migs uoft 2014 anatomy - university of toronto
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Pelvic Anatomy:Staying Out of Trouble
Abheha Satkunaratnam MD, FRCS(C)
Objectives
To focus on key anatomy for the gynaecologic surgeon advancing their minimally invasive gynaecologic skills
To provide and discuss strategies to help minimize surgical complications and
challenges
DisclosuresI have made either presentations, participated on advisory boards or in investigative research on behalf of these pharmaceutical companies in the last 2 years & received financial compensation:
Abbvie Laboratories Canada
Astra-Zeneca
Bayer Canada
Gynecare/Ethicon Canada
I do not have/or had any financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
Abheha Satkunaratnam MD FRCSC
Anatomy 101
Pneumo-peritoneal needle placement is responsible for 90% of vascular and visceral injuries
Abheha Satkunaratnam MD FRCSC
Anterior Abdominal Wall
Abheha Satkunaratnam MD FRCSC
Arcuate Line
Abheha Satkunaratnam MD FRCSC
Verres Insufflation & Primary Trocar
Umbilicus is situated opposite the aortic bifurcation in 80% of cases to within 2 cm
Abheha Satkunaratnam MD FRCSC
Verres Insufflation & Primary Trocar
Beware the roll and the fold...
In thin patients, the umbilicus is perpendicular to the bifurcation or even to the left common iliac vein
Abheha Satkunaratnam MD FRCSC
Anterior Abdominal Wall
Changing Body HabitusAbheha Satkunaratnam MD FRCSC
PrematureTrendelenburg..ation
Abheha Satkunaratnam MD FRCSC
To Lift or Not To Lift
Abheha Satkunaratnam MD FRCSC
Secondary Ports
Abheha Satkunaratnam MD FRCSC
Anterior Abdominal Wall Vasculature
SuperficialSuperficial EpigastricSuperficial Circumflex
Deep
Superior EpigastricMusculophrenic
Deep CircumflexInferior Epigastric
Femoral Artery
Internal Thoracic Artery
External Iliac Artery
Abheha Satkunaratnam MD FRCSC
Anterior Abdominal Wall Vasculature
Abheha Satkunaratnam MD FRCSC
Anterior Abdominal Wall Vasculature
Abheha Satkunaratnam MD FRCSC
Secondary or Ancillary Ports
Abheha Satkunaratnam MD FRCSC
Secondary or Ancillary Ports
5-8cm
Abheha Satkunaratnam MD FRCSC
Secondary or Ancillary Ports
Abheha Satkunaratnam MD FRCSC
Anterior Abdominal Wall
Abheha Satkunaratnam MD FRCSC
Anterior Abdominal Nervous Supply
Thoracoabdominal7-11th intercostal nerves
IliohypogastricMons pubis
IlioinguinalLabia Majora
Abheha Satkunaratnam MD FRCSC
Superficial Iliohypogastric
T12, L1
Lateral cutaneous branch: skin of gluteal region
Anterior cutaneous branch: skin over inguinal region, pubic symphysis, mons
Abheha Satkunaratnam MD FRCSC
Deep Ilioinguinal
L1(L2)
Motor: transversus abdominus
Sensory: pubic symphysis, labia majora (anterior labial nerve)
Abheha Satkunaratnam MD FRCSC
Nerves & Trocar Placement
Abheha Satkunaratnam MD FRCSC
Anterior Abdominal
Abheha Satkunaratnam MD FRCSC
Major Pelvic Vasculature - Ovarian
Abheha Satkunaratnam MD FRCSC
Common iliac (2-4 cm long) bifurcates into Internal & External iliac arteries
Internal Iliac artery (AKA hypogastric artery) is medial bifurcation & includes two “divisions”
Major Pelvic Vasculature - Iliac
Abheha Satkunaratnam MD FRCSC
Anterior
Parietal and viscera branches
Posterior
Parietal branches
Veins
Deep to arteriesForm a complex plexusDrain into common iliac veins
Major Pelvic Vasculature - Iliac
Abheha Satkunaratnam MD FRCSC
Major Pelvic Vasculature
Abheha Satkunaratnam MD FRCSC
Internal Iliac Artery - Anterior Division
Anterior(division(
branches
Inferior(gluteal(artery
Obturator(artery
Inferior(vesical(artery
Middle(rectal(artery
(Internal(pudendal(artery
(Uterine(artery
Vaginal(artery
Umbilical(artery Superior(vesical(artery
Branching)pa+ern)is)extremely)variable!
Abheha Satkunaratnam MD FRCSC
Major Pelvic Vasculature
Abheha Satkunaratnam MD FRCSC
Pelvic Vessels & Spaces
Abheha Satkunaratnam MD FRCSC
Pelvic Spaces
Abheha Satkunaratnam MD FRCSC
Paravesical Space
Abheha Satkunaratnam MD FRCSC
Pararectal Space
Abheha Satkunaratnam MD FRCSC
Important for
Removing pelvic lymph nodes
Dissection of the ureter/bladder
endometriosis
Beware of injuring the genitofemoral nerve which lie laterally on the psoas muscle
to avoid injury to the obturator nerve or to an accessory obturator vein, which is present in approximately 20% of patients
The Paravesical and Pararectal Spaces
Abheha Satkunaratnam MD FRCSC
Vesicovaginal and Vesicocervical Space
Abheha Satkunaratnam MD FRCSC
Vesicovaginal and Vesicocervical Space
Abheha Satkunaratnam MD FRCSC
Rectovaginal Space
Abheha Satkunaratnam MD FRCSC
Rectovaginal Space
Abheha Satkunaratnam MD FRCSC
The Ureter ...Friend or Foe?
Ureteral Caliber
Three distinct narrowings
1. Ureteropelvic junction
2. Crossing of the iliac vessels
3. Ureterovesical junction
Abheha Satkunaratnam MD FRCSC
The Ureter - Nomenclature
Abdominal
Pelvic
Upper
Middle
Lower
22cm
30cmAbheha Satkunaratnam MD FRCSC
Anatomic Relations
Related to psoas muscle posteriorly throughout retroperitoneal course
Gonadal (Ovarian) vessels cross medial to lateral and runs parallel before entry into pelvis
Ureter crosses iliac vessels lateral to medial as it enters the pelvis at bifurcation of internal and external iliac arteries
Abheha Satkunaratnam MD FRCSC
Anatomic RelationsRuns within broad ligament lateral to uterosacral ligament
Ureter crosses under the uterine artery at level of ischial spine to enter the cardinal ligament
Abheha Satkunaratnam MD FRCSC
Anatomic Relations
Courses through cardinal ligament into the ureteric tunnel
Turns medially to cross the anterior upper vagina as it traverses into the bladder wall
Abheha Satkunaratnam MD FRCSC
Blood SupplyMultiple feeding branches
Arterial branches to the upper ureter approach from medial direction
Arterial branches to the lower ureter approach from a lateral direction
These branches course longitudinally within the periureteral adventitia
Abheha Satkunaratnam MD FRCSC
Ureteric Histology
Ureteric Injury
Common Sites of Ureteric Injury During Gynaecologic Surgery
1. Ovarian Artery/Vein (Infundibulopelvic Ligament)
2. Uterine Artery/Vein
3. Vaginal Cuff
Abheha Satkunaratnam MD FRCSC
Prevention and Identification
Anatomic knowledge
Identification of ureters prior to dissection
Ureteral stenting
Fiberoptic catheters
Post-operative cystoscopy
Intravenous pyeologram
Retrograde pyeologram
Abheha Satkunaratnam MD FRCSC
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