MIGS UofT 2014 Anatomy - University of Toronto

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


Anterior Abdominal Wall


Arcuate Line


Verres Insufflation & Primary Trocar

Umbilicus is situated opposite the aortic bifurcation in 80% of cases to within 2 cm


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



Changing Body HabitusAbheha Satkunaratnam MD FRCSC

PrematureTrendelenburg..ation


To Lift or Not To Lift


Secondary Ports


Anterior Abdominal Wall Vasculature

SuperficialSuperficial EpigastricSuperficial Circumflex

Deep

Superior EpigastricMusculophrenic

Deep CircumflexInferior Epigastric

Femoral Artery

Internal Thoracic Artery

External Iliac Artery






Secondary or Ancillary Ports



5-8cm






Anterior Abdominal Nervous Supply

Thoracoabdominal7-11th intercostal nerves

IliohypogastricMons pubis

IlioinguinalLabia 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


Anterior Abdominal


Major Pelvic Vasculature - Ovarian


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


Anterior

Parietal and viscera branches

Posterior

Parietal branches

Veins

Deep to arteriesForm a complex plexusDrain into common iliac veins

Major Pelvic Vasculature - Iliac


Major Pelvic Vasculature


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!


Major Pelvic Vasculature


Pelvic Vessels & Spaces


Pelvic Spaces


Paravesical Space


Pararectal 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

The Paravesical and Pararectal Spaces


Vesicovaginal and Vesicocervical Space


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


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


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


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 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


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


Prevention and Identification

Anatomic knowledge

Identification of ureters prior to dissection

Ureteral stenting

Fiberoptic catheters

Post-operative cystoscopy

Intravenous pyeologram

Retrograde pyeologram


MIGS UofT 2014 Anatomy - University of Toronto

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