Handa 9781496386441 Full Sample Chap 1

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SECTION I  Preparing for Surgery

Ischial spine

Rectum

I

Cervix

Obturator internus m

Parametrium

Arcus tendineus levator ani (ATLA)

Paracolpium

Arcus tendineus fasciae pelvis (ATFP)

Levator ani

Vesical neck

Mid-vagina

Anterior vaginal wall and paracolpium attachments to ATFP

Level II

Mid-vagina (cut)

ATFP

Paracolpium

Rectum

FIGURE 1.28  A: Suspensory ligaments of the female genital tract as seen with the bladder removed. B: Close-up of the lower portion of the midvagina (level II) shows the lateral connective tissue attachments of the midvagina to the tendi- nous arch or the pelvic fascia. The cephalic sur- faces of the transected distal urethra and vagina (level III) are shown.

Posterior vaginal wall and paracolpium

Distal vagina (cut)

attachments to pelvic sidewalls

Level III

Distal urethra

Perineal body

Levator ani

layer has an abundance of connective tissue interspersed between the smooth muscle. Laterally, the mesenteric structures of the cardinal and uterosacral ligaments con- nect the vagina (and uterus) to the muscles and connec- tive tissues that cover the lateral walls of the pelvis. The cardinal and uterosacral ligaments suspend these struc- tures within the pelvis by their downward extension on the lateral margins of the genital tract (see FIG. 1.28 ). The anterior vaginal compartment includes the ante- rior vaginal wall and its connective tissue (endopelvic fas- cia) attachments to pelvic sidewall at the tendinous arch of the pelvic fascia. Between the vagina and bladder is the vesicovaginal space and between the cervix and blad- der is the vesicocervical space. These spaces are separated only by the attachment of the anterior vaginal wall to the cervix and by some augmented bands of connective tis- sue that attach the lower pole of the bladder to the ante- rior cervix and are often referred to as the supravaginal septum. Precise understanding of this surgical anatomy is crucial for safe and proficient performance of anterior colpotomy during vaginal hysterectomy. A median dis- section distance of approximately 3.4 cm is found from initial incision at the cervicovaginal junction to the ante- rior peritoneal reflection when performing anterior col- potomy for vaginal hysterectomy.

The posterior vaginal compartment is unique in its tissue composition and anatomic relationships to the adjacent anal sphincter complex, rectum, and rectouter- ine pouch (see FIG. 1.29 ). Loss of support of the pos- terior vaginal compartment can manifest as rectocele,

Perineal membrane

Ischiopubic ramus

Perineal body

Copyright © 2019 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

FIGURE 1.29  The peripheral attachments of the perineal mem- brane to the ischiopubic rami and direction of tension on fibers uniting through the perineal body.

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