Surgical anatomy or anatomical surgery

the key to a successful and confident surgeon is a clear and unshaken knowledge of anatomy of the pelvis.

1. SURGICAL ANATOMY or
ANATOMICAL SURGERY
Dr. Yamal Patel
Consultant OBGYN
VICE CHAIR, KESES
Nairobi

2. WHY
master
Anatomy?
More efficient → faster surgery
More effective → better results
•↓
More confident → SAFER surgery
Minimize COMPLICATIONS

3. LEARNING OBJECTIVES
Recognize key topography of the pelvis
Describe key structures of the anterior abd wall
Explain the vascular anatomy of the side wall
Discuss surgical strategies to minimize risks to vital structures
Review techniques to safely dissect the pelvis ureter and
retroperitoneal vasculature.

4. Anatomical surgery
•Application of anatomy to assist with
surgery
Accurate anatomical knowledge
Means
Sound surgical technique

5. Laparoscopic
anatomy is
different
•Altered due to effects of
pneumoperitoneum
•Altered due to trendelenburg
•Altered due to traction by uterine
manipulator
•Structures superior on the monitor
are actually anterior and those
inferior are posterior

7. Topographic
anatomy
Umbilicus –L3/L4 level
•Varies with patient weight, height,
presence of panniculus, position on
table etc
Aorta bifurcates L4/L5 in 80%
Ant superior iliac spines
Palmers point

8. Superficial intraperitoneal anatomy
•Ant wall peritoneum
•Raised at 5 sites ( 5 umbilical folds)
•MEDIAN –dome of bladder to umbilicus covering the obliterated
urachus
•Two MEDIAL –overlying the obliterated umbilical arteries
•Two LATERAL –overlying inferior epigastric vessels
[ important landmark for secondary entry]

12. •Posterior wall anatomy
•Uterosacral folds –covering the uterosacral lig
•Ureteric folds –lateral and superior to the above
•IIA –parallel and just posterior to ureter
•EIA –many cm anterior to it on the psoas
•Ureter –Rt crosses EIA
-Lt crosses CIA
•Rt CIA easy to follow up
•Lt CIA difficult to see due to mesentery of sigmoid.

13. PELVIC BRIM
Crossing over
•Ovarian Vessels in IP lig
•Ureter
•Bifurcation of CIA
•CIV –Lt is in the pre sacral space
Deeper
•Medial edge of psoas muscle
•Obturator nerve
•Capsule of sacroiliac joint
•Lumbosacral trunk –medial to
obturator n.

15. CONCERNS IN
SURGERY
•What are the anatomic structures in the
field of dissection?
Intraperitoneal / Retroperitoneal
Important
•How to safely identify and safeguard
these structures in the field of dissection
Very Important

17. SPACES
Pararectal
Paravaginal
Paravesical
Prevesical (Cave of retzius)
POD

19. PARARECTAL
•Only one structure crosses this
space transversely -Uterine A.
•Ureter is always lateral to
uterosacrals
(If you remain medial to
uterosacrals
the ureter cannot be injured.)
•It continues anteriorly into
paravesicalwhich continues as
prevesicalspace.

22. POD
Lies between the
uterosacrals.
During dissection “fat
belongs to rectum”
Two layers of
denonvilliers fascia –with
fat between the layers.

24. PREVESICAL
SPACE
Lies between the
two obliterated
umbilical arteries.
“Fat belongs to
bladder”

27. UTERINE
VESSELS
Uterine A. goes anterior to ureter.
•Uterine veins –deep and superficial
•(Dissection of paravesical space is parallel to
uterine artery and deep till levator ani)
Uterine vein goes posterior to ureter.

28. 11

30. LYMPHATICS
•Follow the veins.
•Dissection to be carried out parallel to
the vessels.
•Cervix –ilio-obturator nodes
•Uterus –para-aortic
•Ovaries –para-aortic
•Vagina –lower third inguinal nodes

31. URETERIC TUNNEL
(vesico uterine lig)
•Condensation of pelvic fascia.
•Is vascular.
•Strands of endopelvic fascia fix
the ureter to upper third of the
vagina.
(For radical type III hysterectomy
lateralize the ureter from the
vagina)
•There is always a vein in the root
of ureteric tunnel.
•Uterine branch to the ureter at
this level need to be cut.
•Lateralizing the ureter at the
tunnel helps develop the
paracolpos.

32. NERVES
•Obturator
•Genitofemoral
•Pelvic splanchnic –nervi erigentes
•Pelvic hypogastric nerve.
•Inferior hypogastric plexus (Van franken hauser
plexus)
(Hypogastric nerve lies between uterosacral lig and
the ureter)

33. NERVES
Hypogastric nerve carries sympathetic
fibers
Further down
Mixes with S2/3 to form in inferior
hypogastric plexus
(The key to identify this is the deep uterine
Vein)
(Stay medial to the hypogastric nerve to
cut the veins-nerve sparing surgery)

35. NERVES
OBTURATOR –LIE
BETWEEN IIA AND EIA
GENITOFEMORAL –LIE ON
PSOAS MUSCLE

37. VASCULAR PELVIC ANATOMY
IIA
Ant
4 Visceral
4 Parietal
Post 3
Uterine, sup vesical, middle
rectal, vaginal
Obturator, intpudendal, inf
gluteal, umbilical
Iliolumbar, latsacral, superior
gluteal

39. Important
vascular
anatomy
1
st
br of IIA ant trunk –uterine (6cm
from start of ant trunk origin)
EIA/EIV –no branch in pelvis
Last br of IIA –sup vesical –
continues as obliterated umb a
Ureter lies in the fork between ut a.
& v.
Uterine v. is guide to autonomic
plexus

42. VITAL RISK
AREA –to
life
EI vessels at level of
IP lig
Post trunk of IIA
Inferior mesenteric A

44. URETERS
•Longest structure in the abdomen
•Enter pelvis at the pelvic brim
Rt ureter crosses the Rt EIA
Lt ureter crosses the Lt CIA
•Stays medial to IIA ant trunk
•3 major areas of risk of injury
•Near IP ligament at pelvic brim
•Where uterine A crosses over it
•Near uterosacralsas it enters
the ureteric tunnel

45. URETERS
•Poor vascularization of ureter
•Thus risk of ischemic injury
•4 arteries
•Vessels arborize thru the adventitia
Do not strip the adventitia even for 1 cm
See peristalsis thru the adventitia

46. Dissection of ureter
•Necessary for every advanced laparoscopy
surgery
•Medial approach usually in
endometriosis
•Lateral approach usually in oncology