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SECTION I  Preparing for Surgery

and uterosacral ligament pedicles are made during a hysterectomy for benign disease and within the tissue removed during a radical hysterectomy. The sensory fibers from the uterine body in the supe- rior hypogastric plexus (the presacral nerve) have some- times been surgically transected in an effort to alleviate refractory visceral pain from the corpus, a procedure called presacral neurectomy. As the superior hypogas- tric plexus does not provide sensory innervation to the adnexal structures or to the peritoneum, this procedure is therefore not useful for alleviating pain arising from those sites. Another important anatomic aspect of the autonomic nervous system is damage to the inferior hypogastric plexus at the time of radical hysterectomy. The extension of the surgical field lateral to the viscera interrupts the connection of the bladder and sometimes the rectum to their central attachments. The ovary and uterine tube receive their neural supply from the plexus of nerves that accompany the ovarian vessels and that originate in the renal plexus and partly from the inferior hypogastric plexus. These fibers originate from the 10th thoracic segment, and

the parasympathetic fibers come from extensions of the vagus nerve. Pelvic Retroperitoneal Space Division of the internal and external iliac vessels occurs in the area of the sacroiliac joint. The course and branches of the external iliac vessels were discussed ear- lier under the retropubic space. Internal Iliac Vessels Unlike the external iliac artery, which is constant and relatively simple in its morphology as discussed earlier, the branching pattern of the internal iliac arteries and veins is extremely variable ( FIGS. 1.11 and 1.36 ). The internal iliac artery supplies the viscera of the pelvis and many muscles of the pelvic wall and gluteal region. It usually divides into an anterior and posterior division about 3 to 4 cm after leaving the common iliac artery ( TABLE 1.3 ). The vessels of the posterior division (the iliolumbar, lateral sacral, and superior gluteal) leave the internal iliac artery from its posterolateral surface to provide some of the blood supply to the pelvic wall and

I

Middle sacral

Internal iliac

Superior rectal

Middle rectal

Pudendal

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FIGURE 1.36  Collateral circulation of the pelvis.

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