Handa 9781496386441 Full Sample Chap 1

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CHAPTER 1  Surgical Anatomy of the Female Pelvis

Superficial inguinal lymph nodes

Fascia lata

Inguinal ligament

Superficial epigastric v.

Superficial circumflex iliac v.

Sartorius m.

Femoral a.

I

Fossa ovalis Large saphenous v.

Femoral v.

Adductor longus m.

FIGURE 1.17  Lymphatic drainage of the vulva and femoral triangle. Superficial inguinal nodes are shown in the right thigh, and deep inguinal nodes are shown in the left thigh. Fascia lata has been removed on the left .

Deep inguinal lymph nodes

Superficial external pudendal v.

longus and gracilis lie the adductors magnus and bre- vis muscles. The adductor brevis lies underneath the adductor longus and between the anterior and posterior branches of the obturator nerve. It originates on the body of the pubis and the inferior pubic ramus. Its func- tion is to adduct the thigh. The adductor magnus is the largest muscle in the medial compartment and lies posterior to the other muscles. It has an adductor part, which originates from the ischiopubic ramus and inserts along the posterior shaft of the femur, and a hamstring head, which originates from the ischial tuberosity and inserts on the medial epicondyle of the femur. The pri- mary action of the adductor part is adduction, and the primary action of the hamstring part is hip extension. Beneath these three adductor muscles lies the obtura- tor externus, which originates from the distal surface of the obturator membrane and adjacent bone and inserts onto the femur. The primary action of the obturator externus is the same as that of the obturator internus muscle, which is lateral rotation of the hip. The muscles of the medial thigh compartment receive blood supply from the femoral and obturator arteries. Although significant variability exists, presented here is a frequent pattern of blood supply. The profunda femo- ris is a branch of the femoral artery that supplies the pectineus and adductors longus, brevis, and magnus. A smaller branch of this vessel, the medial circumflex femoral artery, perforates the adductor brevis, obtura- tor externus, and gracilis muscles. The obturator artery passes through the obturator canal and then separates into anterior and posterior branches, which encircle the obturator membrane. Its branches supply the pectineus and obturator externus muscles. Deep veins of the thigh correspond with the major arteries described. The major source of innervation to the medial thigh is from the obturator nerve. It enters the thigh through the obturator canal and promptly separates into anterior and posterior branches, which travel on the anterior

superficial external pudendal vessels that supply the mons, labia majora, and prepuce of clitoris. Lymphatics from the superficial nodes enter the saphenous opening and drain into one to three deep inguinal nodes, which lie in the femoral canal of the fem- oral triangle. They pass through the saphenous opening in the fascia lata, which lies approximately 3 cm below the inguinal ligament, lateral to the pubic tubercle, along with the saphenous vein on its way to the femoral vein. The membranous layer of the subcutaneous tissues spans this opening as a trabeculate layer called the cribriform fascia, pierced by lymphatics. The deep nodes are found under this fascia in the femoral triangle. Medial Thigh Compartment The medial thigh compartment is one of three anatomic divisions of the thigh. The muscles of the medial thigh primarily function to adduct the thigh at the hip joint. The most anterior and lateral adductor muscle is the pectineus, which originates on the pectineal line of the pubis and inserts onto the femur. This muscle contrib- utes to the floor of the femoral triangle in the anterior thigh, and its primary function is hip flexion. As this muscle has a dual innervation as discussed below, it is considered a transitional muscle between the ante- rior thigh and medial thigh compartments. Medial to the pectineus muscle is the adductor longus muscle, which originates on the superior ramus of the pubis and inserts onto the femur. It forms the medial border of the femoral triangle. Its main action is to adduct and flex the thigh. The gracilis muscle forms the medial border of this region and is the most superficial muscle in the medial thigh. It originates on the body of the pubis and the upper half of the inferior pubic ramus and inserts onto the proximal and medial surface of the tibia. This muscle crosses both the hip and knee joints, and its main function is adduction of the thigh at the hip and flexion of the leg at the knee. Between the adductor

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