Handa 9781496386441 Full Sample Chap 1

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CHAPTER 1  Surgical Anatomy of the Female Pelvis

Parietal peritoneum

Falciform lig.

Ligmentum teres

Umbilicus

I

Median umbilical lig.

Posterior rectus sheath

Medial umbilical lig.

Inf. epigastric artery and vein

FIGURE 1.5  Intraperitoneal view of anterior abdominal wall, demonstrating five peritoneal folds: the median umbilical fold (covering the median umbilical ligament), paired medial umbilical folds (covering the medial umbilical ligaments), and the lateral umbilical folds (cov- ering the inferior epigastric arteries and veins). Note all umbilical peritoneal folds (ligaments) merge at the umbilicus.

Lateral umbilical lig.

Deep inguinal ring

Bladder

Round lig.

Vagina

The umbilical fascia is formed by a thickening in the transversalis fascia behind the umbilicus, with possible contributions from the upward extension of the bladder visceral fascia (umbilicovesical fascia). Neurovascular Supply of the Abdominal Wall Vessels of the Abdominal Wall Knowledge of the course of the abdominal wall blood vessels helps the surgeon anticipate their location dur- ing abdominal incisions or insertion of laparoscopic trocars ( FIG. 1.6 ). The blood vessels that supply the abdominal wall can be separated into those that supply the skin and subcutaneous tissues and those that supply the musculofascial layer. Three groups of vessels provide blood supply to the skin and subcutaneous tissues. The superficial epigastric vessels run a diagonal course in the sub- cutaneous tissue from the femoral vessels toward the umbilicus, beginning as a single artery that branches extensively as it nears the umbilicus. Its position can be anticipated midway between the skin and muscu- lofascial layer, in a line between the palpable femoral pulse and the umbilicus. The external pudendal artery runs a diagonal course medially from the femoral artery to supply the region of the mons pubis. It has many midline branches, and bleeding in its territory of distribution is heavier than that from the abdomi- nal subcutaneous tissues. The superficial circumflex iliac vessels course laterally from the femoral vessels toward the flank. The blood supply to the lower abdominal wall’s deeper musculofascial layer parallels the subcutaneous vessels. The inferior epigastric and the deep circumflex

iliac arteries branch from the external iliac, and their course parallels that of their superficial counterparts (see FIG. 1.6 ). The deep circumflex iliac artery lies between the internal oblique and transversus abdominis muscle. The inferior epigastric artery and its two veins originate lateral to the rectus muscle. They run diagonally toward the umbilicus and intersect the muscle’s lateral border

0 5 10 15 20cm

Superficial vessels

Deep vessel

C

C

Superficial epigastric

Inferior epigastric

Superficial circumflex iliac

A

A

B B

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FIGURE 1.6  Normal variation in epigastric vessels. A , B , and C designate safe spots for laparoscopic trocar insertion. Dotted lines indicate lateral border of the rectus muscle. (Reprinted fromHurd WW, Bude RO, DeLancey JOL, et al. The location of abdominal wall blood vessels in relationship to abdominal landmarks appar- ent at laparoscopy. Am J Obstet Gynecol 1994;171(3):642–646, with permission. Copyright © 1994, Elsevier.)

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