Pelvic Anatomy from a Laparoscopic Perspective:: the ... · Pelvic Anatomy from a Laparoscopic Perspective:: the abdominal wall & ... Pelvic Diaphragm ... fasciae pelvis or white

Pelvic Anatomy from a Laparoscopic

Perspective:: the abdominal wall &

retroperitoenum

•Tommaso Falcone

MD

•Professor &

Chairman

•Cleveland Clinic

Foundation

Disclosure

• No honoraria from Industry

• No research grants from industry

• Receive honoraria

- Editor-in-Chief of JMIG

- Section Editor- UpToDate

Learning Objectives

• Understand the causes of iatrogenic

injuries associated with laparoscopy

• Know how to diagnose and treat

laparoscopic complications

Anterior Abdominal Wall

•Relationship of the

vessels & nerves to

potential entry sites

for trocars

Relationship of the umbilicus

to vessels

Stanhiser et al AJOG 2015

Left common iliac vein

inferior to the bifurcation of the aorta

crosses the sacrum

Left Upper Quadrant Insertion

• 2-cm below the subcostal margin mid-

clavicular line

• Organs

- Aorta-11 cm

- Spleen-12cm

- Stomach-4.4cm

- Liver-4.0cm

- Left kidney 13.2cm

Laparoscopic view of the

spleen

•Spleen is far from

the LUQ, unless

splenomegaly is

present

Pelvic Sidewall Anatomy

•3 layers

- Ureter

- Branches of the

int.iliac artery

- Muscle & nerve

Pelvic Sidewall: ureter

• Pelvic brim

- over the common or external iliac

- under ovarian vessels

• Courses anterior to the internal iliac

- UNDER THE OVARY

- 1.5 -2 CM LATERAL UTERO-SACRAL

LIGAMENTS

• Cervix

- WITHIN 2CM

Pelvic Sidewall: Blood

vessels

• Internal iliac artery

- anterior & posterior division (trunks)

- Umbilical artery

• obliterated

• medial umbilical ligament

• relationship to the uterine artery

Pelvic

Arteriogram

Pelvic & Inguinal Nerves

• Genito-femoral nerve

• Femoral nerve

Retropubic Space

•Anterior

- Pubic bone

•Lateral

- Obturator internus

muscle, fasciae,

neurovascular

bundle

•Posteriorly

- bladder &

pubocervical

fasciae

Pelvic Diaphragm

• Sheet of muscle (Levator ani &

coccygeus) covered on both sides by

fasciae

• From pubis to coccyx & is attached to the

lateral pelvic wall by a thickened band of

obturator fascia called arcus tendineus m.

levator ani

• Anogenital hiatus

Pelvic Diaphragm:Muscle

• Levator Ani

- Pubococcygeus (Puborectalis & pubovaginalis)

- Iliococcygeus

• Iliococcygeus portion that arises from the obturator internus muscle (arcus tendineus m. levator ani) & ischial spine

• Arcus: spine of the ischium forward & upward.

Pelvic Diaphragm: Fasciae • Parietal fasciae on the muscles

• Endopelvic fasciae on the pelvic viscera

- Attached to the parietal fasciae laterally

- Connective tissue attachments stabilize

the vagina

- Attachment along a line of thickened

parietal fasciae called Arcus tendineus

fasciae pelvis or white line

- Mid-vagina is supported by lateral

connections to the white line

Pre sacral space