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EDUCATIONAL MODELS FOR TEACHING PELVIC FLOOR DISORDERS Workshop Director Deborah L Myers MD, Professor of Obstetrics and Gynecology Alpert Medical School of Brown University Women & Infants Hospital of RI Providence RI USA Faculty Vivian C Aguilar MD Cleveland Clinic Foundation Urogynecologist Weston Florida USA Maria F. Paraiso MD Professor of Surgery Cleveland Clinic Foundation Cleveland, OH USA Rebecca G. Rogers, M.D. Professor Director, Division of Urogynecology Director, Fellowship in Female Pelvic Medicine and Reconstructive Surgery University of New Mexico Albuquerque, New Mexico USA 1 WORKSHOP Schedule: 800AM- WELCOME (Myers) CORE TOPICS 810AM- Resources in Urogynecology (Rogers) 825AM: Teaching pelvic anatomy (Myers) 840AM go to stations: do hands on building-each station is 15 minutes. Station 1. Ligaments (Rogers) Station 2. Muscles (Aguilar) Station 3. Perineum (Paraiso) 925AM Wash hands and 20 min break DIAGNOSTIC SKILLS 945AM DIAGNOSTIC SKILLS- Your Urogynecology “toolkit”- (Paraiso) 1000AM go to stations- each station is 15 mins. Station 1: Bladder model demo (Myers) Station 2: Pelvic exam model demo (Rogers) Station 3. Cystoscopy model (Aguilar) PESSARIES AND YOUR LECTURE 1045AM Making your lecture fun! Teaching about pessaries can be fun! (Aguilar) SURGICAL SKILLS 1100AM Surgical skills: resources and overview of teaching surgical skillssimulation/ teaching models (Paraiso) 1110AM go to stations – each station is 12 minutes each Station 1. Mid-urethral sling model- (Myers) Station 2. Laparoscopic skills (Paraiso) Station 3. Vaginal skills model- (Aguilar) FEEDBACK 1145AM- Feedback and learning in the OR (Rogers) WRAP UP 1200noon (Myers) 2 RESOURCES IN UROGYNECOLOGY PROFESSIONAL SOCIETIESMost require membership to access AUGS (need to join) Log in member MEMBER CENTER AUGS website Augs.org Go to Education then to FPMRS education portal Diverges to • FPMRS (AI, UI, POP) pre- test, post- test and lecture ( $25) • AUGS /SUFU virtual FPMRS fellows forums • On demand learning • 2012 Post Graduate courses ($125 each) surgical TX of POP panel sexual dysfunction robotic and traditional laparoscopic colpopexy colo rectal medicine and surgery for the urogynecologist FPMRS VIDEOS Overcoming challenges to the difficult vaginal hysterectomy Authors: Jennifer Klauschie, Javier Magrina , Rosanne Kho Mayo Clinic Arizona, Phoenix, AZ, United States "Punch Ball" Advanced Cystoscopy Trainer Authors: Matt Aungst, Dan Gruber, Chris Sears, John Fischer TRAINING: Medical student urogynecology learning objectives (ACGME) Resident learning objectives (ACGME) AAGL- (need to join) SURGERY U (VIDEOS) Use of A Chicken Thigh Model To Teach Laparoscopic Electrosurgery 3 Minimally Invasive Sacral Colpopexy - Novel Device Evaluation In The Cadaver Model A Novel MIS Training Tissue Model: Practicing In The Box Presented by Mackenzie MW Surgical Management Of Ureteral Injury: A Simulation Training ModelPresented by Tunitsky-Bitton E A 5-Port Technique For TLH In The Teaching Setting Presented by Siedhoff MT Safe Fast-Track Teaching Of Robotic Tubal Reanastomosis Presented by Antonio Gargiulo Hysteroscopic Myomectomy- Resident Teaching Video Presented by Mandi Beman Hysteroscopic Myomectomy - Resident Teaching Video EDUCATION CALENDAR Basic Laparoscopic Suturing Tutorial Video CME Learning objectives→ tools and resources→ performance and learning objectives Fellowship→ educational objectives (objectives for learning) Core reading list for Minimally Invasive Gynecologic Surgery (MIGS) IAPS International Academy of Pelvic Surgery membership needed – free ICS International Continence Society (need to join) Brain and Bladder The proposed course aims at bringing together researchers who are using brain functional imaging methods to study bladder brain interactions. Knowledge about brain-bladder control is emerging rapidly but there has yet to be a meeting of those engaged in this work. Headache in the Pelvis - chronic pelvic pain There will be first an introduction by Ragi Doggweiler and Jeannette Potts on the history and diagnosis of interstitial cystitis/ painful bladder syndrome and chronic prostatitis/ chronic pelvic pain syndrome. OAB- DO WE NEED A NEW PARADIGM? 4 URODYNAMIC EQUIPMENT- LIMITATIONS AND CHALLENGES APGO Association of Professors of Gynecology and Obstetrics (need to join) After log in Educational resources Basic clinical skills Sterile technique Surgical instruments Knot tying Women’s health series Urinary incontinence PowerPoint Principal Author: Steven Swift , MD Cases 3D interactive model ONLINE FACULY DEVELOPMENT RESOURCES TALENTED: The APGO Lectures on Excellence in Teaching and Education Development View video-recorded presentations from APGO meetings, complete with PowerPoint Slides and transcript. How to Grow the Best Resident Teachers for Your Students Effective Preceptor Series These 10 handy pamphlets provide preceptors with practical tools for teaching and evaluating students. Medical Student Educational Objectives The APGO Medical Student Educational Objectives provide clerkship directors, faculty and students with a resource for curriculum development, teaching and learning. Teaching Tips Peruse information packed teaching tips written by fellow physician educators. IUGA (need to join) Surgical video of the year Under physician tools- urogynecology books to buy 5 AMEE -Association for Medical Education in Europe BEME Best Evidence Medical Education 16th Ottawa Conference, Ottawa 2014 ACOG (NON-MEMBER) Search simulation Obstetrics and Gynecology Simulation Night for Medical Students http://www.acog.org/~/media/Departments/Junior%20Fellows/Project%20 1%20-%20D1EvansSimsforMS.pdf?dmc=1&ts=20130317T1445526277 Toolkit Name: A Simulation Training Program to Improve the Visual Estimation of Blood Loss (EBL) in Obstetric Hemorrhage http://www.acog.org/~/media/Departments/Junior%20Fellows/Project%204%20%20D2NirajEBL.pdf?dmc=1&ts=20130317T1445526277 (if join- AS MEMBER) Go to meeting →Prev meeting→Search education→Poster gallery INDUSTRY WEBSITES BOSTON SCIENTIFIC WEBSITE http://www.bostonscientific.com/us/womens-health.html IPAD APP for POPQ Pelvic Floor Institute- need to register (name, address, work, phone, email) Doctors lounge- learning module and interactive pelvic model GYNECARE http://www.ethicon360.com/products/gynecare-tvt-family-products-tension-supincont Health care professionals→ Specialties→ Professional education ClinicalExpertise.com A website resource for training and educational information focused on the proper indications and applications of Ethicon medical devices for usage in surgical repair. Designed for Health Care Professionals, our self6 paced curricula provide you with the background necessary for advanced, or hands-on training, as well as information about Ethicon's innovative medical devices, techniques and services that can help transform your clinical practice. AMERICAN MEDICAL SYSTEMS http://www.americanmedicalsystems.com/home.html Medical professionals → physician training and education ( ALL product related) COLOPLAST http://www.coloplast.com/ product related BARD http://www.bardmedical.com/Professionals register training pelvic health- product information and patient information brochures INTERNET RESOURCES http://www.ispub.com/journal/the-internet-journal-of-medical-simulation/volume-3number-1/an-educational-program-using-a-bladder-model-to-improve-diagnosticcystourethroscopy-skills.html#sthash.2GvIRY6S.h0K9CvBO.dpbs YOU TUBE Human Anatomy Course 3D Interactive Pelvis and Perineum Human Anatomy http://www.youtube.com/watch?v=DP8cGjHNxYQ Anatomy Of The Pelvis - Everything You Need To Know - Dr. Nabil Ebraheim http://www.youtube.com/watch?v=jpScugJrA8g&list=PLM1ILZEFTVXYXQ3VCRL K5Y-LZ2YK-KBKL pelvic floor.mp4 http://www.youtube.com/watch?v=cwBs3nLv9vI 7 TEACHING PELVIC ANATOMY IN CLAY 8 9 10 11 12 13 BUILDING GUIDE FOR THE FEMALE CLAY PELVIC MODEL Deborah L. Myersa, MD Lily A. Aryaa, MD Dianne L. Polsenob, LPN, LMT Edward M. Buchanana, MD Department of Obstetrics and Gynecology a Women and Infants’ Hospital of Rhode Island Brown University School of Medicine Providence, Rhode Island President, Cortiva Institute- MTIb Director of Education Watertown, Massachusetts “WHAT THE HANDS HAVE BUILT THE MIND CANNOT FORGET” -Jon Zahourek 14 Objectives: 1. To identify bony landmarks of the pelvis and upper femur. 2. To learn obstetrical anatomy of the pelvis and its clinical correlation. 3. To learn the ligamentous structures that comprise the pelvis and how they are used in gynecologic surgery. 4. To learn some of the muscle groups of the hip. 5. To learn the muscle groups that make up the pelvis and their action. 6. To learn the course and action of the sciatic, obturator and pudendal nerve. 7. To be able to visualize the anatomy of the pelvis from both the abdominal and perineal view. 15 BACKGROUND Bones and bony landmarks of the pelvic girdle 1. 2. 3. 4. 5. ilium pubis ischium sacrum coccyx Ilium iliac fossa iliac crest anterior superior iliac spine anterior inferior iliac spine posterior superior iliac spine posterior inferior iliac spine arcuate line Pubis pubic rami pubic tubercle iliopubic eminence (where the ilium ends and the pubis begins) pecten pubis pubic symphysis Ischium ischial spine ischial tuberosity Sacrum sacral promontory coccyx sacral ala Coccyx 16 Other bony landmarks acetabulum - (the ilium, pubis and ischium all meet) obturator foramen greater sciatic notch greater sciatic foramen lesser sciatic notch lesser sciatic foramen pubic arch linea terminalis = consisting of sacral promontory, ala of sacrum, arcuate line of the ilium and pecten pubis Femur head of femur neck of femur greater trochanter lesser trochanter trochanteric fossa intertrochanteric ridge DEFINITIONS: pelvis = basin pelvic brim the horizontal plane defined by the linea terminalis pelvic tilt = the plane of the pelvic brim lies 50- 60 degrees to the horizontal. The anterior superior iliac spine is in the same vertical plane as the pubic tubercle. false pelvis (major or greater): lies between the iliac crest and pelvic brim contains no pelvic organs except the gravid uterus, full bladder and GI tract true pelvis (minor or lesser): lies beneath the pelvic brim contains the lower urinary and reproductive tract, terminal large intestine and loops of ileum. 17 PELVIC INLET: superior aperture of the pelvis. Measurements of the pelvic inlet: Conjugate diameters: 1. true conjugate: the anterior posterior diameter that runs from the superior margin of the pubic symphysis to the sacral promontory. (about 11.0 cm) 2. obstetric conjugate: the anterior posterior diameter that runs from the back of the pubic symphysis to the sacral promontory. It is the smallest conjugate. (about 10.0 cm or more) 3. diagonal conjugate: the anterior posterior diameter that runs from the inferior margin of the pubic symphysis to the sacral promontory. (about 11.5 cm, subtract 1.5-2.0 cm to obtain the obstetric conjugate) Oblique diameter: the diameter from the sacroiliac joint to the contralateral iliopubic eminence. (under 13.0 cm) Transverse diameter: the widest distance across the pelvic brim. (13.5 cm) MIDPLANE 1. transverse mid plane diameter (interspinous diameter): between the ischial spines (minimum of 10.0 cm). The smallest diameter of the pelvis and the most important obstetrically. It is the site of deep transverse arrest of the fetus. If less than 9.5 cm that there is a 50% chance that intervention during childbirth will be needed. 18 PELVIC OUTLET: the inferior aperture of the pelvis Measurements of the pelvic outlet: 1. transverse diameter: between the ischial tuberosities (11.5 cm, about the width of a closed fist). 2. anterioposterior diameter: from the inferior aspect of the pubic symphysis to the sacrococcygeal joint. (about 13.0 cm) Urogenital triangle: triangular region bordered by the pubic symphysis and the ischial tuberosities. The urinary and reproductive tract pass through. Anal triangle: triangular region bordered by the coccyx and the ischial tuberosities. The rectum passes through. Characteristics of the female pelvis as compared to the male: larger and lighter 90 degree subpubic angle more shallow outlet larger, greater sciatic notch is wider less funnel shaped Morphological Classification of Pelvic Shapes (based on shape of pelvic inlet): gynecoid (round): common in females, 40 % of white females, 40 % of black females android (heart-shaped): common in males, 32% of white females, 15% of black females anthropoid (oval anteriorly/posteriorly): common in males, 20% of white females, 40% of black females platypelloid (oval transversely): rare in females 19 20 21 22 23 Ligaments of the Pelvic Girdle: sacroiliac ligaments: attaches the lateral aspect of the sacrum both anteriorily and posteriorly to the ilium. During pregancy relaxin is produced which causes this joint to separate and may cause discomfort. obturator membrane: a thin membrane that covers most of the obturator foramen. The anterior superior opening is the obturator canal which carries the obturator nerve, artery and vein. “Obturator” means to “plug”. sacrospinous ligament: attaches from the anteriorlateral sacrum to the ischial spine. This ligament is used surgically to treat vaginal prolapse (SSFix). sacrotuberous ligament: attaches the lateral sacrum to the lateral aspect of the ischial tuberosity. It can be used as alternative to the sacrospinous ligament during surgery. pectineal (Cooper’s) ligament: lies along the pecten pubis. It is used surgically during retropubic bladder suspension surgery. inguinal (Pouparts) ligament: runs from the anterior superior iliac spine to the pubic tubercle. Defines the boundary between the abdomen and the lower extremity. lacunar ligament (pectineal part of the inguinal ligament): attaches the medial end of the inguinal ligament to the medial edge of the pecten pubis. The site of femoral hernias. arcus tendineus fascia pelvis: the thickened inferior edge of the fascia of the obturator internus muscle. Also known as the “white line”, it attaches the lateral edge of the vagina to the pelvic sidewall. median raphe (anococcygeal ligament): attaches the coccyx to the anus. central portion (central tendon) of the perineum: the site where the muscles of the perineum attach between the vagina and the anus. The “hub” of the perineum. uterosacral/cardinal ligaments: condensation of the endopelvic fascia. The uterosacral ligament runs from the posterior aspect of the cervix and upper vagina to the sacrum. The cardinal ligaments run from the cervix to the pelvic sidewalls. The uterosacral/cardinal ligaments are the primary supports of the uterus and upper vagina. These ligaments are cut during total hysterectomy and can be used surgically to resupport the vagina. 24 25 26 27 28 MUSCLES OF THE PELVIC GIRDLE obturator externus: runs from the external medial margin of the obturator foramen to the trochanteric fossa. One of the “deep six” lateral rotators of the hip. obturator internus: runs from the internal medial margin of the obturator foramen to the medial surface of the greater trochanter. One of the “deep six” lateral rotators of the hip. piriformis: runs from the anterior sacrum (S1-S3) to the upper border of the greater trochanter. One of the “deep six” lateral rotators of the hip. iliacus: runs from the iliac fossa to the lesser trochanter. It flexes the hip. psoas major: runs from the vertebral bodies of L1-L4 to the lesser trochanter. It flexes the hip. It also flexes the body at the waist. levator ani: is the muscle complex of the pelvic diaphragm. It is comprised of three muscles: It supports pelvic viscera. 1. puborectalis: runs from the internal surface of the pubis looping around the rectum. It acts as a “sling: and is important in maintaining fecal continence. 2. pubococcygeus: runs from the internal surface of the pubis to the anococcygeal ligament. It is the “tail wagger” in animals. The Kegel squeeze 3. iliococcygeus: runs from the arcus tendineus and ischial spine to the coccyx and anococcygeal ligament. coccygeus (ischiococcygeus): runs from the ischial spine to the anterolateral edge of the sacrum (S4-S5) and coccyx. Keeps the coccyx and lower sacrum forward. 29 30 31 32 33 34 Major Nerves of the Pelvis: sciatic nerve: starts at the plexus of L4-5 and combines with the sacral roots from the foramens of S1, 2, and 3, passes out through the greater sciatic notch under the piriformis and innervates the lower extremity. Injury here causes problems in knee flexion. obturator nerve: starts L2-L4, runs along the medial border of the psoas across the obturator internus at the pelvic brim and out through the obturator canal. It controls adduction to the leg. Can be injured during pelvic surgery. pudendal nerve: starts at the roots of S2-S4, passes out the greater sciatic notch between the piriformis and the coccygeus running behind the sacrospinous ligament at the ischial spine, back through the lesser sciatic foramen through the ischiorectal fossa to the perineum. The dorsal roots provide sensory fibers to the perineal skin, the distal anal mucosa and the lower vaginal wall. It is can be injected with a local anesthetic for vaginal delivery. The ventral roots provide motor fibers to the levator ani external sphincter and the striated muscle of the urethral sphincter. Injury here can lead to problems of incontinence and prolapse. 35 36 37 38 39 MUSCLES OF THE PERINEUM ischiocavernosus: runs under the internal surface of the inferior rami of the pubis. bulbospongiosus (bulbocavernosus): runs from the clitoris and upper portion of the pubic arch surrounding the vaginal opening. It is cut during 2nd degree episiotomy. external anal sphincter: surrounds the distal anus. It is injured in 3rd degree episiotomy. deep transverse perineal: runs from the undersurface of the rami of the ischium and ischial tuberosity to the central tendon of the perineum. It is cut during 2nd degree episiotomy. superficial transverse perineal: runs from the ischial tuberosity to the central tendon of the perineum. It is cut during 2nd degree episiotomy. Types of episiotomy: midline: incision headed directly towards the anus mediolateral: starts at midline but then is angled 45 degrees Degrees of episiotomy/ laceration/ extension: 1st: involves the perineal skin and/or the vaginal mucosa 2nd: involves the the deeper perineal musculature 3rd: involves the anal sphincter 4th: involves the rectal mucosa 40 41 42 43 Clay Pelvis Workshop Set Up: 1. Title: Female Clay Pelvic Model 2. Target audience: Ob/Gyn Residents, medical students, trainees, fellows, faculty 3. Time required: 3 hours- room set up ½ hour, 2 ½ to build and ½ hour room breakdown, faculty also do practice session one week prior- 2 hour 4. Faculty required: Two trainees per model; suggest one faculty member for every 4 students. 5. Approximate cost: (per each model) Ward’s Biology wardsci.com Rochester Office Contact Information 5100 West Henrietta Road P.O. Box 92912 Rochester, NY 14692-9012 Toll-Free: 800-962-2660 Fax (Toll Free): 800-635-8439 Phone: 585-359-2502 Fax: 585-334-6174 [email protected] San Luis Obispo Office Contact Information 812 Fiero Lane P.O. Box 5010 San Luis Obispo, CA 93403-5010 Phone: 805-781-2700 Fax: 805-781-2704 For International Customers: Phone: 1-585-321-9411 Fax: 1-585-321-9105 [email protected] Pelvis with both femurs $51.75 82 V 3315 Or 44 Female Pelvis only: $65 82 V 3905 Femur: $18.35 82 V 3801 Clay: $3.00 per brick –( suggest 13 bricks per model- 3 orange, 4 white, 4 terracotta, 2 pink) may purchase from Bancroft School of Massage Therapy, 333 Shrewsbury St, Worcester, MA, USA 508-757-7923 Craft supplies / Misc: $30 Total: $ 150 per model (2 trainees per model) Re-used annually Yearly syllabus / color photocopying: $40 each trainee 6. Materials needed: (include raw materials for model development and surgical instruments needed to accomplish tasks) Syllabus (anatomy illustrations, lecture outline, building guide, muscle templates folder) Precut pieces if desired to shorten time for building session Anatomy atlas Overheads of syllabus and anatomy drawings Pelvis with attached L femur (screwed together) Clay - terracotta, orange, white, and pink color (muscle groups) Green cord or white twine (nerves) Straw (urethra) Aortic graft- (leftover/expired) large caliber for vagina and small caliber for rectum with rubber bands (uterosacral ligaments) Vinyl table cloths Rolling pins Clay/sculpting tools Paper towels Snaps or Kelly (to run nerves) Wear scrubs Remove hand jewelry/ watches/ bracelets 45 7. Description of set up: (see following figures) One week prior to the session, all participating faculty members meet to review the details for the session. Pre-made clay pieces (levators- [pubococcygeus, puborectalis, and ileococcygeus], and coccygeous- 2 / pelvis) may be made at that time according to the template outlines for the muscle groups although not necessary. Pre- cut muscles will reduce the time at the teaching session. One complete model is constructed at this time by the faculty members. Syllabi are complied. The session begins with a review of anatomy (please see syllabus). Use anatomy atlas of your choice with corresponding illustrations. This is then followed by the interactive clay building session. Suggested room set up: 46 BUILDING GUIDE TO THE FEMALE PELVIS A. Identify the bony landmarks on your pelvis- measure length of hand for clinical pelvimetry B. Build the ligaments on the right side of your pelvis. Use white clay: 47 1. sacroiliac ligament: build both anterior and posterior. use 1/2 brick of white clay and smudge it to fill in the sacroiliac joint. 2. obturator membrane: fill in the lower 2/3rds of the obturator foramen. BUILD INTERNAL SIDE. Leave open superior aspect to create the obturator canal which holds the obturator nerve, artery and vein. 3. sacrospinous ligament: run from the ischial spine to the sacrum. 4. sacrotuberous ligament: run from the lateral aspect of the sacrum starting at the posterior superior iliac spine to the lateral aspect of the ischial tuberosity. 5. pectineal (Cooper’s) ligament: fill in along the pecten pubis. 6. inguinal ligament (Poupart’s) ligament: run from the anterior superior iliac spine to the pubic tubercle. 7. lacunar ligament: fill in the most medial portion between the inguinal ligament and the pecten pubis. These remaining ligaments will be placed after the muscles are built: 7. 8. 9. 10. C. 48 arcus tendineus fascia pelvis median raphe (anococcygeal ligament) central tendon of the perineum uterosacral ligaments Next the muscles of the female pelvis will be built on the left side of the pelvis. Note recommended clay color. USE MUSCLE TEMPLATES AS GUIDE FOR SIZE. 49 1. obturator externus: cover the obturator foramen on the hip side, and run under the neck of the femur and attach to the trochanteric fossa. ( a large tadpole shape) terra-cotta 2. obturator internus: cover the obturator foramen on the abdominal side, run through the lesser sciatic notch to the medial surface of the greater trochanter and insert superficial to the obturator externus. ( a large tadpole shape) terra-cotta 3. piriformis: run from the anterior surface of S2 to the greater trochanter. (Do not cover the sacral foramen) terra-cotta ⇒ insert sciatic nerve: secure twine/ cord to the top of the vertebrae of the spine (anchor with piece of clay). Then run the twine/cord next to the transverse processes of L4-5 (lumbar sacral plexus region) then run thru sacral #2 foramen, through the greater sciatic notch and under (or through) the piriformis and over the insertion tendon of the obturator internus. secure to distal femur at any point with clay. Use twine or cord 4. 50 iliacus: cover the iliac fossa, run under the inguinal ligament and insert onto the lesser trochanter. use 1/2 brick of orange 5. psoas major: run off the anterior surface and transverse processes of the lumbar vertebrae of L1-L4 medial to the iliacus, under the inguinal ligament, and combine with the inserting tendon of the iliacus on the lesser trochanter. use 1 brick of orange 6. build the inguinal ligament on the left. white ⇒ insert obturator nerve: secure twine/ cord to the top of the vertebrae of the spine (anchor with piece of clay) run the twine/ cord on the medial border of and slightly underneath the psoas. Lay it against the obturator internus and punch it through the obturator canal. use twine/ cord 7. 51 coccygeus (ischiococcygeus): run it from the ischial spine to the coccyx, S4 and S5. build on both sides using pink USE MUSCLE TEMPLATES AS GUIDE FOR SIZE. 8. levator ani: Build the three muscles of the levator ani in this order: build on both sides of the pelvis. USE TEMPLATES AS GUIDE (build posterior to anterior) a) iliococcygeus: run it from the insertion of the obturator internus at the arcus tendineus (“white line”) on the ilium to the coccyx and raphe. b) pubococcygeus: run it from the lower edge of the pubis to the coccyx. c) puborectalis:. run it as a “sling” from the pubis around the rectum and back to the pubis. It is the most medial muscle of the levator ani. ⇒ insert the arcus tendineus fascia pelvis. The arcus or “white line” runs on the lower edge of the obturator internus from the ischial spine to the pubic tubercle. Build both sides. white clay ⇒ insert the pudendal nerve: run twine/ cord alongside the sciatic nerve running it between the piriformis and coccygeus out through the greater sciatic notch. Next build both a sacrospinous and sacrotuberous ligament on the left side of the pelvis, then run the pudendal nerve over the sacrospinous ligament just medial to the ischial spine, and then back through the lesser sciatic foramen and out onto the external surface of the levator ani muscles. use twine/ cord. 52 D. Next you will build the muscles of the perineum. Build on both sides. Note recommended clay color. 1. ischiocavernosus: run it under the inferior surface of the pubic ramus and ischial tuberosity. orange 2. bulbospongiosus (bulbocavernosus): run it starting from the pubis and clitoris around the vaginal opening and back to the pubis. Orange ⇒ At this point, lay in the vagina (large caliber graft material with attached uterosacral ligaments) and then the urethra (straw). 3. deep transverse perineal : run a thin layer from the ischial tuberosity to the central tendon. orange 4. superficial transverse perineal: run a small piece atop the deep transverse perineal muscle from the ischial tuberosity to the central tendon. pink 5. external anal sphincter: run it around the distal portion of the rectum (small caliber graft material) and attach to central tendon. Orange You may need to pinch the levator muscles posteriorly to bring them up to the rectum. ⇒ central portion of the perineal body: place a small dot of white clay where the bulbospongiosus meets at the vaginal introitus. white 53 ⇒ median raphe (anococcygeal ligament): runs from the external anal sphincter to the coccyx. white ⇒ stretch the uterosacral ligaments. Stretch the cut rubberbands from the apex of the vagina to the sacrum and tack down with clay. DONE! 54 References: Williams PL Gray’s Anatomy, 38th ed. Churchill Livingstone Publishers, New York, 1995 Netter FH Atlas of Human Anatomy, 2nd ed. Novartis Publishers, East Hanover, New Jersey 1999 Colborn GL and Skandalakis JE Clinical Gross Anatomy. A guide for dissection study and review. The Parthenon Publishing Group, New York, 1993 Rohen JW and Yokochi C. Color Atlas of Anatomy, 3rd ed. Igaku-Shoin Publishers, New York, 1993 Clemente CD Anatomy. A regional atlas of the human body. Lea & Febiger, 3rd ed. Philadelphia, 1977 Williams Obstetrics, 20th ed. Appleton and Lange, Stamford, CT, 1997 Myers DL, Arya LA, Verma A, Polseno DL, Buchanan EM.Pelvic anatomy for obstetrics and gynecology residents: an experimental study using clay models. Obstet Gynecol. 2001 Feb;97(2):321-4. 55 Obturator Externus muscle terra cotta color 56 Obturator Internus muscle terra cotta color 57 Psoas Major orange color 58 Pubococcygeus terra cotta color 59 Iliococcygeus terra cotta color 60 Coccygeus (make 2) Pink color 61 Piriformis Terra cotta color 62 Iliacus orange 63 64 Puborectalis terracotta color 65 66