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Pelvic Anatomy from a Laparoscopic Perspective. Tommaso Falcone MD Professor & Chairman Cleveland Clinic Foundation. Anatomy & Advanced Laparoscopic Surgery Course. Anatomic Areas. Anterior abdominal wall Pelvic sidewall Extra-peritoneal spaces Retropubic space Presacral space

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pelvic anatomy from a laparoscopic perspective
Pelvic Anatomy from a Laparoscopic Perspective
  • Tommaso Falcone MD
  • Professor & Chairman
  • Cleveland Clinic Foundation
anatomic areas
Anatomic Areas
  • Anterior abdominal wall
  • Pelvic sidewall
  • Extra-peritoneal spaces
    • Retropubic space
    • Presacral space
    • Pararectal space
anterior abdominal wall
Anterior Abdominal Wall
  • Relationship of the vessels & nerves to potential entry sites for trocars
retroperitoneal vessels umbilicus
Retroperitoneal Vessels & Umbilicus
  • Bifurcation of the aorta
    • thin patients at umbilicus
    • More caudad with increasing weight
  • Left common iliac vein
    • inferior to the bifurcation of the aorta
    • crosses the sacrum
left upper quadrant insertion
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
Laparoscopic view of the spleen
  • Spleen is far from the LUQ, unless splenomegaly is present
pelvic sidewall anatomy
Pelvic Sidewall Anatomy
  • 3 layers
    • Ureter
    • Branches of the int.iliac artery
    • Muscle & nerve
pelvic sidewall ureter
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
Pelvic Sidewall: Blood vessels
  • Internal iliac artery
    • anterior & posterior division
    • Umbilical artery
      • obliterated
      • medial umbilical ligament
      • relationship to the uterine artery
pelvic inguinal nerves
Pelvic & Inguinal Nerves
  • Genito-femoral nerve
  • Femoral nerve
retropubic space
Retropubic Space
  • Anterior
    • Pubic bone
  • Lateral
    • Obturator internus muscle, fasciae, neurovascular bundle
  • Posteriorly
    • bladder & pubocervical fasciae
pelvic diaphragm
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
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
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