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SECTION VI SURGERY IN GYNAECOLOGIC ONCOLOGY 84 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. 505 506 u Surgical Anatomy in Pelvic Gynecologic Oncology 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. Surgical Anatomy in Pelvic Gynecologic Oncology u 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. 507 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. 508 u Surgical Anatomy in Pelvic Gynecologic Oncology - 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. Surgical Anatomy in Pelvic Gynecologic Oncology u 509 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). 510 u Surgical Anatomy in Pelvic Gynecologic Oncology 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: - - - 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. 511 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 512 u Surgical Anatomy in Pelvic Gynecologic Oncology 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 Surgical Anatomy in Pelvic Gynecologic Oncology u 513 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 514 u Surgical Anatomy in Pelvic Gynecologic Oncology 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 References 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 the vesicovaginal is the inferior part of the same space. Its boundaries are: anteriorly the posterior part of the bladder, posteriorly the cervix (upper part) and vagina (inferior part), laterally the vesico uterine ligaments, inferiorly the first third of the urethra and superiorly the anterior peritoneal fold (Figure 28). 13. 14. 15. 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. 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