Vagina
Arterial-uterine A vaginal br, vaginal A
Middle rectalA, int pudendal A
Vein-internal illiac, int pudendal
69. Lymphatic drainage
• Upper two thirds of the
vagina and uterus -obturator
and internal and external iliac
nodes
• Distal vagina & vulva-
inguinal nodes
• Some lymphatic channels
from uterine corpus extend
along the round ligament to
the superficial inguinal nodes
• Some nodes extend
posteriorly along uterosacral
ligaments to lateral sacral
nodes.
• Ovary -follows ovarian
vessels to aorta & drain into
paraaortic nodes.
70. Ureter
• Tubular viscus
• 25 -30 cm long
• Divided -abdominal and pelvic
portions of equal length
• Inner longitudinal and outer
circular muscle layer.
• In abdomen- extraperitoneal on
posterior abdominal wall
71. Bladder
• Hollow muscular organ
• 2 portions- body(dome) and fundus
(base)
• Musculature -meshwork of
intertwining muscle bundles
• Dome musculature is thin when
bladder distended
• Base thicker, varies less with distension
• Base- Urinary trigone and Detrusor
loop
• Detrusor loop- U shaped band of
musculature, open posteriorly, that
forms the bladder base anterior to
intramural portion of ureter.
• Trigone is made of smooth muscle that
arises from ureters occupy two of its
three corners.
• Continues as the muscle of the vesical
neck and urethra.
72. Relation –
Anteriorly-pubic bone and lower
abdominal wall.
Laterally and inferiorly - pubic bones
Posteriorly – vagina ant fornix and
cervix.
Bladder base - α-adrenergic receptors
Contract when stimulated - favor
continence.
Dome -β or cholinergic stimulation,
with contraction that causes bladder
emptying.
• Sympathetic-pelvic plexus-pain of
overdistension
• Parasympathetic-S234- micturition
73. Artery-superior vesical artery( obliterated
umbilical artery)
Inferior vesical artery,either an independent
br of internal pudendal artery or from
vaginal artery.
Vein- vesicle & vaginal plexus –int illiac
veins
Lymphatics- ext & int illiac lymph nodes
74. Urethra
• Neck of bladder to external urethral meatus
• 4cm lengh, 6mm diam
• Normal PUV(post urethrovesical) angle=100
• Open 2.5cm below clitoris
• vesical neck- urethral lumen traverses bladder base
• Ant- upper2/3rd free, lower 1/3rd attached to pubic ramii-pubourethral lig
• Post-upper 1/3rd free, distal 2/3rd fused with vagina
75. • Muscle layer-outer, circular skeletal muscle layer (urogenital sphincter) and smooth
muscle fibers. Inner longitudinal smooth muscle
• Submucosa – vascular with paraurethral gland
• Mucosa-nonkeratinized squamous epithelium that responds to estrogenic
stimulation
Proximal urethral lumen lined by urothelial cells
At perineal membrane- skeletal ms form spincter urethrovaginalis and compressor
urethrae
• Blood supply-inferior extension of vesical vessels and internal pudendal vessels.
• Nerve supply-Striated ms –somatic innervation via pudendal nerve or sacral plexus
Smooth ms- inferior hypogastric plexus
76. • Chronic infection- urethral diverticula
• Obstruction of terminal duct –cyst
• Skene glands are most distal & largest paraurethral gland drain outside urethral
lumen posterolateral to external urethral orrifice
77. Sigmoid colon and Rectum
Sigmoid colon
Begins S-shaped curve at pelvic brim
Characteristic- three tenia coli lying
over a circular smooth muscle layer.
Blood supply- sigmoid arteries,
branches from inferior mesenteric
artery enters pelvis straightens its
course and becomes rectum
78. Rectum-
Devoid of taeniae coli
Passes posterior to vagina & expands into rectal ampulla.
Anorectal junction is bent at an angle of 90 degrees
Pulled ventrally by puborectalis fibers' attachment to pubes
Posteriorly by external anal sphincter's dorsal attachment to coccyx
79. Anus-
• Thickened circular involuntary muscle-
internal sphincter
• Series of anal valves for closure
• Lower border(dentate/pectinate line),
• Mucosa becomes transitional layer of
non-hair-bearing squamous epithelium
then the hair-bearing perineal skin at
anocutaneous line.
Relations of rectum and anus –
• Posteriorly- sacrum and levator plate
• Anteriorly - vagina.
• Inferiorly- each half of the levator ani
abuts its lateral wall
• Distal terminus by the external anal
sphincter.
80. Lining epithelium:
Upper 2/3- Columnar epi
Lower 1/3- St. Squamous epi.
Arterial supply
1. Superior rectal A. – Br. of IMA.- in sigmoid
mesocolon supply upto rectum
2. Middle rectal A. – Br. of Ant. Div. of Internal
iliac A. – rectum n ampulla
3. Inferior rectal A.- Br. of Internal pudental A.-
anus n ext spincter
Venous drainage:
Rectum and upper 1/3 of anal canal- Superior
rectal V.- to portal circulation
Lower 2/3 of anal canal - Inferior rectal V.- to
systemic circulation.
Lymphatics of rectum and anal canal
Rectum and upper 1/3 of anal canal- Internal Iliac
& preaortic nodes.
Lower 2/3 of anal canal – superficial inguinal
nodes.
81. PELVIC CONNECTIVE TISSUE
• Endopelvic fascia-connect the muscularis of the visceral organs to pelvic
wall muscles
• Composed of blood vessels and nerves, interspersed with a supportive
meshwork of irregular connective tissue containing collagen and elastin
82. Uterine ligaments
Broad ligament
Parts of broad ligament
Infundibulopelvic Ligament (Suspensory Ligament of Ovary):
It includes the portion of broad lig. which extends from the infundibulum of the
follopian tube to the lateral pelvic wall.
It contains: 1.ovarian vessels and nerves and lymphatics from the ovary
2. fallopian tube
3. body of the uterus.
Mesovarium
Ovary is attached to the posterior layer of the broad lig. by a fold of peritoneum called
mesovarium
It contains: 1.ovarian vessels, nerves and lymphatics.
Ovary is NOT enclosed within the broad ligament.
83. Mesosalpinx
It is the part of broad lig. between the fallopian tube and the level of attachment of
the ovary.
It contains: 1. Utero-ovarian anastomotic vessels.
2. vestigial remnants.
Mesometrium
Part of broad lig. below mesosalpinx.
Longest portion which is related with the lateral border of the uterus.
Contents of the broad lig.
1. Fallopian tube.
2. Uterine and ovarian A. , their anastomosis and corresponding veins.
3. Nerves and lymphatics from uterus , fallopian tube and ovary.
84. 4. Round ligament
5. Ovarian ligament
6. Parametrium containing loose areolar tissue and fat. The terminal part of the ureter,
uterine a., paracervical nerve, and lymphatic plexus are lying at the base of the broad
lig.
7. Vestigial structures , such as Duct of Gartner, Epoophoron and paraoophoron.
Function-as packing material and has got steadying effect to maintain the uterus in
position.
85. EXTRAPERITONEAL SURGICAL SPACES
Anterior cul-de-sac
• Recess between the dome of
the bladder and the anterior
surface of the uterus
• Peritoneum is loosely applied in
the anterior culde-sac, allows the
bladder to expand without
stretching its overlying
peritoneum.
• Loose peritoneum forms the
vesico-uterine fold, which can
easily be lifted and incised to
create a bladder flap during
abdominal hysterectomy or
cesarean section.
• Point at which the vesico-cervical
space is normally accessed
during abdominal surgery.
86. EXTRAPERITONEAL SURGICAL SPACES
Posterior cul de sac /recto uterine space
• Upper 1/3rd vagina-anteriorly
• Rectosigmoid posteriorly
• Uterosacral ligaments laterally.
• Peritoneum extends for approximately 4 cm along the posterior vaginal
wall below the posterior vaginal fornix where the vaginal wall attaches
to the cervix. This allows direct entry into the peritoneum from the
vagina when performing a vaginal hysterectomy, culdocentesis, or
colpotomy. The anatomy here contrasts with the anterior cul-de-sac.
• Anteriorly, the peritoneum lies several centimeters above the vagina
whereas posteriorly, the peritoneum covers the vagina. Keeping this
anatomic difference in mind facilitates entering both the anterior and
the posterior cul-de-sacs during vaginal hysterectomy.
87. EXTRAPERITONEAL SURGICAL SPACES
Rectopubic space/prevesical space /spaceof Retzius
Separated from the undersurface of the rectus abdominis muscles by the
transversalis fascia and can be entered by perforating this layer.
• Ventrolaterally- bony pelvis and the muscles of the pelvic wall
• Cranially - abdominal wall.
• Dorsally- proximal urethra and bladder
• Content-Dorsal vein of clitoris
Obturator nerve and vessels as they enter the obturator canal.
Vascular connections between external and internal illiac
system present passing over pubic ramii called pubic vessels – dissection in
this area should be careful
88. EXTRAPERITONEAL SURGICAL SPACES
Vesicovaginal and Vesicocervical Space
• Space between the lower urinary tract and the genital tract
• Lower extent-junction prox 1/3rd n distal 2/3rd urethra
Rectovaginal space
• Apex of the perineal body, about 2 to 3 cm above the hymenal ringI
• Extends upward to the cul-de-sac
• laterally around the sides of the rectum to the attachment of the
rectovaginal septum to the parietal endopelvic fascia.
• It contains loose areolar tissue and is easily opened with finger
dissection.
• At the level of the cervix, some fibers of the cardinal-uterosacral
ligament complex extend downward behind the vagina, connecting it to
the lateral walls of the rectum and then to the sacrum. These are called
the rectal pillars.
