Pelvic Surgical Anatomy

1. Pelvic Surgical Anatomy John L. Dalrymple, MD Division Director, Gynecologic Oncology Department of Obstetrics and Gynecology UT Southwestern Austin Programs

2. I have nothing to disclose.

3. Objectives • Describe basic abdominal and pelvic anatomy related to common gynecologic surgical procedures • Name common potential pitfalls and complications that can occur during gynecologic pelvic surgery • Describe the challenges related to anatomical distortions from pelvic pathology, patient body habitus, and complex procedures • List the physiologic changes related to anatomical changes from pelvic surgery (optional)

4. Why Anatomy is important • Backbone of understanding clinical conditions • What’s normal • What’s abnormal • Why it’s abnormal • How to manage the problem • Surgery is all about anatomy • Obstetrics AND Gynecology is loaded with anatomical clinical correlations

5. General Considerations • Preparation for the OR (PRE-OP) • Review basic/relevant anatomy: • What organs are being removed/corrected/altered? • What anatomy must be traversed to get there? • Understand indications for surgery: • Why is procedure being done/what are goals of surgery? • What alternatives are there and have they been considered?

6. General Considerations • In the OR (INTRA-OP) • Perform the EUA (pelvic AND abdominal exam) • What anatomical distortions are present? • Does this affect the route of surgery? • How will you position the patient? • Performing the procedure: • What are the abdominal wall and pelvic floor anatomical landmarks? • Is the anatomy distorted by the disease process or prior procedures? • Does the patient’s body habitus affect her anatomy? • What potential complications can you expect?

7. General Considerations • After the OR (POST-OP) • Anticipate physiologic changes: • What will the patient/you expect acutely and chronically from anatomical changes (reproductive, GI, GU, sexually, physically, etc)? • Manage complications: • What anatomic/physiologic changes will you expect from common complications (bowel, bladder, vascular, nerve injuries)? • What are the expected postoperative pelvic and abdominal anatomic changes that occur after surgery?

8. General Considerations • In the OR (INTRA-OP) • Perform the EUA (pelvic AND abdominal exam) • What anatomical distortions are present? • Does this affect the route of surgery? • How will you position the patient? • Performing the procedure: • What are the abdominal wall and pelvic floor anatomical landmarks? • Is the anatomy distorted by the disease process or prior procedures? • Does the patient’s body habitus affect her anatomy? • What potential complications can you expect?

9. Case Studies • Relevant surgical anatomy • Special points of consideration • danger areas and potential complications • Physiologic outcomes

10. Case Study 1 • 38 yo G2P2 female with symptomatic menometrorrhagia, dysmenorrhea and anemia. Prior cesarean section x 2. • Examination: BMI – 28; Pelvic – 16 wk fibroid uterus – palpable midway to the umbilicus on abdominal exam • Ultrasound: multiple leiomyomas (>6) measuring in size from 4 to 8 cm, located in fundal, posterior/anterior and lateral uterus. • EMB – proliferative; UPT – neg; Hgb – 8 mg/dL

11. Surgical Approach • PreopDx: Symptomatic Leiomyoma • Planned Procedure: Exploratory laparotomy, Total abdominal hysterectomy (TAH) • Relevant Surgical Anatomy • Abdominal and pelvic examination • Layers of the abdominal wall • Abdominal structures • Pelvic structures

12. The Pelvic Exam Components • External genitalia • Lesions, ulcers, cysts • Vagina • Lesions, prolapse (cystocele, rectocele) • Cervix • Size, shape, mobility, lesions • Uterus • Size, shape, position, mobility • Adnexa • Masses, size, shape, mobility, laterality

13. The Abdominal Exam Components • Visual inspection • Scars • Distortions • Palpation • Masses • Liver and spleen edge (HSM) • Ascites • Umbilicus - hernias • Panus/adipose • Percussion and Auscultation

14. Layers of the Abdominal Wall Skin External oblique muscle Superficial Fascia – fatty layer (Camper’s fascia) Internal oblique muscle Superficial Fascia – membranous layer (Scarpa’s fascia) Transverse abdominis muscle Transversalis fascia Parietal peritoneum Extraperitoneal fat

15. Layers of the Abdominal Wall Ext. oblique m. Int. oblique m. Ext. oblique m. Int. oblique m.

16. Abdominal incisions • Vertical (midline) • Pfannenstiel • Maylard • Cherney

17. Abdominal Structures

18. Abdominal Organs – Major

19. Female Pelvic Organs

20. Uterus/Ovaries

21. Blood Supply and Ligaments

22. The spaces

23. Fibroid Uterus – Distorted Anatomy

24. Special Points of Consideration • Distortion of ligaments • Distortion of retroperitoneal spaces • Course of the ureter • Increased blood supply to uterus --------- • Urologic injury – bladder, ureters • Vascular injury/large EBL – collateral blood supply and increased flow

25. Special Points of Consideration • Distortion of ligaments • Distortion of retroperitoneal spaces • Course of the ureter • Increased blood supply to uterus --------- • Urologic injury – bladder, ureters • Vascular injury/large EBL – collateral blood supply and increased flow

26. 3 points of ureteral injury • When clamping the IP (gonadal vessels) • When clamping the uterine vessels • With inadequate bladder flap development (clamping the cardinal ligaments)

27. Physiologic Outcomes • Abdominal wall and pelvic floor changes • GI/GU changes • Loss of menstruation • Potential change in sexual response

28. Case Study 2 • 24 yo G0 female with severe chronic pelvic pain, dysmenorrhea and dyspareunia. Healthy. • Examination: BMI – 22; Pelvic – NEFG, normal sized retroverted, but slightly fixed uterus with exquisite tenderness and uterosacral nodularity; slight fullness of left adnexa with tenderness • Ultrasound: normal uterus with 5-6 cm left complex adnexal cystic ovary • UPT – negative; cervical cultures – negative for chlamydia and gonorrhea

29. Surgical Approach • PreopDx: Complex adnexal mass, r/o endometriosis • Planned Procedure: Diagnostic laparoscopy, left ovarian cystectomy/salpingo-oophorectomy • Relevant Surgical Anatomy • Abdominal and pelvic examination • Layers of the abdominal wall • Abdominal structures • Pelvic structures

30. Blood Supply of the Anterior Abdominal Wall

31. Laparoscopy – abdominal contents

32. Laparoscopic view of Pelvic Anatomy

33. Anatomical distortions - Endometriosis

34. Special Points of Consideration • Distortion of uterosacral ligaments • Obliteration of posterior cul-de-sac and ovarian fossa • Course of the ureter • Blood supply to ovary/tube --------- • Ureteral injury • Vascular injury/large EBL • Bowel injury

35. Physiologic Outcomes • Improved symptoms and/or pain • Potential loss of ovarian function and/or menopause

36. Case Study 3 • 62 yo G4P4 female with pelvic pressure and bulging/protruding mass per vagina • Examination: Pelvic – near complete uterine prolapse (procidentia) • Pap smear – negative/normal; U/s – atrophic ovaries; uterus with 3 mm endometrial stripe

37. Surgical Approach • PreopDx: Uterine prolapse • Planned Procedure: Total vaginal hysterectomy +/- Bilateral salpingo-oophorectomy • Relevant Surgical Anatomy • Abdominal and pelvic examination • Pelvic structures • Pelvic floor anatomy

38. Perineum

39. Vaginal and pelvic examination

40. The Pelvic Floor

41. Vaginal Hysterectomy

42. Special Points of Consideration • Distortion of bladder and ureters • Atrophic changes --------- • Bladder/ureteral injury • Anal/rectal injury

43. Physiologic Outcomes • Improved pelvic pressure/bulging • Improved GI/GU function

44. Conclusions • Pelvic anatomy is generally preserved and knowledge of key abdominal and pelvic anatomical landmarks is essential for any pelvic surgeon • Complications can best be avoided by anticipating the pathologic changes that result in anatomic alterations as a result of pelvic disease • Knowledge of pelvic and abdominal anatomy is crucial for successful surgical management that will lead to improved patient outcomes

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