Transcript Clinical Anatomy of

Clinical Anatomy of Pelvic
Peritoneum and Fascia
Associate Professor
Dr. A. Podcheko
2015
Review- Pelvis
1 . Iliac crest
2. Gas bubble in colon
3. Ala of ilium
4. Lateral part of sacrum
5. Sacroiliac joint
6. Posterior inferior iliac spine
7. Anterior superior iliac spine
8. Anterior inferior iliac spine
9. Lunate surface of acetabulum
10. Spine of ischium
14. Ischial tuberosity
15. Superior ramus of pubis
16. Symphysis pubis
17. Inferior ramus of pubis
18. Obturator foramen
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24. Greater sciatic notch
25. Transverse process, L5 Vertebra
26. Gas bubble in colon
27. Urinary bladder
Pelvic Cavity
 The pelvic cavity contains
 the
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


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terminal parts of the
ureters and the urinary bladder,
rectum,
pelvic genital organs,
blood vessels, lymphatics, and
nerves.
loops of small intestine (mainly
ileum)
frequently,
large
intestine
(appendix
and
transverse
and/or sigmoid colon).
Pelvic Cavity
 The pelvic cavity is limited
 inferiorly by the musculofascial
pelvic diaphragm, which is
suspended above (but descends
centrally to the level of) the
pelvic outlet, forming a bowllike pelvic floor.
 posteriorly by the coccyx and
inferiormost sacrum, with the
superior part of the sacrum
forming a roof over the
posterior half of the cavity .
 anteroinferior wall :The bodies
of the pubic bones and the
pubic symphysis
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Walls and Floor of the Pelvic Cavity
 The pelvic cavity has an anteroinferior wall, two
lateral walls, a posterior wall (or posterolateral
wall and a roof), and a floor .
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Pelvic Cavity: Anteroinferior Pelvic Wall
 The anteroinferior pelvic wall is formed primarily by the bodies and rami
of the pubic bones and the pubic symphysis
 It participates in bearing the weight of the urinary bladder.
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Anterior wall of the pelvis (posterior view).
Lateral Pelvic Walls
The lateral pelvic walls are formed by the right and left hip bones,
each of which includes an obturator foramen closed by an
obturator membrane
Pelvic Cavity: Lateral Pelvic Walls
 The fleshy attachments of the obturator internus muscles cover and
thus pad most of the lateral pelvic walls.
The fibers of each
obturator internus muscle
converge posteriorly, become
tendinous, and turn sharply
laterally to pass from the
lesser pelvis through the
lesser sciatic foramen to
attach to the greater
trochanter of the femur
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Pelvic Cavity: Posterior Wall
Posterior Wall consists of:
1.
2.
3.
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bony wall and roof in the midline (formed by the sacrum
and coccyx)
musculoligamentous posterolateral walls, formed by the
anterior sacroiliac, sacrospinous, and sacrotuberous
ligaments and piriformis muscles
The piriformis muscles arise from the superior sacrum,
lateral to its pelvic foramina . The muscles pass laterally,
leaving the lesser pelvis through the greater sciatic
foramen to attach to the superior border of the greater
trochanter of the femur .
Pelvic Cavity: Pelvic Floor
 The
pelvic floor is
formed by the bowl- or
funnel-shaped
pelvic
diaphragm,
which
consists
of
the
coccygeus and levator
ani muscles and the
fascias covering the
superior and inferior
aspects
of
these
muscles
 The pelvic diaphragm
separates the pelvic
cavity
from
the
perineum
Relationships between Peritoneum and Peritoneal
Cavity of the Pelvis
The parietal peritoneum lining the abdominal cavity continues inferiorly into
the pelvic cavity but does not reach the pelvic floor
Except for the ovaries and uterine tubes, the pelvic viscera are not completely
ensheathed by the peritoneum.
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Relationships between Peritoneum and
Peritoneal Cavity of the Pelvis
Only the uterine tubes (except for their ostia, which are open)
are intraperitoneal and suspended by a mesentery.
The ovaries, although suspended in the peritoneal cavity by a
mesentery, are not covered with glistening peritoneum; instead
a special, relatively-dull epithelium of cuboidal cells covers
them.
Relationships between Peritoneum and
Peritoneal Cavity of the Pelvis
•A loose connective tissue layer between the abdominal transversalis
fascia and the parietal peritoneum of the inferior part of the anterior
abdominal wall allows the bladder to expand between these layers as it
becomes distended with urine
•The region superior to the bladder is the only site where the parietal
peritoneum is not firmly bound to the underlying structures.
•Supravesical fossa - depression formed when the peritoneum reflects
onto the superior surface of the bladder
Peritoneal Reflections in the Pelvis
Peritoneal Reflections in the Pelvis:Female
1. Descends anterior abdominal
wall
2. supravesical fossa
3. Covers convex superior
surface (roof) of bladder and
slopes down sides of roof to
ascend lateral wall of pelvis,
creating paravesical fossae on
each side
4. Reflects from bladder roof
onto body of uterus forming
vesicouterine pouch
5. Covers body and fundus of
uterus and posterior fornix of
vagina; extends laterally from
uterus as double fold or
mesentery broad ligament that
engulfs uterine tubes, ovaries,
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and round ligaments of uterus
Peritoneal Reflections in the Pelvis
Vesicouterine pouch
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Peritoneal Reflections in the Pelvis:Female
6. Reflects from vagina onto rectum, forming rectouterine
pouch (or cul-de-sac, Pouch of Douglas - POD)
7. Rectouterine pouch extends laterally and posteriorly to
form pararectal fossae on each side of rectum
8. Ascends rectum; from inferior to superior, rectum is
subperitoneal and then retroperitoneal
9. Engulfs sigmoid colon beginning at rectosigmoid junction
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Sagittal unenhanced CT image, the pelvic spaces are filled with
dialysate solution.
The retrouterine space (POD), vesicouterine pouch (arrow), B = bladder, P =
symphysis pubis, U = uterus.
CLINICAL CORRELATES
 The rectouterine pouch is the
lowest portion of the peritoneal
cavity, it can collect fluid and cells
from peritoneal cavity
 Culdocentesis is aspiration of
fluid from the cul-de-sac of
Douglas (rectouterine pouch) by a
needle puncture of the posterior
vaginal fornix near the midline
between the uterosacral
ligaments;
 Indications: the procedure is
done when pain occurs in the
lower abdomen and pelvic regions
and when a ruptured ectopic
pregnancy or ovarian cyst is
suspected!!!
A 29-year-old woman with a ruptured
ectopic pregnancy is admitted to a hospital
for culdocentesis. A long needle on the
syringe is most efficiently inserted through
which of the following structures?
(A) Anterior fornix of the vagina
(B) Posterior fornix of the vagina
(C) Anterior wall of the rectum
(D) Posterior wall of the uterine body
(E) Posterior wall of the bladder
Peritoneal Reflections in the Pelvis: Female
 As the peritoneum passes up and over the uterus in the middle of
the pelvic cavity, a double peritoneal fold, the broad ligament of
the uterus, extends between the uterus and the lateral pelvic wall
on each side, forming a partition that separates the paravesical
fossae and pararectal fossae of each side (shown on the next
slide)
 The uterine tubes, ovaries, ligaments of the ovaries, and round
ligaments of the uterus are enclosed within the broad ligaments.
BROAD LIGAMENT CONTENT
 B Bundle (ovarian neurovascular bundle)
 R Round ligament
 O Ovarian ligament
 A Artefacts (Vestigial Structures)
 Duct (Oviduct – Uterine tube)
A 53-year-old bank teller is admitted to a
local hospital for surgical removal of a
benign pelvic tumor confined within the
broad ligament. There is a risk of injuring
which of the following structures that lies in
this ligament?
(A) Ovary
(B) Proximal part of the pelvic ureter
(C) Terminal part of the round ligament of
the uterus
(D) Uterine tube
(E) Suspensory ligament of the ovary
The answer is D. The uterine tubes lie in the broad
ligament.
The anterior surface of the ovary is attached to the
posterior surface of the broad ligament of the uterus.
The ureter descends retroperitoneally on the lateral
pelvic wall but is crossed by the uterine artery in
the base (in the inferomedial part) of the broad
ligament.
The terminal part of the round ligament of the uterus
becomes lost in the subcutaneous tissue of the labium
majora.
The suspensory ligament of the ovary is a band of
peritoneum that extends superiorly from the
ovary to the pelvic wall.
Peritoneal Reflections in the Pelvis
 As the peritoneum passes up and over the uterus in
the middle of the pelvic cavity, a double peritoneal
fold, the broad ligament of the uterus, extends
between the uterus and the lateral pelvic wall on each
side, forming a partition that separates the
paravesical fossae and pararectal fossae of each side.
1 = Paravesical Fossa
2 = Douglas
(rectouterine) pouch
3 = Pararectal fossa
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Peritoneal Reflections in the Pelvis: Males
1. Loose attachment allows
insertion of bladder as it fills
2. Reflects onto superior
surface of bladder, creating
supravesical fossa
3. Covers superior surface
(roof) of bladder and slopes
down sides of roof to
ascend lateral wall of pelvis,
creating paravesical fossae
on each side
4. Descends posterior
surface of bladder as much
as 2 cm
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Peritoneal Reflections in the Pelvis: Males
5. Ureteric fold - fold over
ureters, ductus deferens, and
superior ends of seminal
glands
6. Rectovesical pouch
7. Extends laterally and
posteriorly to form pararectal
fossae on each side of rectum
8. Ascends rectum; from
inferior to superior, rectum is
subperitoneal and then
retroperitoneal
9. Engulfs sigmoid colon
beginning at rectosigmoid
junction
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Peritoneal Reflections in the Pelvis:Male
•Ureteric fold is formed as the
peritoneum and separating
the paravesical and
pararectal fossae; in this
regard, it is the male
equivalent of the broad
ligament.
•Posterior to the ureteric folds
and lateral to the central
recto-vesical pouch, the
peritoneum commonly cover
the superior ends or
superior posterior surfaces
of the seminal glands
(vesicles) and ampullae of
the ductus deferens
Pelvic Fascia
The pelvic fascia is connective tissue that occupies the space between the
membranous peritoneum and the muscular pelvic walls and floor not occupied
by the pelvic viscera.
•PF consist of 2 types: Endopelvic Fascia and Membranous Pelvic Fascia
•Membranous pelvic fascia has parietal and visceral
components (see the legend for figure)
Membranous Pelvic Fascia: Parietal part (PP)
•PP is a membranous layer
of variable thickness that
lines the inner (deep or
pelvic) aspect of the
muscles forming the walls
and floor of the pelvis.
•PP covers the pelvic
surfaces of the obturator
internus, piriformis,
coccygeus, levator ani, and
part of the urethral
sphincter muscles.
•Specific parts of the
parietal fascia are named
for the muscle they cover
(e.g., obturator fascia)
Membranous Pelvic Fascia: Visceral Part (VP)
1.Tendinous arch of pelvic fascia, a continuous bilateral band running from the pubis
to the sacrum along the pelvic floor adjacent to the viscera
2. Puboprostatic ligament in males; pubovesical ligament in females)
connects the prostate to the pubis in the male or the fundus (base) of the
bladder to the pubis in the female
3. Sacrogenital ligaments from the sacrum around the side of the rectum to
attach to the prostate in the male or the vagina in the female.
•The abundant connective
tissue remaining between
the parietal and the
visceral membranous
layers is considered as
subperitoneal endopelvic
fascia, which is continuous
with both the parietal and
the visceral membranous
fascias
•This fascia forms a
connective tissue
matrix or packing
material for the pelvic
viscera e.g paravesical
space, retropubic space
•The presence of loose
connective tissue in the
spaces between the pubis
and the bladder anteriorly
and between the sacrum
and the rectum
posteriorly
accommodates the
expansion of the urinary
bladder and rectal
ampulla as they fill
Hypogastric sheath - passage to essentially all the vessels and nerves
passing from the lateral wall of the pelvis to the pelvic viscera, along
with the ureters and, in the male, the ductus deferens.
Transverse
cervical
(cardinal)
ligament,
also known
as the lateral
cervical or
Mackenrodt
ligament.
Transverse cervical (cardinal) ligament
•In the superior most portion of
the transverse cervical ligament
(at the base of the peritoneal
broad ligament), the uterine
artery runs transversely toward
the cervix while the ureters
pass immediately inferior to
them as they pass on each side
of the cervix heading anteriorly
toward the bladder.
•This relationship is
particularly important in
surgery (injury of the ureters
during ligation of ovarian
artery).
A 59-year-old woman comes to a local hospital for uterine cancer surgery. As the uterine
artery passes from the internal iliac artery to
the uterus, it crosses superior to which of the
following structures that is sometimes mistakenly ligated during such surgery?
(A) Ovarian artery
(B) Ovarian ligament
(C) Uterine tube
(D) Ureter
(E) Round ligament of the uterus
Transverse cervical (cardinal) ligament and
support of the uterus
•Passive and dynamic supports
together resist the tendency for the
uterus to fall or be pushed through
the hollow tube formed by the vagina
(uterine prolapse).
•The transverse cervical ligament, and
the way in which the uterus normally
rests on top of the bladder, provide the
main passive support for the uterus.
•The perineal muscles provide
dynamic support for the uterus by
contracting during moments of
increased intra-abdominal pressure
(sneezing, coughing, etc.).
uterine prolapse
Uterine Prolapse:
• Most common cause is childbirth
Signs & Symptoms:
• Vaginal pressure sensation
• Vaginal fullness
• Lowback pain
Degrees
of
prolapse:
1 st degree - prolapse is above introitus
2 nd degree - goes to the introitus
3 rd degree - goes past introitus