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CHAPTER 1  Surgical Anatomy of the Female Pelvis

and vessels as they enter the obturator canal. Vascular connections between the external and internal iliac systems that pass over the superior pubic rami are commonly present. These are called pubic vessels or accessory obturator branches. The most common con- nections are venous and found between the inferior epi- gastrics and obturator veins, but these vessels may arise directly from the external iliac. Therefore, dissection in this area should be performed with care. Lateral to the bladder and vesical neck is a dense plexus of vessels called the vesical venous plexus that lie at the border of the lower urinary tract. It includes 2 to 5 rows of veins that course within the paravaginal tissue parallel to the bladder and drain into the internal iliac veins. The dorsal veins of the clitoris drain into the vesical venous plexus. These veins course within paravaginal/paravesical tissue, and although they bleed when sutures are placed here, this venous ooze usually stops when the sutures are tied. Also within this tissue, lateral to the bladder and urethra, lie the nerves of the lower urinary tract. The upper bor- der of the pubic bones that form the anterior surface of retropubic space has a ridgelike fold of periosteum called the pectineal line. This is used to anchor sutures during operations for stress incontinence (Burch procedure). Vesicovaginal and Vesicocervical Space The space between the lower urinary tract and the geni- tal tract is separated into the vesicovaginal and vesico- cervical spaces (see FIG. 1.27 ). The lower extent of the space is the junction of the proximal one third and distal two thirds of the urethra, where the urethra and vagina are fused. This space extends superiorly to lie under the

peritoneum at the vesicocervical peritoneal reflection. It extends laterally to the pelvic side walls, separating the vesical and genital aspects of the cardinal ligaments. Rectovaginal Space On the dorsal surface of the vagina lies the rectovagi- nal space (see FIG. 1.27 ). It begins at the apex of the perineal body, about 2 to 3 cm above the hymenal ring. It extends upward to the cul-de-sac and laterally around the sides of the rectum to the attachment of the rectovaginal fascia (septum) to the parietal endopel- vic fascia. It contains loose areolar tissue and is easily opened with finger dissection. At the level of the cervix, some fibers of the cardinal– uterosacral ligament complex extend downward behind the vagina, connecting the vagina to the lateral walls of the rectum and then to the sacrum. These are called the rectal pillars. They separate the midline rectovaginal space in this region from the lateral pararectal spaces. These pararectal spaces allow access to the sacrospi- nous ligament (mentioned later). They also form the lateral boundaries of the retrorectal space between the rectum and sacrum. Region of the Sacrospinous Ligament and Greater Sciatic Foramen The area around the sacrospinous ligament is another region that has become more important to the gynecologist operating for problems of vaginal support. The sacrospinous ligament lies on the dorsal aspect of the ischiococcygeus (coccygeus) muscle ( FIG. 1.32 ). The

I

Inferior epigastric a.

Umbilical a.

Accessory obturator a.

Inguinal lig.

Superior vesical a.

Obturator a.

Obturator n.

Pubic symphysis

Uterine a.

External iliac a.

Internal iliac a.

Superior gluteal a.

Middle sacral a. and v.

Internal pudendal a. Copyright © 2019 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. Bladder

Ureter (cut)

Inferior gluteal a.

Vagina

Piriformis m.

Rectum

Coccygeus m.

Middle rectal a.

Levator ani m.

FIGURE 1.32  Structures of the pelvic wall.

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