Download educational models for teaching pelvic floor disorders

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
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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)
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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
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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?
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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
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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
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TEACHING PELVIC ANATOMY IN CLAY
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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
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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.
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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
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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.
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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.
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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
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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.
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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.
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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.
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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
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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
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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
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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:
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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:
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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.
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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.
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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.
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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.
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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.
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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
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⇒ 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.
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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
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Piriformis
Terra cotta color
62
Iliacus
orange
63
64
Puborectalis terracotta color
65
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