Layers of the Abdomen

- Skin
- Superficial fascia + subcutaneous fat
- Campers Fascia (contains most of the fat)
- Scarpas Fascia (deep fascia)
- Muscle
o Rectus abdominis
o External oblique
o Internal oblique
o Transverse abdominal
- Fascia transversalis
- Peritoneum


Hesselbachs triangle is defined laterally by the inferior epigastric artery, medially by the rectus abdominis muscle,
and inferiorly by the inguinal ligament.
Abdominal Landmarks for Laparoscopy
Laparoscopic trocars are most commonly placed at the umbilicus, suprapubically and laterally.
Umbilical trocar. The umbilical trocar should be placed at a 45-degree angle in thin women in order to avoid
hitting the aorta or common iliacs. In an obese patient, the trocar can be placed at a more perpendicular
angle due to the amount of adipose tissue that must be traversed.
Suprapubic trocar. The suprapubic trocar is placed two fingerbreadths above the pubic symphysis. It is
placed under direct visualization and after Foley insertion in order to assure that the bladder is not in line of
the trocar path.
Lateral trocars. The lateral trocars are placed at least 5 cm cephalad to the pubic symphysis and 8 cm lateral
to the midline in order to avoid the inferior epigastric vessels. The trocar is placed under direct visualization
lateral to the lateral umbilical folds.


Vagina.
The vagina is shaped like a flattened tube, starting at the distal hymenal ring and ending at the fornices surrounding
the proximal cervix. Its average length is 8 cm; however, this varies depending on the age, parity, and surgical
history.
The epithelial lining is nonkeratinized, stratified squamous epithelium lacking mucous glands and hair follicles.
Pelvic Attachments
The round ligament courses from the anterolateral aspect of the uterus through the inguinal canal to insert into the
labia majora. The utero-ovarian ligament contains the anastomotic vasculature of the uterine and ovarian vessels.
The cardinal ligaments (Mackenrodt's ligaments) extend from the lateral pelvic walls and insert into the lateral
portion of the vagina, uterine cervix, and isthmus. These play an important role in support of the pelvic organs.
The infundibulopelvic ligament (IP ligament, suspensory ligament of the ovary) contains the ovarian vessels. The
ovarian arteries branch directly off of the aorta. The right vein feeds into the inferior vena cava while the left vein
drains into the left renal veins.
The broad ligament is composed of the peritoneum that covers the uterus and fallopian tubes.
At the vaginal apex, this fibromuscular layer coalesces to create the cardinal and uterosacral ligaments. The fan-
shaped cardinal ligament creates a sheath that envelops the uterine artery and vein, fusing medially with the
paracervical ring. Together the cardinal and uterosacral ligaments pull the vagina horizontally toward the sacrum,
suspending it over the muscular levator plate.
The endopelvic fascia of the anterior and posterior vaginal wall are known as the pubocervical fascia and
rectovaginal fascia, respectively. Again, these layers are not true fasciae but composed of fibromuscular sheets.
Superiorly, the pubocervical fascia attaches to the cervix and the cardinal/uterosacral support of the vaginal apex.
Laterally, it coalesces with the fascia of the obturator internus muscle to create the arcus tendineus fascia pelvis
(ATFP) or white line. Inferiorly, it attaches to the pubic symphysis. The rectovaginal fascia in the upper vagina
coalesces with the lateral support of the anterior vaginal wall and fuses with the ATFP. The lower half of the
rectovaginal fascia fuses with the aponeurosis of the levator ani muscles.
There are three levels of support, as described by DeLancey (Fig 23-5).
Level I is the upper vertical axis or uterosacral/cardinal ligament complex. The uterosacral/cardinal ligament
complex supports the cervix and upper vagina to maintain vaginal length and to keep the upper vaginal axis
nearly horizontal so that it rests on the rectum and can be supported by the levator plate.
Level II is the horizontal axis or paravaginal supports. The pubocervical fascia and rectovaginal fascia spread
over the vagina and condense into the ATFP to support the midvagina and create the anterior lateral vaginal
sulci.
Level III is the lower vertical axis or perineal body, perineal membrane, and the superficial muscles
(bulbocavernosus, ischiocavernosus, superficial and deep transverse perineal muscles). This supports and
maintains the normal position of the distal one third of the vagina and introitus, which is nearly vertical in a
standing female.
Levels I, II, and III are connected through continuation of the endopelvic fascia.





Pelvic Floor
The pelvic floor comprises the perineal membrane and the muscles of the pelvic diaphragm. It helps support
the pelvic contents above the pelvic outlet.
The perineal membrane is a triangular sheet of dense fibromuscular tissue that spans the anterior triangle. It
provides support by attaching the urethra, vagina, and perineal body to the ischiopubic rami. The perineal
membrane contains the dorsal and deep nerves and vessels to the clitoris.
The muscles of the pelvic diaphragm comprise the levator ani and coccygeal muscles. These are covered by
the superior and inferior fascias (Fig. 23-9).
o Levator ani muscles
o The puborectalis arises from the inner surface of the pubic bones and inserts into the rectum. Some
fibers form a sling around the posterior aspect of the rectum.
o The pubococcygeus arises from the pubic bones and inserts into the anococcygeal raphe and
superior aspect of the coccyx.
o The iliococcygeus arises from the arcus tendineus levator ani and inserts into the anococcygeal
raphe and coccyx.
o The coccygeus muscle arises from the ischial spine and inserts into the coccyx and lowest area of the
sacrum. It lies cephalad to the sacrospinous ligament.


Vascular Supply
Ovarian artery divides into branches that supply the ovary and tube and then run on to reach the uterus,
where they anastamose with the terminal branches of the uterine artery.
Uterine artery provides main blood supply of the uterus. It supplies a branch to the ureter as it crosses it,
and shortly after another branch is given off to supply the cervix and upper vagina.
The vaginal artery is another branch of the internal iliac artery that runs at a lower level to supply the vagina.
The vesical arteries are variable in numbers. They supply the bladder and terminal ureter
The pudendal artery supplies the perineal unvulval structures, including the erectile tissue of the vestibular
bulbs and clitoris.
The branches of the femoral artery supplying the groin are:
o The superficial epigastric
o Superficial circumflex iliac
o Superficial external pudendal
o Deep external pudendal
The veins around the bladder, uterus, vagina and rectum form plexuses. Venous drainage from the uterine, vaginal
and vesical plexuses is chiefly into the internal iliac veins.
Venous drainage from the rectal plexus is via the superior rectal veins to the inferior mesenteric veins, and the
middle and inferior rectal veins to the internal pudendal veins to the iliac veins.
Pampiniform plexus ovarian veins R into IVC, L into L renal vein
NERVES OF THE PELVIS AND PERINEUM
Pelvic Diaphragm
The pudendal nerve supplies the external anal sphincter and the urethral sphincter.
The anterior branch of the ventral ramus of S3 and S4 innervates the levator ani and coccygeal muscles.
Perineum
The pudendal nerve is the sensory and motor nerve of the perineum.
o The pudendal nerve originates from the sacral plexus (S2-4), exits the pelvis through the greater
sciatic notch, hooks around the ischial spine and sacrospinous ligament, and enters the pudendal
canal (canal of Alcock) in the lesser sciatic notch. It has several terminal branches:
The clitoral nerve runs along the superficial aspect of the perineal membrane to supply the
clitoris.
The perineal nerve runs along the deep aspect of the perineal membrane. Its branches
supply the muscles of the superficial compartment, subcutaneum, and skin of the vestibule,
labia minora, and medial aspect of the labia majora.
The inferior hemorrhoidal nerve (inferior rectal) innervates the external anal sphincter and
the perianal skin.
Nerve Injuries in Gynaecologic Surgery
Nerve injuries are encountered from positioning, incisions, use of retractors, and dissection
TABLE 23-1 Nerve Injuries in Gynecologic Surgery
Nerve Injury Motor Loss Sensory Loss
Femoral L2-4 Deep retraction on psoas muscle,
excessive hip flexion
Hip flexion, knee extension,
knee DTR, leg adduction
Anteromedial thigh,
anteromedial leg and foot
Lateral femoral
cutaneous L2-3
Deep retraction on psoas muscle,
excessive hip flexion
None Anterolateral and
posterolateral thigh
Genitofemoral
branch L1-2
Pelvic sidewall dissection None Mons, labia majora,
anterior superior thigh
Obturator L2-4 Retroperitoneal surgery, lymph node
dissection, paravaginal defect repair
Leg abduction Anteromedial thigh
Sciatic L4-S3 Extensive endopelvic resection Hip extension, knee flexion Lateral calf, dorsomedial
foot

Common peroneal
L4-S2
Compression from stirrups on lateral
calf
Foot dorsiflexion and
eversion
Lateral calf, dorsomedial
foot

Tibial L4-S3 Compression from stirrups on lateral
calf
Foot plantar flexion and
inversion
Toes, plantar foot
Iliohypogastric T12 Transverse abdominal incision None Mons, labia, inner thigh
Ilioinguinal L1 Transverse abdominal incision None Groin, symphysis pubis

LYMPHATIC DRAINAGE OF THE PELVIS
The vulva and lower vagina drain to the inguinofemoral lymph nodes and then to the external iliac nodes.
The cervix drains through the cardinal ligaments to the pelvic nodes (hypogastric, obturator, and external
iliac) and then to the common iliac and para-aortic lymph nodes.
The uterus drains through the broad ligament and intraperitoneal ligament to the pelvic and para-aortic
lymph nodes.
The ovaries drain to the pelvic and para-aortic lymph nodes.
The bony pelvis
The pelvis is made up of three bones: the two innominate bones and the sacrum. When articulated they enclose a
cavity. The sacrum is wedged between the two innominate bones. Each innominate bone is made up of three parts:
ilium
ischium
pubis.
The innominate bones are joined anteriorly at the symphysis pubis.
Pelvic brim
The pelvic brim is formed by the pubic crest, the pectineal line of the pubis, the arcuate line of the ilium, the alae of
the sacrum, and the promontory of the sacrum. The brim separates the false pelvis above from the true pelvis
below. Inferiorly, it is separated from the perineum by the urogenital diaphragm. The plane of the pelvis is at an
angle of 55 to the horizontal. In the anatomical position, the pelvic cavity projects backward from the pelvic brim.
The upper border of the symphysis pubis, the ischial spines, the tip of the coccyx, the head of the femur, and the
greater trochanter lie in the same plane.
The female pelvis
The female pelvis differs from the male pelvis. The basic differences are:
The female pelvis is broader than the male pelvis and the female pelvic bones, including the neck of the
femur, are more slender than those of the male.
The outline of the male pelvic brim is heart-shaped and the brim is widest towards the back, whereas the
female pelvic brim is transversely oval (widest further forwards) because of less prominence of the sacral
promontory.
The female pelvis has evolutionally developed for giving birth. Therefore it is roomier. The outlet is also
wider than that of the male pelvis.
The subpubic angle is acute (like a Gothic arch) in the male pelvis, whereas it is rounded (like a Roman arch)
in a female pelvis.
The major obstetric interest in the bony pelvis is that it is not distensible. Only minor degrees of movement are
possible at the symphysis pubis and sacroiliac joints. Therefore its dimensions are critical at childbirth. The diameters
of the pelvis vary at different parts of the pelvis.
In addition, the shape of the pelvis determines the availability of pelvic diameters. There are four basic shapes:
Gynecoid type. The classical female pelvis with the inlet transversely oval and a roomier pelvic cavity.
Android type. The inlet is heart-shaped. The cavity is funnel-shaped with a contracted outlet.
Anthropoid type. This results from high assimilation, i.e. the sacral body assimilated to the fifth lumbar
vertebra. It is long, narrow, and oval in shape.
Platypelloid type. This is a wide pelvis flattened at the brim with the promontory of the sacrum pushed
forward.
The ideal female pelvis should be able to accommodate the head of a fetus at term. It has an oval brim, a shallow
cavity, non-prominent ischial spines, a curved sacrum with large sciatic notches (>90), and a sacrospinous ligament
more than 3.5 cm long. The angle of the pelvic brim is 55 to the horizontal. The anterior-posterior diameter of the
inlet is at least 12 cm and the transverse diameter is about 13.5 cm. The subpubic arch is rounded and is >90 and
the ischial intertuberous distance is at least 10 cm. The pelvis is said to be clinically favorable if:
The sacral promontory cannot be felt.
The ischial spines are not prominent.
The subpubic arch and base of the sacrospinous ligaments both accept two fingers and the intertuberous
diameter accepts four knuckles on pelvic examination.
Menstrual Cycle
The female hormonal system, like that of the male, consists of three hierarchies of hormones, as follows:
1. A hypothalamic releasing hormone, gonadotropin-releasing hormone (GnRH)
2. The anterior pituitary sex hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), both
of which are secreted in response to the release of GnRH from the hypothalamus
3. The ovarian hormones, oestrogen and progesterone, which are secreted by the ovaries in response to the
two female sex hormones from the anterior pituitary gland
These various hormones are not secreted in constant amounts throughout the female monthly sexual cycle; they are
secreted at drastically differing rates during different parts of the cycle.
Menstrual Phases
Cycle Day 1-5 6-14 15-28
Ovarian Phase Early follicular Follicular Luteal
Endometrial phase Menstrual Proliferative Secretory
Oestrogen/Progesterone Low levels Oestrogen Progesterone

The hypothalamus releases pulses of gonadotropin-releasing hormone (GnRH) into the portal circulation at defined
frequencies and amplitude. Gonadotropin-releasing hormone stimulates the synthesis and secretion of the
gonadotropins, that is, luteinizing hormone (LH) and follicle-stimulating hormone (FSH), by the gonadotrope cells of
the anterior pituitary gland. These gonadotropins enter the peripheral circulation and act on the ovary to stimulate
both follicular development and ovarian hormone production. These ovarian hormones include the steroid
hormones (oestrogen, progesterone, and androgens), as well as the peptide hormone inhibin. As suggested by its
name, inhibin blocks FSH synthesis and secretion. Gonadal steroids are inhibitory in both the pituitary and the
hypothalamus. Development of a mature follicle results in a rapid rise in oestrogen levels, which acts positively at
the pituitary to generate a surge in LH release.
Following ovulation, LH stimulates luteinization of the follicular granulosa cells and surrounding theca with the
formation of the corpus luteum. The corpus luteum continues to produce oestrogen, but also secretes high levels of
progesterone. Progesterone converts the endometrium to a secretory pattern. If pregnancy occurs, the corpus
luteum is "rescued" by human chorionic gonadotropin (hCG) secreted from early trophoblastic cells. If pregnancy
does not occur, then progesterone and oestrogen secretion ceases, the corpus luteum regresses, and endometrial
sloughing ensues.