28 The anatomy of the apical segment

Abstract

The objective of this video is to use cadaveric dissections to define the apical segment and discuss how this landmark may be used to navigate and understand the special relationships of important surrounding anatomical structures. The apical segment is a term recently proposed and defined by the Society of Gynecologic Surgeons Pelvic Anatomy Group and refers to a region of the pelvis that includes the uterus and cervix, ovaries, uterine tubes, superior vagina, vesicouterine ligaments, cardinal ligaments, uterosacral ligaments, and distal ureters. The complex three-dimensional nature of this area can make its components and their relationships difficult to visualize, yet it is vitally important that surgeons understand the relationships of these structures when performing complex hysterectomies, prolapse repairs, and any procedure that may involve distorted anatomy. We use the cervico-vaginal junction, the circumferential area where the upper vagina attaches to cervix, as a reference point. In this video, we highlight the distal ureter, uterine artery, and cardinal and uterosacral ligaments using cadaveric dissections that show how the structures relate to each other and the cervico-vaginal junction. The cervico-vaginal junction may be used as a midline reference point where many apical segment structures converge. Understanding these relationships is imperative to performing safe, effective surgical procedures.