Surgical Anatomy of the Female Pelvis

Abstract

Introduction A three-dimensional conceptual understanding of the abdomen and pelvis is essential for the gynecologic surgeon. Few things in medicine remain as constant as the anatomy. Yet there are nuances such that knowledge can be gained throughout one's entire career. This chapter will present the anatomy of the abdominal wall and of the female pelvis. The review focuses on benign gynecologic surgery. Scope of the Problem A common line in most consent forms for gynecologic surgical procedures includes “risk of bleeding, infection, injury to other organs including bowel, bladder, ureter, blood vessels, and nerves.” In the interest of patient safety and excellent health care, there is an increasing move nationally toward compensation being tied to outcomes. Surgical outcomes are a major component of this. A thorough understanding of anatomy will help to avoid complications, will improve surgical outcomes, and will provide safe and effective health care. Abdominal Anatomy Musculature The anterior abdominal wall is comprised of the internal and external oblique muscles, the transversus abdominis, and two strap-like muscles – the rectus abdominus and the pyramidalis. The pyramidalis provides minimal support to the abdominal wall. The oblique muscles and transversus abdominis serve, among other functions, to increase intraabdominal pressure to assist with respiration. The muscles insert centrally into the linea alba. Therefore a midline incision will interrupt this support and the suture line will be under greater tension than a transverse incision. The fascia of the internal oblique splits at the rectus muscle and travels anterior and posterior to the rectus muscle helping to form the rectus sheath. Inferior to the arcuate line, at about the level of the anterior superior iliac spine, the aponeurosis of this muscle passes only anterior to the rectus muscle. The fascia of the transversus abdominis passes behind the rectus muscle, fusing with the posterior portion of the internal oblique aponeurosis before contributing to the linea alba. At the level of the arcuate line it passes anterior to the rectus muscles. Below the arcuate line the abdominal wall is weaker and more susceptible to hernia formation. [1] Vasculature The inferior epigastric artery arises from the external iliac artery at the level of the inguinal ring and travels anteromedially to enter the transversalis fascia. It then travels along the lateral border of the rectus inferiorly before entering the rectus sheath at the arcuate line.