Objectives. Pelvic Anatomy: Staying Out of Trouble. Disclosures. Anatomy 101. Anterior Abdominal Wall. Arcuate Line. Abheha Satkunaratnam MD, FRCS(C)

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1 Objectives Pelvic Anatomy: Staying Out of Trouble Abheha Satkunaratnam MD, FRCS(C) 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 Disclosures I 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 Pneumo-peritoneal needle placement is responsible for 90% of vascular and visceral injuries Anatomy 101 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. Wall Arcuate Line

2 Verres Insufflation & Primary Trocar Umbilicus is situated opposite the aortic bifurcation in 80% of cases to within 2 cm Verres Insufflation & Primary Trocar In thin patients, the umbilicus is perpendicular to the bifurcation or even to the left common iliac vein Beware the roll and the fold... Wall Premature Trendelenburg..ation Changing Body HabitusAbheha Satkunaratnam MD FRCSC To Lift or Not To Lift Secondary Ports

3 Wall Vasculature Wall Vasculature Superficial Superficial Epigastric Superficial Circumflex Deep Superior Epigastric Musculophrenic Deep Circumflex Inferior Epigastric Femoral Artery Internal Thoracic Artery External Iliac Artery Wall Vasculature Secondary or Ancillary Ports Secondary or Ancillary Ports Secondary or Ancillary Ports 5-8cm

4 Wall Nervous Supply Thoracoabdominal 7-11th intercostal nerves Iliohypogastric Mons pubis Ilioinguinal Labia Majora Superficial Iliohypogastric T12, L1 Lateral cutaneous branch: skin of gluteal region Anterior cutaneous branch: skin over inguinal region, pubic symphysis, mons Deep Ilioinguinal L1(L2) Motor: transversus abdominus Sensory: pubic symphysis, labia majora (anterior labial nerve) Nerves & Trocar Placement

5 Major Pelvic Vasculature - Ovarian Major Pelvic Vasculature - Iliac 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 Major Pelvic Vasculature Anterior Parietal and viscera branches Posterior Parietal branches Veins Deep to arteries Form a complex plexus Drain into common iliac veins Internal Iliac Artery - Anterior Division Obturator(artery Major Pelvic Vasculature Umbilical(artery Superior(vesical(artery (Uterine(artery Anterior(division( branches Vaginal(artery Inferior(vesical(artery Middle(rectal(artery Branching)pa+ern)is) extremely)variable! (Internal(pudendal(artery Inferior(gluteal(artery

6 Pelvic Vessels & Spaces Pelvic Spaces Paravesical Space Pararectal Space The Paravesical and Pararectal Spaces Vesicovaginal and Vesicocervical Space 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

7 Vesicovaginal and Vesicocervical Space Rectovaginal Space Rectovaginal Space The Ureter... Friend or Foe? Ureteral Caliber Three distinct narrowings 1. Ureteropelvic junction 2. Crossing of the iliac vessels 3. Ureterovesical junction 22cm Abdominal The Ureter - Nomenclature Upper Middle Anatomic Relations Related to psoas muscle posteriorly throughout retroperitoneal course Gonadal (Ovarian) vessels cross medial to lateral and runs parallel before entry into pelvis Pelvic 30cm Lower Ureter crosses iliac vessels lateral to medial as it enters the pelvis at bifurcation of internal and external iliac arteries

8 Anatomic Relations Runs within broad ligament lateral to uterosacral ligament Ureter crosses under the uterine artery at level of ischial spine to enter the cardinal ligament 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 Blood Supply Multiple feeding branches Ureteric Histology 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 Ureteric Injury Common Sites of Ureteric Injury During Gynaecologic Surgery 1. Ovarian Artery/Vein (Infundibulopelvic Ligament) 2. Uterine Artery/Vein 3. Vaginal Cuff Prevention and Identification Anatomic knowledge Identification of ureters prior to dissection Ureteral stenting Fiberoptic catheters Post-operative cystoscopy Intravenous pyeologram Retrograde pyeologram