Blood Supply
Arise from the Femoral Artery just below the inguinal ligament within the femoral triangle
a) Superficial Epigastric
b) Superficial Circumflex Iliac
c) Superficial External Pudendal
Supply the skin and subcutaneous layers of the anterior abdominal wall and mons pubis.
Superficial Epigastric vessels course diagonally toward the umbilicus.
With a low transverse skin incision, can usually be identified at a depth halfway between the
skin and the anterior rectus sheath, above Scarpa fascia, and several centimeters from the
midline.
Branches of the External Iliac Vessels
a) Inferior Deep Epigastric
Transverse sections of anterior abdominal wall above (A) and below (B) the arcuate line.
b) Deep Circumflex Iliac
Supply the muscles and fascia of the anterior abdominal wall
EXTERNAL GENERATIVE ORGANS
Inferior Epigastric vessels initially course lateral to, then posterior to the rectus abdominis
Vulva
muscles, which they supply.
Mons Pubis, Labia, and Clitoris
Pass ventral to the posterior rectus sheath and course between the sheath and the rectus
Pudenda
muscles.
Commonly designated the vulva
Near the umbilicus, anastomose with the Superior Epigastric Artery and Veins, which are
Includes all structures visible externally from the symphysis pubis to the perineal body.
branches of the Internal Thoracic Vessels.
Includes: Mons Pubis, Labia Majora and Minora, Clitoris, Hymen, Vestibule, Urethral
Maylard incision: Inferior Epigastric Artery may be lacerated lateral to the rectus belly
Opening, Greater Vestibular (Bartholin Glands), Minor Vestibular Glands and Paraurethral
during muscle transection.
Glands
These vessels rarely may rupture following abdominal trauma and create a rectus Sheath
Hematoma
Hesselbach Triangle
Lie on each side of the lower anterior abdominal wall
Bounded: L-inferior epigastric vessels, I: inguinal ligament, M: lateral border of the rectus
muscle.
Direct Inguinal Hernias: hernias that protrude through the abdominal wall in Hesselbach
triangle.
Indirect Inguinal Hernias: hernias that protrude through deep inguinal ring, which lies
lateral to this triangle, and then may exit out the superficial inguinal ring.
Innervation
Anterior Abdominal Wall is innervated by
a) Intercostal Nerves (T711)
b) Subcostal Nerve (T12),
c) Iliohypogastric and Ilioinguinal Nerves (L1)
Intercostal and Subcostal Nerves are Anterior Rami of the Thoracic Spinal Nerves
Run lateral and then anterior abdominal wall between the transversus abdominis and
internal oblique muscles(Transversus Abdominis Plane)
Near the rectus abdominis lateral borders, these nerve branches pierce the posterior sheath,
rectus muscle, and then anterior sheath to reach the skin.
May be severed during a Pfannenstiel incision at the point in which the overlying anterior
rectus sheath is separated from the rectus muscle.
Iliohypogastric and Ilioinguinal Nerves originate from the Anterior Ramus of the First Lumbar
Spinal Nerve
Vulvar structures and subcutaneous layer of the anterior perineal triangle
Emerge lateral to the psoas muscle and travel across the quadratus lumborum
Note the continuity of Colles and Scarpa fasciae.
inferomedially toward the iliac crest.
Inset: Vestibule boundaries and openings onto the vestibule.
Near this crest, both nerves pierce the transversus abdominis muscle and course ventrally.
2 to 3 cm medial to the anterior superior iliac spine, they pierce the internal oblique muscle
Mons Pubis
and course superficial to it toward the midline
Also called the Mons Veneris
Iliohypogastric Nerve
Fat-filled cushion overlying the symphysis pubis.
Perforates the external oblique aponeurosis near the lateral rectus border to provide
After puberty, it is covered by curly hair that forms the escutcheon. In women, hair is
sensation to the skin over the suprapubic area.
distributed in a triangle, whose base covers the upper margin of the symphysis pubis
Ilioinguinal Nerve
In men and some hirsute women, the escutcheon is not so well circumscribed and extends
Course medially through the inguinal canal and exits through the Superficial Inguinal
onto the anterior abdominal wall toward the umbilicus.
Ring, which forms by splitting of external abdominal oblique aponeurosis fibers.
Labia Majora
Supplies the skin of the mons pubis, upper labia majora, and medial upper thigh.
Homologous with the male scrotum.
Ilioinguinal and Iliohypogastric Nerves can be severed during a low transverse incision or
7-8 cm in length, 2-3 cm in depth, and 1-1.5 cm in thickness
entrapped during closure, especially if incisions extend beyond the lateral borders of the rectus
S: continuous directly with the mons pubis and round ligaments terminate at their upper
muscle
borders.
These nerves carry sensory information only and injury leads to loss of sensation within the
P: taper and merge into the area overlying the perineal body to form the Posterior
areas supplied.
Commissure.
Rarely, chronic pain may develop.
Hair covers the labia majora outer surface but is absent on their inner surface.
T10 dermatome approximates the level of the umbilicus.
Apocrine, eccrine, and sebaceous glands are abundant.
Regional analgesia for cesarean delivery or for puerperal sterilization ideally blocks T10
Beneath the skin is a dense connective tissue layer, which is nearly void of muscular
through L1 levels.
elements but is rich in elastic fibers and adipose tissue.
Transversus Abdominis Plane Block can provide broad blockade to the nerves that
Mass of fat provides bulk to the labia majora
traverse this plane
Supplied with a rich venous plexus
May be placed post cesarean to reduce analgesia requirements
During pregnancy: vasculature commonly develops varicosities, especially in parous women
Ligaments
Several ligaments that extend from the uterine surface toward the pelvic sidewalls
Include
a) Round Ligaments
b) Broad Ligaments
c) Cardinal Ligaments
d) Uterosacral Ligaments
Round Ligament
Corresponds embryologically to the male gubernaculum testis
Originates below and anterior to the origin of the fallopian tubes.
Orientation can aid in fallopian tube identification during puerperal sterilization
Uterus, adnexa, and associated anatomy. Important if pelvic adhesions limit tubal mobility and thus limit fimbria visualization prior
Uterus to tubal ligation.
Nonpregnant uterus: situated in the pelvic cavity Each extends laterally and downward into the inguinal canal, through which it passes, to
Between the bladder (A) and rectum (P) terminate in the upper portion of the labium majus.
Entire posterior wall of the uterus is covered by serosa (Visceral Peritoneum) Sampson Artery
Lower portion of this peritoneum forms the anterior boundary of the Rectouterine Cul- Branch of the uterine artery
De-Sac (Pouch Of Douglas) Runs within this ligament
Only the upper portion of the anterior wall of the uterus is so covered. Nonpregnant women: 3-5 mm in diameter
Peritoneum in this area reflects forward onto the bladder dome to create the Vesicouterine Composed of smooth muscle bundles separated by fibrous tissue septa
Pouch During pregnancy, these ligaments undergo considerable hypertrophy and increase appreciably in
Lower portion of the anterior uterine wall is united to the posterior wall of the bladder by well- both length and diameter.
defined loose connective tissue layer (Vesicouterine Space) Broad Ligaments
During cesarean delivery, peritoneum of the vesicouterine pouch is sharply incised, and the Two wing like structures that extend from the lateral uterine margins to the pelvic sidewalls.
vesicouterine space is entered. With vertical sectioning through this ligament proximate to the uterus
Dissection caudally within this space lifts the bladder off the lower uterine segment for Triangular shape can be seen
hysterotomy and delivery Uterine vessels and ureter are found at its base
Pear shaped Divide the pelvic cavity into anterior and posterior compartments.
Consists of two major but unequal parts. Each consists of a fold of peritoneum (Anterior and Posterior Leaves)
a) Body or Corpus : upper triangular portion This peritoneum drapes over structures extending from each cornu.
b) Cervix Peritoneum
Lower, cylindrical portion a) Mesosalpinx: Overlies the fallopian tube
Projects into the vagina b) Mesoteres : Around the round ligament is the
c) Isthmus Mesovarium: Over the uteroovarian ligament
Union site of these two Infundibulopelvic Ligament or Suspensory Ligament of the Ovary
Special obstetrical significance because it forms the lower uterine segment during Peritoneum that extends beneath the fimbriated end of the fallopian tube toward the pelvic
pregnancy. wall forms the.
At each superolateral margin of the body is a Uterine Cornu Contains nerves and the ovarian vessels
From which a fallopian tube emerges During pregnancy, these vessels, especially the venous plexuses, are dramatically enlarged.
This area is the origins of the round and uteroovarian ligaments. Diameter of the ovarian vascular pedicle increases from 0.9 cm to reach 2.6 cm at term
Between the points of fallopian tube insertion is the convex upper uterine segment (fundus) Cardinal Ligament
Bulk of the uterine body is muscle Also called the Transverse Cervical Ligament or Mackenrodt Ligament
Inner surfaces of the anterior and posterior walls lie almost in contact Thick base of the broad ligament
Cavity between these walls forms a mere slit Medially united firmly to the uterus and upper vagina
Nulligravid uterus: 6-8 cm in length Each uterosacral ligament originates with a posterolateral attachment to the supravaginal
Multiparous uterus: 9-10 cm portion of the cervix
Averages 60 g and typically weighs more in parous women Inserts into the fascia over the sacrum
Nulligravidas: fundus and cervix are approximately equal in length Ligaments are composed of connective tissue, small bundles of vessels and nerves, and some
Multiparas: cervix is only a little more than a third of the total length. smooth muscle.
Pregnancy stimulates remarkable uterine growth due to muscle fiber hypertrophy Covered by peritoneum, these ligaments form the lateral boundaries of the pouch of
Uterine fundus, previously flattened convexity between tubal insertions, now Douglas.
becomes dome shaped. Parametrium
Describe the connective tissues adjacent and lateral to the uterus within the broad
ligament.
Posterior Division
Extend to the buttock and thigh
Include the superior gluteal, lateral sacral, and iliolumbar arteries. during
internal iliac artery ligation
Many advocate ligation distal to the posterior division to avoid compromised blood flow to
the areas supplied by this division
Lymphatics
Endometrium is abundantly supplied with lymphatic vessels that are confined largely to the basalis
layer.
Lymphatics of the underlying myometrium are increased in number toward the serosal
surface and form an abundant lymphatic plexus just beneath it.
Lymphatics from the cervix terminate mainly in the internal iliac nodes
Situated near the bifurcation of the common iliac vessels
Lymphatics from the uterine corpus are distributed to two groups of nodes.
Vessels drains into the Internal Iliac Nodes
After joining certain lymphatics from the ovarian region, terminates in the Paraaortic
Lymph Nodes.
Innervation
Peripheral nervous system is divided
a) Somatic Division
Pelvic viscera and their connective tissue support
Innervates skeletal muscle
b) Autonomic Division
Innervates smooth muscle, cardiac muscle, and glands.
Pelvic visceral innervation is predominantly autonomic
Further divided in Sympathetic and Parasympathetic Components.
Sympathetic Innervation to pelvic viscera begins with the Superior Hypogastric Plexus
(Presacral Nerve)
Beginning below the aortic bifurcation and extending downward retroperitoneally, this
plexus is formed by sympathetic fibers arising from spinal levels T10-L2.
At the level of the sacral promontory, divides into a Right and a Left Hypogastric Nerve,
which run downward along the pelvis side walls
Pelvic arteries
Blood Supply
During pregnancy, there is marked hypertrophy of the uterine vasculature
Supplied principally from the Uterine and Ovarian Arteries
Uterine Artery
main branch of the Internal Iliac Artery
previously called the Hypogastric Artery
Enters the base of the broad ligament and makes its way medially to the side of the uterus.
2 cm lateral to the cervix, the uterine artery crosses over the ureter.
This proximity is of great surgical significance as the ureter may be injured or ligated
Pelvic innervation
during hysterectomy when the vessels are clamped and ligated.
Once the uterine artery has reached the supravaginal portion of the cervix, it divides
Parasympathetic Innervation
Cervicovaginal Artery
Derives from neurons at spinal levels S2-S4
Supplies blood to the lower cervix and upper vagina
Axons exit as part of the anterior rami of the spinal nerves for those levels.
Main branch turns abruptly upward and extends as a highly convoluted vessel that
These combine on each side to form the pelvic splanchnic nerves (Nervi Erigentes)
traverses along the lateral margin of the uterus
Blending of the two Hypogastric Nerves (sympathetic) and the two Pelvic Splanchnic Nerves
Extends into the upper portion of the cervix,
(parasympathetic) gives rise to the Inferior Hypogastric Plexus (Pelvic Plexus)
Numerous other branches penetrate the body of the uterus to form the Arcuate
Retroperitoneal plaque of nerves lies at the S4-S5 level
Arteries
From here, fibers of this plexus accompany internal iliac artery branches to their respective
Encircle the organ by coursing within the myometrium just beneath the
pelvic viscera.
serosal surface.
Inferior Hypogastric Plexus
These vessels from each side anastomose at the uterine midline. Divides into three plexuses
From the arcuate arteries, Radial Branches originate at right angles, traverse inward a) Vesical Plexus
through the myometrium, enter the endometrium, and branch there to become
Innervates the bladder and the middle rectal travels to the rectum
Basal Arteries or coiled Spiral Arteries.
b) Uterovaginal Plexus (Frankenhuser Plexus)
Spiral Arteries
Reaches the proximal fallopian tubes, uterus, and upper vagina.
Supply the functionalis layer.
Extensions of the inferior hypogastric plexus also reach the perineum along the vagina and
Vessels respond by vasoconstriction and dilatation to a number of hormones urethra to innervate the clitoris and vestibular bulbs
serve an important role in menstruation Composed of variably sized ganglia, but particularly of a large ganglionic plate that is
Basal Arteries situated on either side of the cervix, proximate to the uterosacral and cardinal ligaments
Also called Straight Arteries Most afferent sensory fibers from the uterus ascend through the inferior hypogastric plexus
Extend only into the basalis layer and enter the spinal cord via T10-T12 and L1 spinal nerves
Not responsive to hormonal influences. Transmit the painful stimuli of contractions to the central nervous system
Just before the main uterine artery vessel reaches the fallopian tube, it divides into three Sensory nerves from the cervix and upper part of the birth canal pass through the pelvic splanchnic
terminal branches nerves to the second, third, and fourth sacral nerves.
Ovarian Branch of the uterine artery Those from the lower portion of the birth canal pass primarily through the Pudendal Nerve.
Forms an anastomosis with the terminal branch of the Ovarian Artery Anesthetic blocks used in labor and delivery target this innervation.
Tubal branch Ovaries
Makes its way through the mesosalpinx During childbearing years: 2.5 -5 cm in length, 1.5-3 cm in breadth, and 0.6-1.5 cm in thickness.
Supplies part of the fallopian tube Usually lie in the upper part of the pelvic cavity
Fundal branch Rest in a slight depression on the lateral wall of the pelvis (Ovarian Fossa of Waldeyer)
penetrates the uppermost uterus Between the divergent external and internal iliac vessels.
Ovarian Artery Uteroovarian Ligament
Direct branch of the aorta Originates from the lateral and upper posterior portion of the uterus
Enters the broad ligament through the infundibulopelvic ligament. Beneath the tubal insertion level
Ovarian hilum: divides into smaller branches that enter the ovary. Extends to the uterine pole of the ovary
As the ovarian artery runs along the hilum, it also sends several branches through the 3-4 mm in diameter
mesosalpinx to supply the fallopian tubes. Made up of muscle and connective tissue
Main stem traverses the entire length of the broad ligament and makes its way to the covered by Mesovarium
uterine cornu. Blood supply traverses to and from the ovary through this double-layered mesovarium to enter the
Forms an anastomosis with the ovarian branch of the uterine artery. Dual uterine blood ovarian hilum.
supply creates a vascular reserve to prevent uterine ischemia if ligation of the uterine or Consists of a cortex and medulla
internal iliac artery is performed to control postpartum hemorrhage. Young women: outermost portion of the cortex is smooth
Uterine veins accompany their respective arteries. Tunica Albuginea: dull white surface
Arcuate Veins unite to form the Uterine Vein On its surface, there is a single layer of cuboidal epithelium, (Germinal Epithelium of Waldeyer)
Empties into the internal iliac vein and then the Common Iliac Vein. Beneath this epithelium, the cortex contains oocytes and developing follicles.
Within the broad ligament, these veins form the large pampiniform plexus that terminates Medulla
in the Ovarian Vein. Central portion
Right Ovarian Vein empties into the Vena Cava Composed of loose connective tissue.
Left Ovarian Vein empties into the Left Renal Vein. There are a large number of arteries and veins and small number of smooth muscle fibers.
Blood supply to the pelvis is predominantly supplied from branches of the Internal Iliac Artery. Supplied with both sympathetic and parasympathetic nerves.
Organized into anterior and posterior divisions
Sacrum
Forms the posterior wall of the true pelvis
Upper anterior margin corresponds to the
promontory that may be felt during
bimanual pelvic examination in women with
a small pelvis. Provide a landmark for clinical
pelvimetry
Normally, the sacrum has a marked vertical
and a less pronounced horizontal concavity,
The fallopian tube of an adult woman with cross-sectioned illustrations of the gross structure in several which in abnormal pelves may undergo
portions: (A) isthmus, (B) ampulla, and (C) infundibulum. Below these are photographs of corresponding important variations.
histological sections Straight line drawn from the promontory to
the tip of the sacrum usually measures 10 cm
Fallopian Tubes Distance along the concavity averages 12 cm
Called Oviducts
Serpentine tubes extend 8-14 cm from the uterine cornua Pelvic Joints
Anatomically classified along their length as an A: pelvic bones are joined together by the symphysis pubis.
a) Interstitial Portion Consists of fibrocartilage and the superior and Inferior Pubic Ligaments.
b) Isthmus Frequently designated the arcuate ligament of the pubis.
c) Ampulla P: pelvic bones are joined by articulations
d) Infundibulum Between the sacrum and the iliac portion of the innominate bones to form the Sacroiliac
Interstitial Portion Joints.
Most proximal These joints in general have a limited degree of mobility.
Embodied within the uterine muscular wall. During pregnancy, there is remarkable relaxation of these joints at term, caused by upward
Isthmus gliding of the sacroiliac joint
Narrow 2-3 Mm Displacement, which is greatest in the dorsal lithotomy position, may increase the
Adjoins the uterus and widens gradually diameter of the outlet by 1.5-2.0 cm.
Ampulla Main justification for placing a woman in this position for a vaginal delivery.
5-8 mm But this pelvic outlet diameter increase occurs only if the sacrum is allowed to
More lateral rotate posteriorly.
Infundibulum Thus, it will not occur if the sacrum is forced anteriorly by the weight of the
funnel-shaped fimbriated distal extremity of the tube maternal pelvis against the delivery table or bed
opens into the abdominal cavity Sacroiliac joint mobility is also the likely reason that the McRoberts maneuver often is successful in
Latter three extrauterine portions are covered by the Mesosalpinx at the superior margin of the releasing an obstructed shoulder in a case of shoulder dystocia
broad ligament. Attributed to the success of the modified squatting position to hasten second-stage labor
Extrauterine fallopian tube contains a mesosalpinx, myosalpinx, and endosalpinx Squatting position may increase the interspinous diameter and the pelvic outlet diameter
Pelvic Outlet
Consists of two approximately triangular areas whose boundaries mirror those of the
perineal triangle
Base is a line drawn between the two ischial tuberosities
Apex of the posterior triangle is the tip of the sacrum
Lateral boundaries are the sacrotuberous ligaments and the ischial tuberosities
Anterior triangle is formed by the descending inferior rami of the pubic bones
Rami unite at an angle of 90-100 degrees to form a rounded arch under which the fetal head
must pass.
Clinically, three diameters of the pelvic outlet usually are describe
Anteroposterior
Transverse
Posterior sagittal
Unless there is significant pelvic bony disease, the pelvic outlet seldom obstructs vaginal
delivery.
The four parent pelvic types of the CaldwellMoloy classification. A line passing through the widest
transverse diameter divides the inlets into posterior (P) and anterior (A) segments.
Pelvic Shapes
Caldwell-Moloy anatomical classification of the pelvis based on shape, and its concepts aid an
understanding of labor mechanisms.
Greatest transverse diameter of the inlet and its division into anterior and posterior
segments are used to classify the pelvis as
a) Gynecoid
b) Anthropoid
c) Android
d) Platypelloid
Posterior segment determines the type of pelvis
Anterior segment determines the tendency.
Both determined because many pelves are not pure but are mixed types.
Gynecoid pelvis with an android tendency means that the posterior pelvis is gynecoid and
the anterior pelvis is android shaped.
Configuration of the gynecoid pelvis would intuitively seem suited for delivery of most
fetuses.
Gynecoid pelvis was found in almost half of women.