pelvic anatomy from a laparoscopic perspective:: the ... · pelvic anatomy from a laparoscopic...
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Pelvic Anatomy from a Laparoscopic
Perspective:: the abdominal wall &
retroperitoenum
•Tommaso Falcone
MD
•Professor &
Chairman
•Cleveland Clinic
Foundation
Disclosure
• No honoraria from Industry
• No research grants from industry
• Receive honoraria
- Editor-in-Chief of JMIG
- Section Editor- UpToDate
Learning Objectives
• Understand the causes of iatrogenic
injuries associated with laparoscopy
• Know how to diagnose and treat
laparoscopic complications
Left Upper Quadrant Insertion
• 2-cm below the subcostal margin mid-
clavicular line
• Organs
- Aorta-11 cm
- Spleen-12cm
- Stomach-4.4cm
- Liver-4.0cm
- Left kidney 13.2cm
Pelvic Sidewall: ureter
• Pelvic brim
- over the common or external iliac
- under ovarian vessels
• Courses anterior to the internal iliac
- UNDER THE OVARY
- 1.5 -2 CM LATERAL UTERO-SACRAL
LIGAMENTS
• Cervix
- WITHIN 2CM
Pelvic Sidewall: Blood
vessels
• Internal iliac artery
- anterior & posterior division (trunks)
- Umbilical artery
• obliterated
• medial umbilical ligament
• relationship to the uterine artery
Retropubic Space
•Anterior
- Pubic bone
•Lateral
- Obturator internus
muscle, fasciae,
neurovascular
bundle
•Posteriorly
- bladder &
pubocervical
fasciae
Pelvic Diaphragm
• Sheet of muscle (Levator ani &
coccygeus) covered on both sides by
fasciae
• From pubis to coccyx & is attached to the
lateral pelvic wall by a thickened band of
obturator fascia called arcus tendineus m.
levator ani
• Anogenital hiatus
Pelvic Diaphragm:Muscle
• Levator Ani
- Pubococcygeus (Puborectalis & pubovaginalis)
- Iliococcygeus
• Iliococcygeus portion that arises from the obturator internus muscle (arcus tendineus m. levator ani) & ischial spine
• Arcus: spine of the ischium forward & upward.
Pelvic Diaphragm: Fasciae • Parietal fasciae on the muscles
• Endopelvic fasciae on the pelvic viscera
- Attached to the parietal fasciae laterally
- Connective tissue attachments stabilize
the vagina
- Attachment along a line of thickened
parietal fasciae called Arcus tendineus
fasciae pelvis or white line
- Mid-vagina is supported by lateral
connections to the white line