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Gyn

1. Retroperitoneal Anatomy
Anatomical & Surgical importance
What Gynecologist need to know
BY
Dr. Hosam Al-Azazy
Lecturer of Obstetrics & Gynecology
Faculty of Medicine-Alazhar University

2. Retroperitoneum
1.Topographicretroperitonealanatomy
Theposteriorabdominalwallistheposteriorboundaryoftheabdominalcavity,whichis
thecontinuouspartofposteriorthoracicwallfromthelevelofdiaphragmcraniallyand
posteriorpelvicwallcaudally.Thelumbarvertebra,pelvicgirdle,posteriorabdominalwall
muscles[musculus(m)quadratuslumborum,m.psoasmajor,m.psoasminor,m.iliacus,
andmusclesofdiaphragm]andtheirfasciaarethemembersofthisregion.
Theretroperitoneumisapartoftheabdominalcavity;surroundedanteriorlybythe
parietalperitoneumandposteriorlybythetransversalisfascia(Figure1)(1).Itisawide
areafromthepelvistothediaphragmandcontainsnumerousorgansandstructures;
structuresbehindtheperitoneumarecalled‘retroperitoneal’(Figure2)(2).Theprimary
retroperitonealorgansaretheadrenalglands,kidneys,ureter,theabdominalaorta,inferior
venacavaandtheirbranches.Thesecondaryretroperitonealorgans,whichwereinitially
intraperitonealandbecameretroperitonealstructuresduringembryologicdevelopment
duetotheregressionofperitonealissuelyingontheposteriorwalloftheabdominalcavity
(themesenteryofthesestructuresfusewiththeposteriorabdominalwall),arethe
ascendinganddescendingcolon,duodenumexceptthebulbuspart(firsthalfofduodenum
segment1)andpancreas.

3. Figure 1. Transverse section of the anterior abdominal
wall; the extraperitoneal fascia with fatty tissue under the
parietal peritoneum lies on the posterior abdominal wall
called the retroperitoneum (Gray’s Anatomy for tudents,
3rd Edition, Churchill Livingstone/Elsevier, 2015)

4. Figure 2. Pelvic viscera and retroperitoneum
(Atlas of Human Anatomy, 6th Edition,
Saunders/Elsevier, 2014) surface and cutting
it either with scissors or energy devices is an
easy and safe way of opening the
retroperitoneum (Figure 4).

5. Clinicaltip:Howtoentertheretroperitonealarea?
Whenthereisadistortedanatomyofperitonealstructures,toachieveanormalanatomy
andresectallpathologiclesions,thesurgeonneedstogainaccesstotheretroperitoneum,
whichismainlysafeandthatleadstoacomprehensivedissectionandvisualizationofthe
relevantanatomy.
Theperitonealreflectionbetweentheroundligament[ligamentum(lig)teresuteri](lateral)
andinfundibulopelvicligament(medial)isaneasywaytoentertheretroperitoneum
(Figure3).Gentletractiononthelateralparietalperitonealsurfaceandcuttingiteither
withscissorsorenergydevicesisaneasyandsafewayofopeningtheretroperitoneum
(figure4).

6. Figure 3. Demonstration to enter the retroperitoneum between the round
ligament and infundibulopelvic ligament (lateral parietal peritoneum), right
pelvic side wall (cadaveric dissection)

7. Figure 4. Demonstration of opening retroperitoneum, right pelvic side wall (cadaveric dissection) 2 cm
below the level of the left renal vein. On the left side, it goes over the psoas major muscle and enters
the pelvic cavity by crossing the common iliac artery. On the right side, first

8. 2.Pelvicretroperitonealvasculature
A.Arteries
Abdominalaorta
Thethoracicaortaiscalledtheabdominalaortabecauseitenterstheabdominalcavitythrough
thediaphragmanditliesattheposteriorabdominalwall,anteriortothevertebralcolumn.The
abdominalaortaisdividedintotherightandleftcommoniliacarteriesattheleveloftheL4-L5
vertebra,andthecommoniliacarteryisdividedintotwopartsastheexternalandinternaliliac
arteryatthepelvicbrim.Theovarianartery,mediansacralartery,externaliliacartery,internal
iliacarteryanditsbranchesareimportantstructuresofpelvicretroperitonealvasculature
(Figure5).
Ovarianartery:Thisislocatedontheanterolateralsurfaceoftheabdominalaorta,atthe
leveloftheL2vertebra,generally2cmbelowtheleveloftheleftrenalvein.Ontheleftside,it
goesoverthepsoasmajormuscleandentersthepelviccavitybycrossingthecommoniliac
artery.Ontherightside,firstitcrossesovertheanteriorsurfaceofinferiorvenacavathengoes
downwardbesidetheascendingcolon1cmabovetherightureterandentersthepelviccavityby
crossingoverthecommoniliacarteryorsometimestheexternaliliacartery.

9. Mediansacralartery:Thisisthecontinuationoftheabdominalaortaonthe
anteriorsurfaceofthesacrumandcoccyx.Itiscrossedbytheleftcommoniliac
veinandcareshouldbetakenduringhysteropexyandcolpopexyoperations.
Commoniliacartery:Thecommoniliacarterydividesintotheexternaland
internaliliacartery.Itisthepointwherepolarrenalarteriesmostlyarise
(Figure6);meticulousdissectionisimportantduringsurgicalprocedures
regardingthisfield(3).
Externaliliacartery:Thisgoesalongthemedialborderofthepsoasmuscleto
theleveloffemoralring,whichisbelowtheinguinalligament.The
genitofemoralnerveisfoundonthelateralborderoftheexternaliliacartery
(lateralborderofpelviclymphadenectomy)(Figure7).Itistheprincipalartery
ofthelowerlimb.Itsbranchesarethedeepcircumflexfemoralarteryandthe
inferiorepigastricartery.

10. Internaliliacartery:Thisrunsinfero-mediallyafterthepelvic
brimandisthemajorvascularsupplyofthepelviccavity.Ithas
twotrunks;posteriorandanterior(4).Thebranchesofthe
posteriortrunkarethesuperiorglutealartery,lateralsacral
artery,andiliolumbarartery.Thebranchesoftheanteriortrunk
aretheumbilical,uterine,superiorandinferiorvesical,vaginal,
obturator,middlerectal,internalpudendalandinferiorgluteal
artery(Figure7).
Clinicaltip:InternaliliacarteryandperipartumbleedingDuring
intractablepelvichemorrhageorperipartumbleeding,ligationof
theanteriortrunkoftheinternaliliacarterybilaterallywill
decreasetheamountofbleedingdramaticallybecausetheinternal
iliacarteryisthemajorvascularsupplyofthepelviccavity.

11. Umbilicalartery:Thisistheendarteryoftheinternaliliac
artery(anteriortrunk).Itgoeslongitudinallytothe
abdominalwallandbecomesthemedialumbilicalligament.
Whentractionisappliedtotheumbilicalarteryduring
laparoscopicprocedures,itwillindicatetheoriginofthe
uterineartery.Uterineartery:Theuterinearteryarises
fromtheanteriortrunkandgoesmediallythroughthe
broadligament(lig.latumuteri)[withinthecardinal
ligament(lig.Transversumcervicis)]towardstheisthmic
portionoftheuterustosupplytheuterusandcervix(Figure
7).Itcrossestheureterclosetotheuterus.

12. Figure 5. Paraaortic region, aorta and inferior vena cava after paraaortic
lymphadenectomy (surgical archieve)

13. Figure 6. Polar renal artery arising from the right common iliac artery and
also abdominal aorta (surgical archive)

14. Figure 7. Uterine artery, right pelvic side wall (surgical archive)

15. B.Veins
Inferiorvenacava
Theinferiorvenacava(IVC)beginsjustinferiortotheL5vertebra,
wheretheabdominalaortahasabifurcationofcommoniliacarteries.
Undertheleveloftheumbilicus,itisslightlyattheposteriorplaneofthe
abdominalaorta.Itascendsovertherightpsoasmajormuscle,rightto
theaorta,andabovethelevelofumbilicusitgetsclosertotheanterior
lineoftheabdominalaorta(Figure5).
Clinicaltip:Renalveinandovarianvein
Theleftrenalveincrossesovertheabdominalaortabelowtheoriginof
thesuperiormesentericarteryanddrainsintothevenacavainferior.It
receivesbloodfromtheleftovarianandadrenalveinsandascending
lumbarvein.Ontherightside,theovarianveinentersdirectlyintothe
IVC.

16. Externaliliacvein:Thisisthecontinuationofthefemoralvein
abovetheinguinalligamentandrunsontheposteriorsideofthe
externaliliacartery.
Pubicvein:Thisisavascularconnectionbetweentheexternal
iliac/inferiorepigastricandobturatorvein,andhemorrhageofthis
veiniscalledcoronamortis.Itisontheposteriorpartofpubicbone
overtheobturatorfossa(Figure8).Thisareaisdissectedduring
pelviclymphadenectomyingynecologiconcologypractice,andthe
surgeonshouldbecarefultopreventhemorrhagefromthisvenous
connection(5).
Internaliliacvein:Correspondingbranchesoftheinternaliliac
arterygenerallyrunwiththeirveins.Therearenumerous
anomalousandcollateralveinsthatdrainintotheinternaliliacvein.

17. Commoniliacvein:Thisstartsfromtheconjunctionpointof
theinternalandexternaliliacveinsandformstheinferiorvena
cavawithitscounterpart.
Figure 8. Pubic vein, left pelvic
side wall (surgical archive)

18. Clinicaltip:Promontorium:Itisattheupperpartofpelvic
cavityonthemedialsideofsigmoidcolon.Transparietal
fixationoftheperisigmoidandperirectalfattytissueorfixation
ofthesigmoidcolonbyappendixepiploicasaftermobilization
mayprovideadequateexposureofthisfield.Themediansacral
arteryandleftcommoniliacveinarejustsuperiortothe
promontoriumandtheinternaliliacarterywiththeureterare
incloseconnectionatthelateralpart

19. Clinicaltip:Leftcommoniliacvein:Itisapotential
dangerpointduringdissectionofthefieldofthe
promontorium,whichliesonthemedialpartoftheleft
commoniliacartery(Figure9).Duringlaparoscopic
surgery,obesityandbadtrocarangleswillincreasethe
likelihoodofaninjurytotheleftcommoniliacvein.

20. Figure 9. Left and right common iliac veins and arteries (surgical archive)

21. 3.Ureter
Theureterisamuscularstructure,functioninginthetransportof
urinefromthekidneytothebladder.Itisabout23-30cminlength.
Therenalpelvisnarrowsasitpassesthroughthehilumofthekidney
andformstheureter,whichcontinuesinferiorly.Aftercrossingthe
bifurcationofthecommoniliacarteriesortheoriginoftheexternal
iliacarteryoverthepelvicbrim,itgoesonthemedialsideofthe
psoasmajormuscleandrunsalongtheposteriorleafofthebroad
ligamentbeforeenteringtheurinarybladder.Thedistalureteris
crossedbytheuterinearteryanterosuperiorly.Theendpartofthe
distalureterentersthebladderobliquelytothesmoothmusclewall
ofthebladder,providingasphincter-likeaction.

22. Thenarrowestpointsoftheureter:
Theureteropelvicjunction
Pelvicbrim,wheretheureterscrossthecommoniliacvessels
Theureterovesicaljunction,wheretheuretersenterthesmoothmusclewallof
thebladderAnatomically,theureterisdividedintoabdominal,pelvic,and
intravesicalparts.Theabdominalpartisonthemedialborderofthepsoas
musclefasciaoverthegenitofemoralnerve.Therightureterstartsfromthe
levelwheretheposteriorofthesecondpartofduodenumisfoundanddescends
withintheperitoneumoftheascendingcolonclosetotherightcolicandileocolic
artery,lateraltotherootofthesmallbowelmesenteryandinferiorvenacava
undertheovarianvessels.Afterwards,itpassesposteriortotheterminalileum
andcecum.Theleftureterdescendsonthelateralpartoftheabdominal
aortaoverthepsoasmusclefasciaandcrossedanteriorlybytheleftcolicartery
andovarianvessels.Duringthiscourseoftheleftureter,itliesparalleltothe
inferiormesentericvein(Figure10)andpassesalongtheposteriorofthe
sigmoidcolon.Theureterscrossthebifurcationofthecommoniliacarteryover
thepelvicbrim.

23. Whentheureterentersthetruepelvis,itrunsinferiortothe
ovarianvessels,andgoesthroughthatpathtothebladderon
theposteriorleafofthebroadligament.Itgoesanteromedially
whilecrossingtheuterineartery(waterunderthebridge)
afterwards,itenterstheureterictunnel(webtunnel)withinthe
cardinalligament.Theureterpasseslateraltotheantero-lateral
vaginalfornixwithinthebladderpillarandentersthetrigoneof
thebladder.Theorificesoftheuretersareseenonthepostero-
lateralpartofthetrigone.Theureterstakea1.5-2cmcoursein
thebladderwall.

24. Theureterdoesnothaveaprimaryarterialvesselforblood
supply,itreceivesarterialbranchesfromtherenal,ovarian,
commoniliac,internaliliac,uterine,superiorgluteal,vaginal,
middlerectal,inferiorandsuperiorvesicalarteriesthroughits
pathwayfromtherenalpelvistothebladder(Figure11)(6).
Thesebloodvesselsanastomosewitheachotherandshapea
continuouslongitudinalbloodsupply.Theuretersareveryrich
ininnervationandtheyshapetheuretericplexus.Theprimary
sensationoftheureter(visceralafferentfibers)isprovidedby
nervesfromT12-L2(sympatheticsystem).Visceralefferent
fiberscomefrombothsympatheticandparasympathetic
bundles.

25. Figure 10. Right ureter below the right ovarian vein medial to the ascending colon and lateral to inferior vena
cava, and left ureter underneath the mesentery of descending colon, medial/ parallel to the inferior mesenteric vein
and lateral to aorta/ superior hypogastric plexus (surgical archive)

26. Figure 11. Vascularization of ureter from the kidney to the bladder (left side), while dissecting the
ureter traction should be applied towards the side of blood vessels (Moore Clinically Oriented
Anatomy, 7th Edition, Wolters Kluwer/Lippincott Williams & Wilkins, 2013) (6

27. Clinicaltip:Vascularizationofureter
Injurytothelongitudinalbloodvesselsoftheureter
maycauseischemiaornecrosisontheadventitiaof
ureter.Iftheadventitiaoftheureterisnotstrippedor
thefattytissueoverit(mesoureterinclinicalterm)has
notbeensacrificed,thesurgicalmobilisationofthe
uretercouldeasilybeperformedwhileavoidinginjuries.
Internaliliacarteryisthemostimportantvascular
supplyofureterinthepelvis(Figure12).

28. Figure 12. Vascular branch to ureter from internal iliac artery, right pelvic side wall, in the
pelvis the most important vascular supply of the ureter is the branch from the internal iliac
artery (surgical archive)

29. Clinicaltip:Ureterinjuries
Duringinfundibulopelvic(IP)ligamentligation,wheretheureterpasses
inferiortoit,especiallywhentheanatomyisdistortedbecauseoftumors,
massesorsevereadhesions,theIPligamentshouldbeisolatedandthe
uretermustbedissectedtoavoidinjuries.
Theureter,whereitcrossesundertheuterinearteryabovethevaginal
artery,neartheisthmicpartoftheuterus,isasiteofinjuryduring
uterinearteryligationwhileperforminghysterectomy.Theureterstands
veryclosetothecervix,andtoavoidinjuries,theuterusmustbepulled
towardstheothersidecraniallytomaximizethedistancebetweenthe
ureterandthecervix.
Aftercrossingtheuterineartery,theureterpassesveryclosetothe
anterolateralpartofvaginaandduringcardinal-uterosacralligament
ligation,theureterwillbeinjured(Figure13).

30. Figure 13. Sites of ureter injury, left pelvic side wall: Zone I, during infundibulopelvic ligament
ligation just below the level of pelvic inlet; zone II, during uterine artery ligation (ureter crosses the
cardinal ligament-uterine artery complex); zone III, during vaginal excision (ureter is anterolateral to
the anterior vagina before entering the bladder-trigone) (cadaveric dissection)

31. 4.Avascularspacesinthepelvis
Pelvicconnectivetissuedividesthesubperitonealpelvicareaintodifferent
spaces.Thesespacesarefilledbyfattyorlooseareolarconnectivetissues,which
aregenerallyavascular.Thesepotentialspaceshavearoleinthefunctioningof
urinary,reproductive,andgastrointestinalsystems.Theyhaveacrucialrolein
themanagementofpelvicoperationsbecauseknowingthemexactlyallows
restorationofnormalanatomyandavoidsinjuryofpelvicvisceraand
structures.
Thesepelvicspacesareasfollows(Figure14)(7):
Retropubic(Retzius)space
Paravesicalspace
Presacral(Retrorectal)space
Pararectalspace
Vesicovaginal(Vesicouterine)space
Rectovaginalspace

32. Figure 14. Avascular spaces and supporting ligaments in the pelvis (Sobotta Atlas of Human
Anatomy, 15th Edition, Elsevier, Urban&Fischer. Copyright 2013/Gray’s Anatomy, The
Anatomical Basis of Clinical Practice, 41 th edition, Elsevier, 2016) (7)

33. Retropubic(Prevesical/Retzius)space
Thisisthepotentialextraperitonealspacebetweenthebladder
andthepubicbonethatgenerallycontainsfat.Itsboundaries
are(Figure15):
Anteriorly:Pubicsymphysis,
Posteriorly:Bladder,
Superiorly:Parietalperitoneum(anteriorabdominalwall),
Laterally:Arcustendinousfasciapelvisandischialspines.

34. Figure 15. Prevesical space and contents (cadaveric dissection)

35. Graspingthemedianumbilicalligament(Urachus)withdownward
tractionandcuttingitwillopenthespaceofRetzius.Thedorsalclitoral
neurovascularbundleisfoundatthemidline,andtheobturatornerve
bundleislocatedonthelateralplane.Anaccessoryobturatorarteryfrom
theexternaliliacarterythatrunsalongtheposteriorpartofpubicbone
orapubicveinfromtheexternaliliacveinoranarterialbranchfromthe
inferiorepigastricarterywillbedetectedatthelateralborderofthatfield
duringitspathtoobturatorforamen.Moreover,lateraltothebladder
neckandurethra,nervesinnervatingthebladderandurethraanda
venousplexus(Santoriniplexus),(whichcouldbeinjuredduringsuture
placementforBurchretropubiccolposuspension)arefound.

36. Clinicaltip:Burchcolposuspension
Thisisaretropubiccolposuspensionoperationforstressurinaryincontinenceinwhich
thesuturesstartingfromtheparavaginaltissueareanchoredtotheileopectineal
ligament(Cooper’sligament),thesuperiorborderoftheischiopubicramitomaintain
thetensiononbladderneckandurethra.
Paravesical(andparavaginal)space
ThisislocatedwithinthelateralpartoftheRetziusspaceanteriortothecardinal
ligament,bilaterally.Itsboundariesare(Figure16):
Superiorly:Lateralumbilicalfolds(peritonealthickeningofinferiorepigastricvessels),
Inferiorly:Pubocervicalfasciawhereitentersintothetendinousstructureoflevatoranimuscle,
iliococcygeusmuscle,
Anteriorly:Superiorpubicramus,arcuatelineoftheosilium,
Posteriorly:Endopelvicfascialsheaththatcoverstheinternaliliacarteryandvein,cardinal
ligamentwhichseparatesitfromtheanteriorpartofpararectalspaceanduterineartery,
Medially:Bladderpillars,
Laterally:Pelvicsidewall,obturatorinternusandlevatoranimuscle.
Lateraltothemedianumbilicalligament,afterdetectingthelateralborderofbladder,
themedialumbilicalligament(obliteratedumbilicalartery)canbeidentifiedandit
dividestheparavesicalspaceintotwoparts(medialandlateral).

37. Thelateralpartistheobturatorspace(undertheexternaliliacvessels)
andthemedialpartistheventralparametrium.Theobturatorspace
contains(Figure8)theobturatornerve,obturatorarteryandvein,and
fattyandlymphatictissue.Duringpelviclymphadenectomytodissectthe
obturatorlymphnodes,thesurgeonneedstoopentheparavesicalspace
firstthendissectthelateralpartonthepelvicsidewall.Overthe
obturatorfossa,therearenumerousanomalousandcollateralvessels,
whichneedtinyandcarefuldissectiontopreventhemorrhagedueto
injury(8).Paravesicalspacecontainsobliteratedumbilicalarteryanditis
incloserelationwithobturatorneurovascularbundleandexternaliliac
vesselswiththelymphaticandfattytissue(9).

38. Clinicaltip:Paravesicalspace
TheparavesicalspaceisgenerallyaccessedduringBurch
colposuspension,paravaginaldefectrepair,pelvic
lymphadenectomyandsomeendometriosisoperationsafter
openingtheretroperitonealspaceentirely.Radicalhysterectomy
isanothersurgicalprocedurethatneedsadequateexposureofthe
paravesicalspaceduringtheoperation.Afteropeningthe
retroperitonealspacebytransectingtheroundligamentand
cuttingtheanteriorleafofbroadligamentinfero-medially,the
placelateraltothemedianumbilicalligament(medialtoround
ligament),adjacenttothebladder,istheparavesicalspaceandit
developsinferiorlytotheleveloflevatoranimuscle

39. Figure 16. Paravesical space, right pelvic side wall (cadaveric dissection)

40. Presacral(retrorectal)space
Theretrorectalspaceisbetweentherectumandthesacralcoccygeal
partofspine.Thepresacralspaceisaretroperitonealarea,whichis
betweenthepresacralfasciaofthesacrum(Waldeyer’sfascia)and
parietalperitoneumoftheposteriorabdominalwall.Itsboundariesare
(Figure17):
Superiorly:Peritoneal(parietal)reflections,
Anteriorly:Distalportionofthesigmoidmesentery,posteriorrectal
fascia,rectum,
Posteriorly:Anteriorlongitudinalligament,sacralpromontoriumand
anteriorpartofthesacrum,
Inferiorly:Levatoraniandcoccygeusmuscle,
Laterally:Ureter,internaliliacvesselsandhypogastricnerves.

41. Thepresacralspacestartsfromtheparietalperitonealreflectionatthe
rectosigmoidjunctiontothepelvicbottom,whichcontainsfattytissue,lymph
nodes,nerveplexusesandbloodvessels,mediansacralvessels(theartery
isfromtheaorta)andsuperiorrectalvessels(thearteryisfromtheinferior
mesentericartery).
Figure 17. Presacral space
(cadaveric dissection)

42. Clinicaltip:Presacralspace
Theremaybesomeanatomicvariationsinthisfield;presacralanastomoses
betweenthelateralandmiddlesacralveinsneedcarefuldissectionduring
surgery.Moreover,itisveryclosetothehypogastricnervesandsympathetic
trunk.Belowtheleveloftheaorticbifurcation,theleftcommoniliacvein
crossesthesacralpromontoriumfromrighttoleft.Themediansacralartery
isdetectedatthemidlineorveryclosetothemidlineoverthesacrum,so
caremustbetakenduringsacrocolpopexyprocedureandparacoccygeal
procedures.Thesuperiorhypogastricplexusmayalsobeseenatthesuperior
partofthepresacralspaceoverthesacralpromontorium(Figure18).
Primarylesionsofthisareaarerare;however,lesionsfromadjacent
structuresmaybeseeninthisfield.Afterrectalorrectosigmoidresections,
thisfieldcouldbeaplaceforaccumulationoffluidleakages.

43. Figure 18. Presacral space and superior hypogastric plexus
(surgical archive)

44. Clinicaltip:Presacralhemorrhage
Aseriousbleedingmayhappenbecauseofinjuriesofthemiddlesacral
arteryorveinparticularlyduetoanastomoses.
Ifthevesselstructureisretractedintothesacralforamina,itwillbeharder
tocontrolthehemorrhage.Athumbtackcouldbeappliedifneeded.
Pararectalspace
Thepararectalspaceislocatedlateraltotherectumandretrorectalspace,
anditisattheposteriorpartofthecardinalligament.Itsboundariesare
(Figure19):
Anteriorly:Cardinalligament,
Medially:Rectalpillars,uterosacralligament,ureter,
Laterally:Internaliliacartery,
Posteriorly:Sacrum,
Caudally:Puborectalismuscle.

45. Itcontainsfattyandconnectivetissue,andtheureter
passesalongthepararectalspaceatthemedialpart.After
atinydissectionoftheureterwithinthepararectalspace,
theureterwilldivideitintotwoparts;medialis
Okabayashi’sspaceandlateralisLatzko’sspace(Figure
20).Itisseparatedfromtheparavesicalspacebythe
cardinalligament/uterinearteryandfromthepresacral
spacebytherectalsepta.

46. Figure 19. Pararectal space, right pelvic side wall (cadaveric
dissection)

47. Okabayashi’sspace
ThemedialpararectalspaceiscalledOkabayashi’sspaceanditis
betweentheureterandtherectouterineligament,whichisdeveloped
afteropeningtheposteriorleafofthebroadligament(Figure20).
Latzko’sspace
ThelateralpararectalspaceiscalledLatzko’sspaceanditisbetween
theureterandpelvicsidewall,whichisdevelopedafterdissectionof
internaliliacartery(Figure20).
Middlerectalarterycouldbeseenatthelateralrectalwallbytheway
thepelvicsplanchnicnervesandthefibersoftheinferiorhypogastric
plexus,whichliesunderthemiddlerectalartery,couldbepreserved.

48. Figure 20. Right pelvic side wall; the paravesical space, anterior to the cardinal ligament is divided
into two parts by the obliterated umbilical artery and the pararectal space, posterior to the cardinal
ligament is divided into two parts by the ureter, the lateral part is called Latzko’s space and the medial
part is called Okabayashi’s space (cadaveric dissection)

49. Clinicaltip:Pararectalspace
WhenthepouchofDouglas(rectovaginalspace)isobliteratedby
atumor,severeadhesionsorendometriosis,thesurgeonshould
primarilyopentheretroperitonealspace,findtheureter,andafter
ureterolysisthepararectalspaceshouldbedevelopedtodissect
therectumfromthevaginaandopentherectovaginalspace.
Duringradicalhysterectomy,thepararectalspaceshouldbe
developedtoexcisethecardinalligamententirely.Afterdissection
oftheposteriorleafofthebroadligamentposteromedially,the
pararectalspaceisdevelopedbetweentheureterandinternaliliac
arteryanteriortothesacrum

50. Vesicovaginal(Vesicouterine)space
Thevesicovaginal,vesicocervical,andvesicouterine
spacesareallatthesamelongitudinalaxisandthisarea
isalsoknownastheanteriorcul-de-sac.Theboundaries
ofthevesicocervicalspaceare(Figure21):

51. Theboundariesofthevesicovaginalspace:
Anteriorly:Trigoneofbladder,
Posteriorly:Vagina,
Laterally:Bladderpillars,pubocervicalligament,
Inferiorly:Urogenitaldiaphragm.
Aftercuttingthevesicouterinepouch(betweenthedomeofthe
bladderandtheanteriorpartoftheuterus)andwithposterior
tractionofuterustowardsthepromontorium,thisfieldcanbe
openedeasily.Thelateralbladderpillarscontainbloodvessels,
vesicalveins(inferior,superior),cervicalterminalbranchesfromthe
uterineartery,andconnectivetissuefromthecardinalligament.

52. Clinicaltip:Vesicovaginalspace
Duringradicalhysterectomybeforeexcisingtheanterior
parametrium,thebladdershouldbedissectedtothelevel
ofthetrigone,afterwardstheuretershouldbedissected
fromtheparametrium.Moreover,vesicovaginalspace
dissectionshouldbeperformedmediallyatthemidline
withinthelooseareolartissuebecauselateralextensions
duringdissectioncouldcausebleedingfromthebladder
pillars(vesicalveins).

53. Figure 21. Vesicovaginal space (cadaveric dissection)

54. Rectovaginalspace
Therectovaginalspaceisfromtherecto-uterineperitonealfold
(pouchofDouglas)totheleveloftheperinealbody.
Accesstothisareacanbemaintainedbycuttingtherectouterine
peritonealstructurebetweentheinsertionsoftheuterosacral
ligament,whichliebilaterally.Itsboundariesare(Figure22):
Anteriorly:Posteriorwallofthevagina,
Posteriorly:Anteriorwalloftherectum,
Laterally:Uterosacralligament,rectalpillars.

55. Clinicaltip:Rectovaginalspace
Therecto-uterine,recto-vaginalpouchwillbeenclosedbysevere
adhesionsduetoendometriosis,tumororabscess.
Dissectionofthevaginafromtherectumanduterosacral
ligamentsafterdevelopingthepararectalspacecanmaintainan
extrafieldforsurgery.Thelooseareolartissuebetweenthe
rectumandvaginacanbebluntlydissectedeasily;however,the
fattytissueinthisareabelongstotherectum.Therectalpillars
arefibro-connectivetissues,whicharevascularizedbythemiddle
rectalarteriesfromtheinternaliliacarteryoverthecardinal
ligament(11)

56. Figure 22. Rectovaginal space (cadaveric dissection)

57. Clinicaltip:Cervicalfiroids
Boththevesicouterineandrectouterinepouch(anterior
andposteriorcul-de-sac)shouldbecut,thebladder
shouldbedissecteddownwardtothelevelofanterior
vagina,andtheuretermustbeidentifiedbilaterally.In
particular,lateraltotherectovaginalspace,theureteris
incloseproximitytotheuterosacralligaments(atthe
lateralpartofuterosacralligaments)andmeticulous
dissectionshouldbeappliedwithregardtothevascular
connectionsanddepthofacervicalmass(12).

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