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SECTION VI
SURGERY IN GYNAECOLOGIC
ONCOLOGY
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Surgical Anatomy in Pelvic Gynecologic
Oncology
Hugo R. Gasper, MD
Introduction
The aim of this chapter is to provide the anatomical concepts
needed to understand the surgical procedures described. It
is not a complete description but a practical approach to the
anatomy.
Transversalis
fascia
Peritoneum
Anterior Abdominal Wall
Anatomic knowledge of anterior abdominal wall is crucial to
avoid neurovascular complications and hernias.
Ventral layer of
the rectus sheath
Medial umbilical
ligament (uracaus)
Transversus
abdominis muscle
Internal oblique
Rectus abdominis
mucsle
Medial
umbilical
ligament
External
oblique muscle
Muscles
They can be divided into: the flank muscles (external oblique,
internal oblique and transversus abdominis muscles) and the
vertical muscles (rectus abdominis and pyramidal muscles).
The external oblique muscle is inserted into the lower
ribs and the iliac crest and its fibers are oriented caudal and
medially. The internal oblique muscle arises from the iliac
crest and lower ribs but its fibers run cranial and medially.
The deepest flank muscle is the transversus abdominis and
its fibers are almost horizontal (transverse).
The rectus abdominis is inserted into the xiphoid process
and cartilages of the ribs and, caudally, it is attached to the
pubic bone. It has fibrous interruptions mostly above the
umbilicus.
All of the flank muscles terminate in an aponeurotic
portion that involves the rectus abdominis (the rectus sheath
or conjoined tendon) and fuse in the midline (linea alba). In
the lower part, all the aponeurosis run anteriorly to the rectus
muscle and, in the upper part, the aponeurosis of the internal
oblique muscle divides into two layers: one ventral to the
rectus and one dorsal (Figure 1). The demarcation between
these parts is made by the arcuate line or Douglas’s arcade,
located 4-5 cm caudally to the umbilicus.
Transversalis
Linea alba
Apneurosis of the
fascia
Peritoneum
internal oblique muscle
Dorsal layer of
the rectus sheath
Figure 1. Transverse sections of the anterior abdominal wall. (A) Below
the arcuate line. (B) Above the arcuate line.
-
-
Transversalis fascia: It is visible underneath the posterior
layer of the rectus sheath and the transversus abdominis
muscle.
Peritoneum: The parietal peritoneum covers the entire
abdominal wall, having five vertical folds that are caused
by different structures: a single median fold (uracus), two
medial umbilical folds (obliterated umbilical arteries) and
two lateral umbilical folds (inferior epigastric vessels).
Umbilicus
The umbilicus is the thinnest area of the abdominal wall making
it the most frequent entry point in laparoscopic surgery. The
umbilicus (or umbilical region) is located in the middle line,
cranially to a line that crosses over both anterior superior iliac
spines. This level corresponds dorsally to the level of the fourth
lumbar vertebra (or L4-L5). Knowledge of the anatomy of this
region is essential to avoid dangerous vascular complications
(mainly aortic, inferior vena cava, iliac and inferior mesenteric
vessels). The distance between the umbilicus and the large
vessels is different among patients (it can be very short in
slim patients). So the angle of the introduction of the Veress
needle should be close to 90º in obese patients and 45º
(towards the uterine fundus) in slim patients. Trendelenburg
position changes the normal anatomy, decreasing the
distance between the sacral promontory (therefore the major
blood vessels) and the umbilical region. So it should only be
made after the introduction of the umbilical trocar.
Layers
The anterior abdominal wall can be divided into several layers
from the skin to the peritoneal cavity (Figure 1):
- Skin: The orientation of the dermal fiber (Langer lines) is
mainly transverse (with a slightly curving concave upward
line). Due to this fact, the vertical incisions have worst
cosmetic results.
- Subcutaneous tissue: Can be divided into to a superficial
layer- Camper’s fascia (fattier and less fibrous) and a
deeper layer- Scarpa´s fascia.
- Muscularaponeurotic layer: previously described.
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Palmer’s point
It is located in the left upper quadrant, 3 cm below the middle
left costal margin (Figure 2). At this point the abdominal
wall is relatively thin (2-3 cm) and no major retroperitoneal
vessels run below it. This is an alternative side for primary
trocar insertion for patients who have an increased risk of
umbilical adhesions but it should be avoided in patients with
splenomegaly and previous stomach and transverse colon
surgery.
Blood Vessels
The blood supply of the abdominal wall has several origins:
- Femoral artery branches: The superficial epigastric,
superficial circumflex and external pudendal arteries arise
just below the inguinal ligament. The superficial epigastric
vessels run medial and cranially. They can be identified
during transverse incisions and by transillumination in
laparoscopic surgery (mostly in thin patients).
- External iliac artery branches: the inferior epigastric
artery and the deep circumflex artery. The first enters the
rectus sheath at the level of the arcuate line. The inferior
epigastric artery and vein can and should be identified in
laparoscopic surgery because they produce the lateral
umbilical fold. These vessels can also be damaged in
transverse incisions (especially if they go beyond the
lateral limit of the rectus abdominis) (Figure 2).
- Internal thoracic (mammary) artery branches: The
superior epigastric and the musculophrenic arteries. The
first descends in rectus sheath posterior to muscle and
anastomosis with inferior epigastric artery.
Nerves
The abdominal wall is innervated by the thoracoabdominal,
the ilioinguinal and iliohypogastric nerves. The ilioinguinal and
iliohypogastric nerves have only a sensory function. These
nerves can be injuried during low abdominal incisions and
Figure 2. Vessels and nerves of the anterior abdominal wall and
location of the Palmer’s point.
lateral placement of laparoscopic trocars. Anatomic studies
have shown that the risk is minimized if secondary trocars
are placed above the level of the anterior superior iliac spine
(Figure 2).
Pelvic Anatomy
Bones, Ligaments and Muscles
The bony pelvis is formed by the sacrum, the coccyx and two
hip (os coxae, innominate) bones (Figure 3).
Sacrum and Coccyx
The sacrum is formed by the fusion of the 5 sacrum vertebrae.
It has one anterior (or pelvic) and one posterior (or dorsal)
surface, each with four paired foramina (sacral foramina): exit
holes of the sacral nerves and anteriorly also the vessels.
Laterally, by the sacral alae (“wings”), it articulates with
the hip bone (sacroiliac joint) and inferiorly with the coccyx.
Figure 3. The female pelvis: the
pelvic bones, joints, ligaments and
foramina.
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Superiorly it articulates with the fifth lumbar vertebrae
(lumbosacral joint). The sacral promontory is an anterior
projection located in the first sacral vertebrae.
Hip or Innominate Bones (Os Coxae)
It is formed by 3 components (originated by different
ossification points): Ileum, Ischium and Pubis.
Ligaments
There are several pelvic ligaments, with different functions
and compositions.
Surgically the most important are:
- Inguinal ligament: It is formed by the lower border of
the aponeurosis of the external oblique muscle and it
stretches from anterior superior iliac spine to pubis. It
an important landmark for hernia repair and inguinal
lymphadenectomy.
- Cooper´s or pectineal ligament: It is located along the
pectineal line, being the anterior limit of the retropubic
space.
- Sacrospinous and anterior longitudinal ligament:
Important for pelvic organ prolapse surgery.
- Sacrotuberous ligaments: Extends from the ischial
tuberosity to the anterior surface of the sacrum and
coccyx.
Muscles
Surgically the most important muscles are the piriformis and
obturator internus (located at the pelvic side wall) and levator
ani and coccygeus muscles (pelvic floor) (Figure 4).
Muscle piriformis: Arises from the anterior surface of the
sacrum (S2-S4), passes through the great sciatic foramen
and inserts at the greater trochanter of the femur.
Muscle obturator internus: Its’ origins are at the ilium and
ischium, exits the pelvis by the lesser sciatic foramen and
inserts to the greater trochanter of the femur.
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Muscle levatador ani: It is the most important muscle of
the pelvic floor. Anatomically consists of 3 different parts: the
pubococcygeus, puborectalis and iliococcygeus.
Muscle coccygeus: Arises from the ischial spine and
sacrospinous ligament and inserts at the lateral aspect of the
coccyx and fifth sacral vertebra.
The pelvic diaphragm is composed of the levator ani and
coccygeus muscles and it is important to the support of the
pelvic viscera because it counteracts the intra-abdominal
pressure. The loss of tone of these muscles predispase to
pelvic organ prolapse.
Arteries
Abdominal Aorta
It descends in the retroperitoneal space from the aortic hiatus
in the diaphragm until the level of the fourth lumbar vertebrae
(or between L4-L5) where it divides into three branches: two
major ones- the common iliac arteries and a smaller one – the
middle sacral artery (Figures 5 and 6).
For gynecologic surgery the most important branches
are:
- Lumbar arteries: They are five on each side. The first four
arise from the posterior aspect of the aorta and the last is
a branch of the middle sacral artery.
- Ovarian artery: It originates at the anterolateral surface of
the aorta between the second and third lumbar vertebra,
below the renal arteries. On the left, it crosses the psoas
muscle and enters the pelvis by crossing the common
iliac artery. On the right, it crosses the anterior aspect of
the inferior vena cava and enters the pelvis at level of the
external iliac artery.
- Inferior mesenteric artery: it arises 3-4 cm above the aortic
bifurcation.
Middle Sacral Artery
It is the smallest terminal. It continues in the direction of the
aorta in the anterior surface of the sacrum and coccyx.
Figure 4. Superior view of the pelvic diaphragm.
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-
Deep circumflex iliac artery.
Inferior epigastric artery; which, together with the vein,
produce a prominence in the anterior peritoneum called
lateral umbilical fold. In laparoscopic surgery this vessels
should be visualized before placement of the lateral trocar
(Figure 2).
Internal (Hypogastric) Iliac Artery
Figure 5. View of the abdominal aorta (during laparoscopic
extraperitoneal aortic dissection). IMA, inferior mesenteric artery; LA,
lumbar artery; RV, renal vein.
Common Iliac Artery
They measure about 5 cm in length and are located between
the aortic bifurcation and the sacroiliac joint. At this level
they divide into: external and internal iliac arteries. The right
common iliac artery is ventral and medial to the vein and the
left one is caudal to the artery.
External Iliac Artery
It courses along the medial border of the psoas muscle until
the femoral ring (below the inguinal ligament), having laterally
the genitofemoral nerve. The terminal branches are:
There is an important anatomic variation in the pattern of
branching of this artery and the pelvic surgeon should be
aware of variations from classic anatomical descriptions. The
internal iliac artery is about 4 cm long and, on the right, it
is related with the vein laterally and, on the left, the vein is
in the posteriolateral aspect of the artery. The pelvic ureter
runs medially. These structures (ureter and vein) should
be identified during the ligation of the internal iliac artery.
Classically, we define two trunks of branching:
- Anterior trunk: Supplies most of the pelvic viscera. The
arteries are: umbilical; superior, middle and inferior
vesical; middle rectal (hemorrhoidal); obturator; internal
pudendal; inferior gluteal; uterine and vaginal.
- Posterior trunk: Iliolumbar (anastomoses with the fifth
lumbar artery and the deep circumflex iliac artery), lateral
sacral (anastomoses with the middle sacral artery) and
superior gluteal artery (supplies the gluteal muscles).
An important anatomical landmark is the umbilical artery,
which produces the medial umbilical fold that can be seen
at the anterior abdominal wall. Following the umbilical artery
to its origin, the surgeon will identify the origin of the uterine
artery (Figure 7).
Veins
The common iliac veins are formed by the union of the
internal and external iliac veins. On the right, the vein is dorsal
Figure 6. Arteries and veins of the pelvis.
Figure 7. View of left side of the pelvis. BL, broad ligament; D, pouch
of Douglas; EIV, external iliac vein; OF obturator fossa; ON, obturator
nerve; PrS; pararectal space; PvS, Paravesical space; R, rectum; U,
uterus; UA, uterine artery; Umb. A; umbilical artery.
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Figure 8. Aortic bifurcation and left common iliac vein.
and lateral to the artery. The left common iliac vein is dorsal
and medial to the artery. It is longer and a more oblique,
occupying the cranial part of the presacral space (in front of
the first sacral vertebra) (Figure 8).
The inferior vena cava is formed by the union of the
common iliac veins at the level of the fifth lumbar vertebra
and ends at the right atrium. It is located to the right of the
lumbar spine. The most important collateral branches of the
inferior vena cava are:
- Lumbar veins: One for each artery.
- Renal veins: The left renal vein is longer than the right and
it crosses ventrally the aorta (in a few cases the vein can
be circumaortic or retroaortic) and dorsally the superior
mesenteric artery (Figure 9).
- Ovarian veins: The right ovarian vein drains into the
inferior vena cava but the left ovarian vein drains into the
left renal vein.
Pelvic Lymphatic Drainage
The lymphatic drainage of the uterus and adnexa is complex
and variable, being the subject of debate among surgeons
Figure 9. Left renal vein crossing ventrally the aorta.
Figure 10. Lymph vessels and nodes of pelvis.
and anatomists. Generally, the drainage follows the course
of the main blood vessel and the lymph nodes and channels
surround these vessels (Figure 10). Normally, there is an
avascular plane between the vessels and the lymphatic tissue
but care should be taken for small perforating vessels.
Classically, the drainage of the cervix can de divided
into three major trunks: anterior, lateral and posterior (Figure
11). The lateral trunk is the most important route. It has
three branches (upper, middle and lower) and drains to the
interiliac, common iliac, obturator, inferior gluteal, superior
gluteal and/or presacral. The posterior trunk runs along the
Figure 11. Lymphatic drainage of the cervix marked with blue dye (right
side).
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Figure 13. Obturator fossa (left side). BL, posterior leaf of the broad
ligament; EIA and EIV, external iliac artery and vein; OF, lymphatic
tissue of the obturator fossa; ON, obturator nerve; Umb. A, umbilical
artery.
Figure 12 Nerves of the pelvic viscera.
uterosacral ligament and drain to the common iliac, superior
gluteal, presacral and/or aortic nodes. The anterior trunk runs
in the posterior aspect of the bladder and drains into the distal
interiliac nodes. Recently, Cibula and Abu-Rustum described
two major lymphatic trunks: superficial and a deep trunk. The
anatomy of these trunks is based on surgical dissections and
is important for pelvic lymphadenectomy.
The lymphatics of the uterine corpus can follow three
major routes: Channels from the fundus that follow the ovarian
vessels to the upper part of the aortic nodes; channel along
the broad ligament that drain to the interiliac nodes and a path
through the round ligament to the inguinal nodes.
Regarding the ovary, the lymphatics follow the vessels
and drain mostly into the aortic nodes but in some women
another route drains into the external and internal iliac nodes.
Pelvic Nerves
The innervation of the pelvis is made by both the somatic and
the autonomic systems (Figure 12).
The somatic innervation is provided by the lumbar, sacral
and coccygeal plexus. The most relevant nerves in pelvic
gynecological surgery are:
- Iliohypogastric nerve: Provides sensory innervation to
hypogastric region (Figure 2).
- Ilioinguinal nerve: Provides sensation to the skin that
covers the groin, inner thigh, mons and labia majora
(Figure 2).
- Genitofemoral nerve: Provides innervation also to the
groin and the labia majora.
- Obturator nerve: Provides motor innervation to the
adductor muscle of the thigh and sensation to the skin of
the medial thigh and knee. This nerve should be identified
and spared during pelvic lymphadenectomy (Figure 13).
Pudendal nerve: It’s the motor nerve of the perineal
muscles, urogenital diaphragm and external anal
sphincter. Provides sensation to the perianal and vulvar
regions and also to the lower vagina, urethra and clitoris.
The autonomic innervation of the pelvis exerts control
of the rectal, bladder and genital function. It has both,
efferent (motor) and afferent (sensitive) pathways. It can be
divided into sympathetic and parasympathetic systems. The
sympathetic nerves cause the internal anal sphincter (smooth
muscle) contraction and play a minor role in the contraction
of the sphincter vesicae. The parasympathetic system is
responsible for the relaxation of urethral and anal smooth
muscle sphincters and for the contraction of the detrusor. The
innervation of the external anal sphincter and the external
urethral sphincter (both striated muscles) is provided by the
pudendal nerve (somatic innervation).
The most important components are the superior
hypogastric plexus (SHP), the hypogastric nerves (HN) and
the inferior hypogastric plexus (IHP). Knowledge of these
structures is mandatory for nerve-sparing procedures.
The SHP is located in the lower part of the abdominal
aorta and its bifurcation. It receives sympathetic fibers from
the aortic plexus and the lumbar and pelvic parts of the
sympathetic trunks.
At the level of the sacral promontory, the SHP divides into
two hypogastric nerves. These nerves run postero-laterally
to the posterior rectal wall, medially to the posterior division of
the internal iliac artery, dorsally to the ureter and lateral to the
uterosacral ligament; ending at the IHP (Figure 14).
The IHP is located in the pelvic side wall and it has the
shape of a triangle. It stretches from the lateral aspect of the
rectum, passing the cervix and vaginal fornix laterally until the
Surgical Anatomy in Pelvic Gynecologic Oncology u
Figure 14. Left hypogastric nerve. BL, posterior leaf of the broad
ligament, HN, hypogastric nerve; OS, Okabayashi´s space; Ur, Ureter.
bladder base. It is located below the ureter. At its’ posterior
edge it receives the sacral roots (pelvic splanchnic nervesS2-S4), which are parasympathetic afferents of the IHP
(Figure 15). The efferents of the IHP are:
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-
-
Vaginorectal plexus: Emerges medially to the intersection
between the uterine artery and the ureter and divides into
two branches (one vaginal and one to the superior part of
the rectum).
Vesical plexus: Runs lateral and caudally to the ureter.
Below the ureterovesical junction it branches into a vesical
and trigonal nerve. These nerves should be spared to
prevent vesical function disorders, so any dissection
caudal and lateral to the ureter should be avoided (Figure
20).
Inferior rectal plexus: Arises from the caudal part of the
IHP.
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Figure 16. Relationship between the ureter and the IP ligament (right
side).
Ureter
The major cause of ureteral injury is gynecological surgery.
Knowledge of the histology and anatomy is mandatory to
avoid this complication.
Histology
The ureter has three concentric layers: The inner layer is the
mucosa (composed of transitional epithelium); the middle
layer is the muscular (composed of smooth muscle fibers
with a circular direction externally and longitudinal direction
internally) and the outer layer is the adventitia. The adventitia
is very important in surgery because it contains the blood
supply of ureter (and also the nerves and lymphatics). The
ureter obtains its vascularisation from renal, common iliac
and uterine arteries. The branches from these arteries form
an anastomotical network in the adventitia that should be
preserved.
Anatomy
Figure 15. Autonomic nervous system (left side). BL, posterior leaf
of the broad ligament; D, pouch of Douglas; HN, hypogastric nerve;
OS, Okabayashi´s space; PrS, pararectal space; R, rectum; SN,
splanchnic nerves; Ur, Ureter (pulled laterally).
In normal adults the ureters measure between 25 and 30 cm.
They are retroperitoneal extending from the renal pelvis to
the urinary bladder. Its course is divided differently among
the authors. In this description the ureter is divided into an
abdominal and pelvic segments, being the demarcation level
the pelvic brim.
The abdominal ureter runs in the ventral surface of the
psoas muscle. The right ureter contacts ventrally with the
second part of the duodenum, medially with the inferior vena
cava and at the level of the third lumbar vertebra, the ovarian
vessels cross its ventral surface and course laterally. The left
ureter is posterior to the colic vessels, lateral to the aorta; it’s
also crossed by the ovarian vessels and passes through the
posterior attachment of the sigmoid mesocolon. At the level of
the pelvic brim, the right ureter enters the pelvis by crossing
the external iliac artery and the left ureter by crossing the
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Figure 19. Ureteral tunnel (left side). Ur, ureter; VVS, vesicovaginal
space; VUL- anterior leaf of the vesicouterine ligament.
Figure 17. Fenestration of the broad ligament.
common iliac artery, both run medially to the infindibulopelvic
(IP) ligament (Figure 16). This is a common site of ureteral
injury, which occurs during IP ligament ligation. To avoid
this complication the IP should be isolated and the ureter
localization should be known (Figure 17).
At the pelvis the ureters descend in the lateral pelvic
sidewall, they run in a position parallel and medial to the
internal iliac artery. In this area the ureter is in connective
tissue sheath attached to the posterior leaf of the broad
ligament. This connective tissue extends dorsally from the
ureter and contains the hypogastric nerve, being called the
“mesoureter “. A “meso” is a peritoneal fold that attaches the
intra-abdominal viscera to the abdominal wall, so the term
“mesoureter” is mostly a surgical one. Subsequently, the
ureters run under the uterine artery (“the way to memorize”:
water under the bridge) and above the vaginal artery. This
is another site of ureteral injury because normally the ureter
is located 1.5 to 2 cm lateral to the cervical edge but this
distance can be inferior to 0.5 cm. In order to avoid it, the
uterus should be pushed to the other side and elevated (in
laparoscopic and laparotomic hysterectomies) since this
maneuver increases the distance between the ureter and the
uterine cervix (Figure 18).
Figure 20. Posterior leaf of the vesicouterine ligament. The vesical
plexus (efferent of the inferior hypogastric plexus) runs laterally and
caudally to the ureter, so any dissection of this area should be avoided
and careful haemostasis is advisable.
After crossing with the uterine artery, the ureter enters
the ureteral (or Wertheim’s) tunnel (Figures 19 and 20). The
nomenclature of this area varies among authors. It can be
describe as anterior or ventral parametrium, bladder pillar
and vesicouterine ligament. The important issue is that the
ureter divides these structures into a medial or anterior part
and a lateral or posterior part. Regarding the bladder pillar
it is split by the ureter into a medial and lateral portions (or
ligaments); the ventral parametrium into vesicouterine and
lateral ligament of the bladder and the vesicouterine ligament
into anterior and posterior leafs.
Pelvic Connective Tissue
Figure 18. Traction of the uterus to avoid injuring the ureter.
The anatomy of the female pelvic connective tissue has been
discussed from more than a century. The description given in
this chapter is in our opinion the most comprehensive one.
The pelvic connective tissue can be divided into three
groups: parietal, visceral and extraserosal pelvic fascias.
These fascias are partially fused together.
The parietal pelvic fascia covers the structures (bones
and muscles) limiting the pelvis. This fascia presents fibrous
bands: the tendinous arch of the pelvic fascia and the one
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Figure 21. Uterosacral ligament (left side). HN, hypogastric nerve;
OS, Okabayashi´s space; RVS, rectovaginal space; US, uterosacral
ligament.
of the levator ani, both are important in pelvic reconstructive
surgery (Figure 4).
The visceral pelvic fascia envelops the pelvic viscera and
attaches them to the pelvic walls, preventing the prolapse of
the organs. It is formed by the pubocervical fascia, rectovaginal
fascia, uterosacral ligaments, rectovaginal ligaments, rectal
stalks and rectosacral fascia. The last four structures should
be considered a single anatomical fascial block that arises
from the lateral aspect of the sacrum (S2-S4) and the ischial
spine and run to different organs: the uterus (uterosacral
ligament), vagina (rectovaginal ligament) and rectum (rectal
stalk). Lateral to this structure runs the hypogastric nerve
(Figure 21).
The last group is the extraserosal pelvic fascia. It is
responsible for providing support to vascular, neural and
lymphatic structures and to allow expansion and contraction of
the pelvic organs. It is formed by the parametrium, paracervix,
superior vesical ligament, lateral ligament of the rectum and
the presacral fascia.
Figure 23. Schematic drawing of the connective tissue and the spaces
of the pelvis.
The parametrium consists of the tissues between the
uterus and the pelvic side wall that cross over the ureter. It’s
formed by the tissue that surrounds the uterine artery, the
superficial uterine vein and lymphatics (Figure 22). Some
authors consider the superficial portion of the vesicouterine
ligament as a ventral expansion of the parametrium.
The paracervix is below to the ureter. It has a medial
part which is mainly fibrous and a lateral part that consist of
cellulolymphatic tissue. The deep uterine vein is an important
anatomical landmark; below it is the inferior hypogastric
plexus.
Pelvic Spaces
The pelvic viscera and the pelvic connective tissue divide
the subperitoneal pelvis into different spaces, the so-called
pelvic spaces. Anatomically these spaces are filled with fatty
or areolar connective tissue and are relatively avascular,
working as surgical cleavage planes. Their knowledge is
imperative for surgeons.
Retropubic, Prevesical or Retzius Space
This space is limited anteriorly by the symphysis pubis and
Cooper´s ligament, posterioly by the urinary bladder and
laterally it continues with the paravesical space (laterally
to the bladder pillars) being limited laterally by the internal
obturator muscle. The floor is the pubocervical fascia. This
space contains: the dorsal clitoral vessels (that drain into
the periuretheral-perivesical plexus – plexus of Santorini),
the proximal urethra and, in the lateral part, the obturator
neurovascular bundle.
Figure 22. Parametrium and Paracervix (right side). The ureter runs
between the superficial and the deep uterine veins. DUV, deep uterine
vein; IIA, internal iliac artery; SUV, superficial uterine vein; UA, uterine
artery.
Paravesical Space
This space is considered by some authors as the lateral part
of the prevesical space. It is limited medially by the urinary
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Figure 24. Paravesical space.
bladder, laterally by obturator fascia, ventrally by the superior
pubic ramus, dorsally by the cardinal ligament and caudally
by the iliococcygeus muscle (part of the levator ani muscle)
(Figure 24).
The content of this space is the umbilical artery, the
obturator neurovascular bundle, lymphatic tissue and in the
lateral and upper part, the external iliac vessels (Figure 25).
Vascular connections, either arterial (between 8 and 25
% of the cases) or venous (between 67 and 95%), can occur
between the obturator and external iliac or inferior epigastric
vessels, designated as Corona Mortis or accessory obturator
vessels. These run posteriorly to the superior pubic ramus
therefore careful dissection of this area is advisable.
Presacral or Retrorectal Space
This space can be divided into two segments: one inferior- the
Retrorectal space and one superior the Presacral space (that
continues superiorly with the retroperitoneal space).
Its’ boundaries are: posteriorly the anterior longitudinal
ligament, the sacral promontory and the anterior aspect of the
sacrum; anteriorly the rectum and the parietal peritoneum and
Figure 26. Presacral space (retroperitoneal view).
Figure 25. Pararectal and paravesical spaces. BL, broad ligament; D,
pouch of Douglas; EIV, external iliac vein; OF obturator fossa; ON,
obturator nerve; PrS; pararectal space; PvS, Paravesical space; R,
rectum; U, uterus; UA, uterine artery; Umb. A; umbilical artery.
laterally the common iliac artery and ureter. It begins at the
level of the aortic bifurcation until the pelvic floor.
The vasculature within this space is very important: The
left common iliac vein runs in the superior part (below the
aortic bifurcation) crossing the sacral promontory from the left
to the right; beneath this vessel emerges the middle sacral
vessels (Figure 26). Many anatomic studies showed variations
of the pattern of the vessels and distances between them and
the middle line, proving therefore that careful dissection of
this space is advisable because the specific location of the
vasculature cannot be predicted.
The superior hypogastric plexus is located beneath the
parietal peritoneum, in front of the aortic bifurcation, left
common iliac vein and middle sacral vessels.
Figure 27. Pararectal and Okabayashi´s space (Right side). BL,
posterior leaf of the broad ligament; D, pouch of Douglas; EIA and
EIV, external iliac artery and vein; OS, Okabayashi´s space, ON,
obturator nerve; PrS; pararectal space; R, rectum; U, uterus.
Surgical Anatomy in Pelvic Gynecologic Oncology u
515
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1.
2.
3.
4.
5.
6.
7.
Figure 28. Vesicovaginal and vesicouterine spaces.
Pararectal Space
The pararectal space continues laterally the retrorectal
space. It is limited ventrally by the base of the broad ligament,
caudally by the puborectalis muscle, laterally by the internal
iliac artery and medially by the uterosacral ligament (Figure
25). This space can also be called the Latzko´s space.
The Okabayashi´s space is between the posterior leaf of
the broad ligament and the so-called mesoureter. Opening
this space is important to isolate the hypogastric nerve
(Figure 27).
8.
9.
10.
11.
12.
Vesicovaginal and Vesicouterine Space
The vesicouterine or vesicocervical is the upper part and
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13.
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Rectovaginal Space
The rectovaginal space is located between the posterior wall
of the vagina and the anterior wall of the rectum. It begins at
the cul-de-sac of Douglas and extends until the upper part of
the perineal body (Figure 21).
Acknowledgments
Special thanks to Amina Lubrano MD, PhD, Octavio Arencibia
MD and Virginia Benito MD, PhD (Department of Gynaecology
Oncology, University Hospital of Canary Islands, Spain) for
their mentorship and hospitality. I would also like to express
my gratitude to A.J. Gonçalves-Ferreira MD, PhD (Department
of Anatomy, Lisbon Faculty of Medicine, Portugal) for his
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