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CHAPTER 2 The Abdomen, Pelvis and Perineum
Left hepatic
hepatic artery
Cystic duct
Gall bladder
Right hepatic
51
• e common hepatic duct and supraduodenal part of
the common bile duct lie in the free edge of the lesser
omentum. eir relations are as follows:
• bile duct: anteriorly to the right
• hepatic artery: anteriorly to the le
• portal vein: posterior
• IVC, posteriorly: separated from the portal vein by
the epiploic foramen.
Gall Bladder
• Pear-shaped organ adherent to the undersurface of the
liver, lying in a fossa which separates the morphological
right and le lobes.
• Acts as a reservoir for bile, which it also concentrates.
• Holds about 50 mL of bile when physiologically
distended.
• e gall bladder consists of:
• fundus
• body
• neck: the neck opens into the cystic duct, which con-
veys bile to and from the common bile duct.
• e lumen of the cystic duct contains a spiral mucosal
valve (of Heister).
• e gall bladder is related inferiorly to the duodenum
and transverse colon.
• A small pouch may be present on the ventral aspect of
the gall bladder just proximal to the neck (Hartmann's
pouch); a stone may lodge in the pouch.
Blood Supply (Fig. 2.27)
• Via the cystic artery (usually a branch of the right
hepatic artery).
• Cystic artery lies in a triangle made up of the liver, the
cystic duct and the common hepatic duct, i.e. Calot’s
triangle.
• Cystic artery passes behind the common hepatic duct
and cystic duct to gain the upper surface of the neck of
the gall bladder.
• Occasionally the cystic artery arises from the main
hepatic artery and crosses in front of or behind the
(common) bile duct or common hepatic duct.
• Gall bladder also obtains a blood supply directly from
arteries in the bed of the liver.
• Venous drainage is via small veins draining directly into
the bed of the liver.
Clinical Points
• Variations in the anatomy of the extrahepatic biliary
system are not uncommon (Fig. 2.28).
• e close relationship between the fundus of the gall
bladder and duodenum may result in inamed gall
artery
Cystic artery
Fig. 2.27 The gall bladder and its arterial supply.
artery
Common
Common bile
duct
bladder ulcerating into the duodenum, causing a
cholecystoduodenal stula and subsequent gallstone
‘ il eu s ’.
• Haemorrhage during cholecystectomy or from liver
trauma may be controlled by compressing the hepatic
artery and portal vein in the free edge of the lesser
omentum (Pringle’s manoeuvre).
• Gangrene of the gall bladder is rare because, even if the
cystic artery thromboses, it gets a second blood supply
directly from the liver bed.
• e wall of the gall bladder and cystic duct contains
smooth muscle. is is virtually absent in the bile
duct, hence little pain from a gallstone in the bile duct.
• e mucosa is lined throughout by columnar cells and
bears a considerable number of mucus-producing goblet cells.
• When the neck of the gall bladder is obstructed, bile is
absorbed and the goblet cells produce mucus, resulting
in a mucocele of the gall bladder.
The Portal Venous System (Fig. 2.29)
• A portal system is one that has capillaries at each end.
• e portal venous system drains blood from:
• the abdominal part of the alimentary canal (exclud-
ing the lower part of the anus)
• spleen
• pancreas
• gall bladder.
52
vein
IVC
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SECTION I Anatomy
A
Fig. 2.28 Variations in the extrahepatic biliary anatomy. (A) A long cystic duct joins the common hepatic duct
behind the duodenum. (B) The cystic duct is short or absent, the gall bladder opening directly into the common
hepatic duct. (C) The cystic duct enters the right hepatic duct. (D) Accessory hepatic ducts may open into the
gall bladder or cystic duct.
Hepatic veins
draining into IVC
B
C
D
• Portal vein ascends to porta hepatis where it divides into
right and le hepatic branches, breaking up into capillaries running between the lobules of the liver.
• ese capillaries drain into the radicles of the hepatic
vein, eventually emptying into the IVC.
• ere are no valves in the portal system so that obstruction, e.g. due to cirrhosis of the liver, causes a rise in
Portal vein
pressure throughout the system.
• To escape, the blood passes through any anastomosis
between portal and systemic system and the anastomotic veins become dilated and may bleed.
• Sites of anastomosis between portal and systemic
venous system are:
Splenic vein
• between the oesophageal branch of the le gastric
vein (portal) and the oesophageal tributaries of the
Inferior mesenteric
vein
Superior mesenteric
azygos system (systemic); in the presence of portal
hypertension oesophageal varices will develop that
may be the source of severe haematemesis
• between the superior rectal branch of the inferior
Fig. 2.29 The portal venous system.
mesenteric vein (portal) and the inferior rectal veins
(systemic); this may give rise to dilated veins in the
anal canal which bleed
• between the portal tributaries in the mesentery and
• Portal vein is formed by the junction of the splenic vein
and superior mesenteric vein behind the neck of the
pancreas.
• Inferior mesenteric vein ascends above the point of origin of its artery to enter the splenic vein behind the body
of the pancreas.
• Portal vein ascends behind rst part of duodenum,
entering the free edge of the lesser omentum in the anterior wall of the foramen of Winslow.
• At this point it lies immediately posterior to bile duct
and hepatic artery.
retroperitoneal veins (systemic), resulting in retroperitoneal varices
• between the portal veins in the liver and the veins
of the abdominal wall (systemic) via veins passing
along the falciform ligament to the umbilicus; this
may result in the formation of a group of dilated
veins radiating out from the umbilicus known as a
caput medusae
• between portal branches in the liver and the veins of
the diaphragm (systemic) in relation to the bare area
of the liver.
CHAPTER 2 The Abdomen, Pelvis and Perineum
Main pancreatic duct (of Wirsung)
Superior mesenteric artery and vein
A
Common bile duct
53
ccessory pancreatic duct
Fig. 2.30 The pancreas and duodenum, showing the common bile duct and pancreatic ducts with their orifices.
Clinical Point
• Surgery on patients with portal hypertension may be
very complicated and very bloody. is is because of
dilated veins in the abdominal wall, in the mesentery
and in the retroperitoneal area. Pressure in these veins
may be extremely high, resulting in considerable portal
venous bleeding.
(of Santorini)
Duodenal papilla
• e stomach and rst part of the duodenum lie partly
in front of the head of the pancreas, separated from it by
the lesser sac.
• Behind the neck of the pancreas lies the junction of the
superior mesenteric vein and splenic vein, forming the
portal vein.
• e body of the pancreas is in contact posteriorly with
the aorta, the le crus of the diaphragm, and the supra-
Pancreas
e pancreas lies retroperitoneally in the upper abdomen
in the transpyloric plane. It is divided into:
• head
• uncinate process
• neck
• body
• tail.
e head of the pancreas lies in the C-shape of the duo-
denum and is continuous with the uncinate process below,
which passes posterior to the superior mesenteric vessels as
they in turn pass from behind the head of the pancreas and
into the root of the mesentery (Fig. 2.30).
renal gland and le kidney.
• e tail of the pancreas lies at the splenic hilum.
• e tortuous splenic artery runs along the superior border of the pancreas.
• e splenic vein runs behind the pancreas.
• e transverse mesocolon is attached along the anterior
aspect of the pancreas.
• Below the attachment of the transverse mesocolon, the
DJ exure, the le exure of the colon and the small
intestine lie in relation to the gland.
• e main pancreatic duct (of Wirsung) passes along the
gland from the tail to the head, joining the common bile
duct before entering the medial aspect of the second
part of the duodenum at the ampulla of Vater.
Relations
• e head of the pancreas is adherent to the medial
aspect of the C-shaped portion of the duodenum and
lies in front of the IVC, renal vessels and superior mesenteric vessels.
• e accessory duct (of Santorini) passes from the lower
part of the head in front of the main duct, usually communicating with it, and, if present, opens into the duodenum approximately 2 cm proximal to the ampulla of
Vate r.
• e uncinate process lies behind the superior mesenteric vessels.
• e common bile duct passes through a groove on the
posterior aspect of the head of the pancreas.
Structure
• Gland encapsulated by brous capsule sending septae
into the gland, forming lobules.
54
Hepatic area
Area for suprarenal glands
Pancreatic
Inferior vena cava
Areas for diaphragm
transversus
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SECTION I Anatomy
• Lobules composed of acini of serous cells, which secrete
pancreatic enzymes.
• Ducts lined by cuboidal epithelium drain secretions
into pancreatic ducts.
• Scattered throughout the pancreas are the islets of
Langerhans, which appear as spheroidal clusters of palestaining cells with a rich blood supply.
• Cells of islets of Langerhans secrete insulin and glucagon.
Blood Supply
• From splenic artery via arteria pancreatica magna.
• Supply to head and uncinate process is from superior
pancreaticoduodenal artery, which is a branch of the gastroduodenal artery, and the inferior pancreaticoduodenal
artery, which is a branch of the superior mesenteric artery.
Lymphatics
• ese drain into:
• nodes along the upper border of the pancreas
• nodes related to the medial aspect of the duodenum
and head of the pancreas
• nodes in the root of the mesentery.
Spleen
• About the size of the patient's clenched st.
• Lies in the le hypochondrium.
• Forms the le lateral extremity of the lesser sac.
• e gastrosplenic ligament connects it to the greater
curvature of the stomach (carries the short gastric and
le gastroepiploic vessels).
• e lienorenal ligament connects it to the posterior
abdominal wall (carries the tail of the pancreas and the
splenic vessels).
Relations
• Anteriorly: the stomach.
• Posteriorly: the le part of the diaphragm separating it
from the pleura, le lung and 9th, 10th and 11th ribs.
• Inferiorly: the splenic exure of the colon.
• Medially: the le kidney.
Blood Supply
• Via the splenic artery, which is a branch of the coeliac axis.
• e splenic vein is joined by the superior mesenteric
vein to form the portal vein.
• e splenic artery and vein, lymph nodes and the tail of
the pancreas are enclosed in the lienorenal ligament.
Clinical Points
• Trauma to the le lower chest wall and le upper abdomen may result in damage to the spleen; look particularly for fractures of the le lower ribs.
• Accessory spleens (splenunculi) occur near the hilum,
tail of the pancreas, omentum, small bowel mesentery;
if le behind they may hypertrophy and result in persistence of symptoms following splenectomy, e.g. for
thrombocytopenic purpura.
Kidneys
• e kidneys lie retroperitoneally on the posterior
abdominal wall. e right kidney lies lower than the le
owing to downward displacement by the liver.
Relations (Figs. 2.31 and 2.32)
• At the medial aspect of the kidney there is a vertical slit,
the hilum, which transmits from backwards the renal
vein, the renal artery and the pelvis of the ureter.
• Lymphatics and nerves also enter at the hilum.
Duodenal area
Aorta
Colic area
Fig. 2.31 The anterior surfaces of the kidneys and
their relations.
Suprarenal
glands
Areas for
quadratus
lumborum
Areas for psoas major
Fig. 2.32 The posterior relations of the kidneys.
Gastric area
Splenic area
area
Colic
area
Jejunal area
Left renal vein
Areas for
abdominis
CHAPTER 2 The Abdomen, Pelvis and Perineum
55
• e kidney lies in a fatty cushion (perinephric fat) contained within the renal fascia.
• Above, the renal fascia blends with the fascia over
the diaphragm, leaving a separate compartment
for the suprarenal gland (it is therefore easily separated from the kidney and le behind during a
nephrectomy).
• Medially, the fascia blends with the sheaths of the aorta
and IVC.
• Laterally, it is continuous with transversalis fascia.
• It remains open inferiorly.
• e kidney has three capsules:
• fascial (renal fascia)
• fatty (perinephric fat)
• a true brous capsule, which strips readily from the
kidney surface.
Blood Supply
• From the renal artery directly from the aorta.
• e renal vein drains into the IVC.
• e le renal vein (which is longer than the right and
receives two tributaries), the adrenal and gonadal vein
(which passes in front of the aorta immediately below
the origin of the superior mesenteric artery).
• e right renal artery passes behind the IVC.
• Aberrant vessels are common.
Lymphatic Drainage
• Lymph drains directly to the para-aortic lymph nodes.
Clinical Points
• Hypermobility of the kidney may occur (floating
kidney): the kidney can be moved up and down in
its fascial compartment, but not from side to side.
• Blood from a traumatic rupture of the kidney or pus in
a perinephric abscess will distend the renal fascia and
then take the line of least resistance, tracking down
within the fascial compartment to the pelvis.
• Anatomy of surgical exposure of the kidney via a loin
approach:
• an oblique incision is made halfway between the
12th rib and iliac crest, extending forwards from the
lateral border of erector spinae to the lateral border
of rectus abdominis
• latissimus dorsi and serratus posterior inferior are
divided
• the free posterior border of external oblique is iden-
tied and split along the line of its bres
• internal oblique and transversus are then divided,
revealing peritoneum anteriorly
• the peritoneum is swept forwards
• the renal fascial capsule is opened
• the subcostal nerve and vessels are usually encountered and are preserved
• if more room is required, the lateral edge of quadratus lumborum is divided and part of the 12th
rib excised, being careful not to damage the pleura
which descends below the medial half of the rib.
Ureter
• Conveys urine from kidneys to bladder.
• Each ureter is 25–30 cm long and approximately 3 mm
in diameter.
• e ureter is a hollow muscular tube which commences
at the renal pelvis and terminates at its entry into the
bladder.
• e upper end of each ureter is expanded at the pelvis,
which is divided into two parts called major calyces.
ese are subdivided into about 12 minor calyces.
• Papillae project into the calyces, the latter being the apices of the renal pyramids.
• e ureter is divided into three parts:
• abdominal
• pelvic
• intravesical.
• Relations of the ureter in the abdomen:
• anterior: peritoneum, colic vessels, testicular or
ovarian vessels, ileum and mesentery (right side),
sigmoid colon and sigmoid mesocolon (le side)
• posteriorly: psoas major, psoas minor tendon (occa-
sionally), genitofemoral nerve and bifurcation of
common iliac artery
• the right ureter lies close to the lateral side of the IVC.
• Relations in the pelvis:
• In the male:
• each ureter enters the pelvis by crossing the bifurcation of the common iliac artery; runs down to
ischial spine, crossing the obturator nerve and the
anterior branches of the internal iliac artery; turns
medial to reach the bladder and passes below the
vas deferens just before entering the bladder.
• In the female:
• course as above for male, but ureter crosses close
to the lateral fornix of the vagina below the uterine artery and posterior part of bladder, and ends
as in male.
• Narrowest parts of ureter are:
• pelviureteric junction
• at the brim of the pelvis
• at entry to bladder.
• Calculus may impact at one of these three areas.
Blood Supply
• e ureter receives a rich segmental blood supply from:
56
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SECTION I Anatomy
• renal arteries (may receive a considerable contribution from a lower polar artery)
• testicular or ovarian artery
• internal iliac artery
• inferior vesical arteries.
Clinical Points
• Ureter readily identied at operation as it strips up
with the peritoneum and worm-like movements can be
noticed in its wall, particularly if it is stimulated by the
tip of a pair of forceps.
• A ureteric stone on a plain radiograph may be seen
along the course of the ureter projected onto the bony
skeleton:
• runs along the tips of the transverse processes
• crosses in front of the sacroiliac joint
• swings out on the pelvic wall and crosses the ischial
spine
• passes medially to bladder.
Suprarenal Glands
• Asymmetrical.
• Right is pyramidal and embraces the upper pole of the
right kidney.
• Le is crescentic and embraces the medial border of the
le kidney above the hilum.
Relations
• Anteriorly: right side—liver, IVC; le side—stomach
across the lesser sac.
• Posteriorly: the diaphragm.
• Inferiorly: the upper pole of the kidney.
Bladder
e bladder is a distensible reservoir with muscular walls.
It lies in the true pelvis posterior to the symphysis pubis. It
does not rise above the pubis until it is very full. When fully
distended, the adult bladder projects from the pelvic cavity
into the abdomen, liing the peritoneum upwards from the
abdominal wall as it distends.
Relations
• Anteriorly: the pubic symphysis.
• Superiorly: covered by peritoneum with coils of small
intestine and sigmoid colon resting on it. e relationship between the sigmoid colon and bladder is important in diverticular disease when a colovesical stula
may arise. In the female the body of the uterus lies superior to the bladder.
• Posteriorly: in the male, the rectum and seminal vesicles; in the female, the vagina and supravaginal part of
the cervix.
• Laterally: the bladder is separated from levator ani
and obturator internus muscle by loose connective
tissue.
• e neck of the bladder fuses with the prostate in the
male.
• In the female it lies directly on the pelvic fascia surrounding the short urethra.
Blood Supply
• Superior and inferior vesical arteries, which are branches
of the anterior division of the internal iliac artery.
• Rich venous plexus around the bladder, draining into
the internal iliac veins.
Blood Supply
• A branch from the aorta.
• A branch from the inferior phrenic artery.
• A branch from the renal artery.
• Venous drainage on the right is via a short vein directly
into the IVC.
• Venous drainage on the le is by a longer vein into the
le renal vein.
Structure
• Comprises a cortex and a medulla.
• Medulla derived from neural crest (ectoderm).
• Cortex derived from mesoderm.
• Medulla receives preganglionic sympathetic bres from
the greater splanchnic nerve and secretes adrenaline
and noradrenaline.
• e cortex secretes mineralocorticoids (from zona glomerulosa), glucocorticoids (from zona fasciculata) and
sex hormones (from the zona reticularis).
Lymphatic Drainage
• Drainage along the vesical vessels to the internal iliac
nodes and then to the para-aortic nodes.
Nerve Supply
• Eerent parasympathetic bres from S2, S3, S4 accompany the vesical arteries to the bladder and carry motor
bres to muscles of bladder wall and inhibitory bres to
internal sphincter.
• Sympathetic eerent bres carry inhibitory bres to
bladder muscles and motor bres to its sphincter.
• e external sphincter is made up of striated muscle
supplied by the pudendal nerve.
• Sensory bres, stimulated by distension, are conveyed
in both sympathetic and parasympathetic nerves.
Cystoscopy
• Inspection of the interior of the bladder and three orices, i.e. the internal meatus and both ureters.
CHAPTER 2 The Abdomen, Pelvis and Perineum
57
• Submucosa and mucosa of most of bladder are only
loosely adherent to underlying muscles, and are thrown
into folds when bladder is empty.
• Over the trigone, the mucosa is adherent and remains
smooth even in the empty bladder.
• Between the ureters there is a raised fold of mucosa
called the interureteric ridge.
Prostate
e prostate surrounds the prostatic urethra. ere are two
principal components to the prostate:
• glandular component
• smooth muscle component.
Approximately 25% of the normal prostate is composed
of smooth muscle. e majority of the prostate lies on the
lateral and posterior aspect of the urethra with little anterior prostatic tissue.
Relations
• Anteriorly: the pubic symphysis separated by the
extraperitoneal fat of the retropubic space (cave of
Retzius).
• Posteriorly: the rectum separated by the fascia of
Denonvilliers.
• Superiorly: the prostate is continuous with the neck of
the bladder.
• Inferiorly: the apex of the prostate rests on the external
urethral sphincter within the deep perineal pouch.
• Laterally: levator ani.
Clinically, the prostate is divided into lobes:
• the posterior lobe lies posterior to the urethra and inferior to the plane dened by the course of the ejaculatory
ducts
• a median lobe lies between the ejaculatory ducts and
posterior to the urethra
• two lateral lobes (right and le lobes) are separated by a
shallow posterior median groove, which can be felt on
rectal examination
• anterior to the urethra there is a narrow isthmus only,
consisting of mainly bromuscular tissue.
Normally there are two prostatic capsules but, with
benign prostatic hypertrophy, a third develops.
• True capsule: a thin, brous sheath surrounding the
prostate.
• e false capsule: condensed extraperitoneal fascia
continuous with the fascia surrounding the bladder
and with the fascia of Denonvilliers posteriorly—the
prostatic venous plexus lies between the true and false
capsules.
• Pathological capsule: benign prostatic hypertrophy
compresses the normal peripheral part of the gland,
creating a capsule.
• In enucleation of the prostate for benign prostatic
hypertrophy, it is the plane between the adenomatous
mass and the pathological capsule that is entered.
Blood Supply
• Via the inferior vesical artery, which is a branch of the
internal iliac artery.
• Venous drainage is via the prostatic venous plexus,
which drains into the internal iliac vein on each side.
• Some venous blood drains posteriorly around the rectum to the valveless vertebral veins of Batson—this may
explain why prostatic carcinoma metastasizes early to
the bones of the lumbar spine and pelvis.
Seminal Vesicles
• Lie one on each side in the interval between the base of
the bladder anteriorly and the rectum posteriorly.
• Lie lateral to the termination of vas deferens.
• Each seminal vesicle has a common drainage with its
neighbouring vas via the common ejaculatory duct.
• e normal vesicles are usually impalpable on rectal
examination; however, if they are enlarged by infection,
e.g. tuberculosis, they become palpable.
Uterus (Fig. 2.33)
e uterus is a pear-shaped organ, which is approximately
7 cm long, 5 cm from side to side at its widest point and
3 cm anteroposteriorly. It is composed of:
• fundus
• body
• cervix.
e fallopian tubes enter into each supralateral angle,
which lie above the fundus.
Relations
• Anteriorly: the body of the uterus is related to the uterovesical pouch of peritoneum and lies on either the superior
surface of the bladder or occasionally on coils of intestine.
e part of the cervix lying outside of the vagina is related
directly to the bladder, whereas the infravaginal cervix has
the anterior fornix as an immediate anterior relation.
• Posteriorly: lies the rectouterine pouch (of Douglas),
which is directly related to coils of intestine lying in the
pouch.
• Laterally: lies the broad ligament; the ureter lies superiorly and lateral to the supravaginal cervix.
Blood Supply (Fig. 2.34)
• e uterine artery (from the internal iliac artery) runs
in the base of the broad ligament, and about 2 cm lateral
to the cervix, it passes anterior and superior to the ureter, reaching the uterus at the level of the internal os.
58
Uterovesical pouch
h
Anastomoses between uterine
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SECTION I Anatomy
Sacral promontory
Cavity of uterus
Fundus of uterus
Bladder
Pubic symphysis
Rectouterine pouc
(of Douglas)
Rectum
Cervix of uterus
Vagina
Fig. 2.33 Sagittal MRI through the female pelvis showing the uterus and its relations.
Suspensory ligament of ovary
and ovarian arteries
Ligament of ovary
Ovary
Uterine artery
Vaginal artery
Midline artery
• Uterine veins accompany the arteries, draining to the
internal iliac vein.
Fig. 2.34 The arterial supply of the ovary, uterine tube, uterus and vagina.
• e uterine artery then ascends in a tortuous manner,
Ovarian artery
running up the lateral side of the body of the uterus
before turning laterally and inferiorly to the uterine
tube (fallopian tube), where it terminates by anastomosing with the terminal branches of the ovarian
ar tery.
• e uterine artery also gives o a descending branch,
which supplies the cervix and upper vagina.
Lymphatic Drainage
Lymphatics from the uterus drain as follows.
• e fundus:
• drains along the ovarian vessels to the para-aortic
nodes
CHAPTER 2 The Abdomen, Pelvis and Perineum
59
• some drains with lymphatics, which pass via the
round ligament to the inguinal nodes
• metastases from the fundus of the uterus therefore
may occur in the inguinal nodes.
• Body drains via lymphatics in the broad ligament to the
iliac lymph nodes.
• e cervix drains in three directions:
• laterally via the broad ligament to the external iliac
nodes
• posteriorly in the uterosacral fold to the sacral lymph
nodes
• posterolaterally along the uterine vessels to the inter-
nal iliac nodes.
Fallopian Tubes
e fallopian or uterine tubes are 10–12 cm long and run
from the lateral side of the body of the uterus to the pelvic
wall, where they end by opening near the ovary. e opening of the fallopian tube is called the ostium. e broad ligament of the peritoneum is draped over the fallopian tube
like a sheet over a washing line.
• Each tube comprises the following parts:
• the infundibulum: this is the trumpet-shaped extrem-
ity which opens into the peritoneal cavity at the ostium.
Its opening is mbriated and overlies the ovary
• the ampulla, which is wide, thin-walled and tortuous
• the isthmus, which is narrow, straight and thick-walled
• the intramural part.
• e fallopian tube:
• is covered by peritoneum except for the intramural
part
• contains a muscular coat of outer longitudinal and
inner circular bres
• is lined by mucosa in the form of columnar–ciliated
cells and lies in longitudinal ridges, each of which is
thrown into numerous folds
• functions to propel ova along the lumen to the
uterus, accompanied by muscular contraction, ciliary action and the production of lubricating uid.
• A fertilized ovum may occasionally implant ectopically
in the tube—this gives rise to ectopic pregnancy, which
may cause rupture of the tube with intraperitoneal
haemorrhage.
• e distal end of the tube is open into the peritoneal
cavity, providing direct communication between the
peritoneum and the outside, and is therefore a potential
pathway for infection.
Broad Ligament
• A fold of peritoneum which connects the lateral margin of the uterus with the side wall of the pelvis. e
broad ligament contains or attaches to the following
structures:
• the fallopian tube in its free edge
• the round ligament
• the ovarian ligament
• the uterine vessels and branches of the ovarian
vessels
• the mesovarium attaching the ovary to its posterior
aspect
• lymphatics.
• In the base of the broad ligament, the ureter passes forwards to the bladder lateral to and then immediately
above the lateral fornix of the vagina.
Vagina
• A muscular tube approximately 7 cm in length.
• e cervix opens into the anterior wall superiorly, bulging into the vaginal lumen.
• e vagina forms a ring around the cervix and, although
this ring is continuous, it is divided into anterior, posterior and lateral fornices.
• It surrounds the cervix of the uterus and then passes
downwards and forwards through the pelvic oor to
open into the vestibule (the area enclosed by the labia
minora and containing the urethral orice lying immediately behind the clitoris).
Relations
• Anteriorly: cervix enters the vagina above, and below
this is the base of the bladder and the urethra, which is
embedded in the anterior vaginal wall.
• Posteriorly: the posterior fornix is covered by peritoneum in the rectouterine pouch (of Douglas). Below
this, the anterior wall of the rectum is immediately posterior to the vagina, and below that, the anal canal is
separated from it by the perineal body.
• Superiorly: the ureter lies superior and lateral to the lateral fornix.
• Laterally: levator ani and pelvic fascia.
Blood Supply
• e arterial blood supply is derived from several sources
on each side:
• the vaginal artery
• the uterine artery
• the middle rectal artery
• the internal pudendal artery supplying the lower
third.
• Venous drainage is via a plexus of veins in the connective tissue around the vagina draining into the internal
iliac vein.
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SECTION I Anatomy
Lymphatic Drainage
• From the upper and middle third drain into the external
iliac nodes.
• From the lower third drains into the supercial inguinal
nodes.
Ovary
• Size and shape of an almond.
• Attached to the posterior aspect of the broad ligament
by the mesovarium.
• e superior pole is attached to a prominent fold of peritoneum, the suspensory ligament of the ovary, which
passes upwards over the pelvic brim and external iliac
vessels to merge with the peritoneum over psoas major.
• Ovarian artery gains access to the ovary through the
mesovarium and suspensory ligament.
• A further ligament, the ovarian ligament, runs within
the broad ligament to the cornu of uterus.
Relations
• Extremely variable in position.
• Lies on the side wall of the pelvis in a shallow ovarian
fossa surrounded by the external iliac vessels in front
and the ureter and internal iliac vessels behind.
• Fascia over obturator internus forms the oor of this
fossa and obturator nerve is close by.
• Ovary is very variable in position and may prolapse into
the pouch of Douglas.
• Relations of the ovary are of considerable importance
clinically. ey may be divided into:
• structures within the broad ligament
• structures on the lateral wall of the pelvis
• abdominal and pelvic viscera.
Blood Supply
• From the ovarian artery, which is a branch of the aorta
arising at the level of the renal artery.
• e right ovarian vein drains into the IVC.
• e le ovarian vein drains into the le renal vein.
Lymphatic Drainage
• Follows the ovarian arteries to the para-aortic nodes.
Vaginal examination
• Inspection of the introitus while the patient strains
detects uterine prolapse and stress incontinence.
• Anteriorly, the urethra, bladder and pubis may be felt.
• Posteriorly, the rectum may be felt and the presence of
invasion of the posterior vaginal wall by a rectal neoplasm assessed; abnormalities may be felt in the pouch of
Douglas, e.g. ovarian lesions, malignant deposits.
• Laterally, the ovary, tube and side wall of the pelvis may
be felt; rarely a stone may be palpated in the ureter via
the lateral fornix.
• At the apex, the cervix is felt projecting back from the
anterior wall of the vagina. In the normal anteverted
uterus the anterior lip of the cervix presents rst; in retroversion either cervical os or posterior lip are felt rst;
cervical neoplasia can be felt.
• Bimanual examination assesses pelvic size, size of
uterus, position of uterus, enlargement of ovary, abnormalities of uterine tube.
OSCE SCENARIOS
OSCE Scenario 2.1
A 19-year-old male presents with a history of vague central abdominal pain of 8 h duration. He has now developed
a sharp pain in the right iliac fossa which is exacerbated
by moving and coughing. He has a temperature of 37.4°C
and a white cell count of 15 × 109/L. He is tender with
rebound in the right iliac fossa. A provisional diagnosis
is made of acute appendicitis and he elects for an open
appendicectomy.
1. Explain the anatomical basis for the two types of pain he
has experienced.
2. Describe the structures encountered in a gridiron inci-
sion for appendicectomy.
3. What variations in position of the appendix may be
encountered when attempting to locate the appendix?
OSCE Scenario 2.2
A 40-year-old male presents with severe pain in the right
loin radiating into the right groin. A diagnosis of right ureteric colic is made and a plain abdominal radiograph is
requested.
1. Where would you look for the course of the ureter pro-
jected onto the bony skeleton?
2. At which points along the course of the ureter is a stone
likely to impact?
3. How would you identify the ureter during an extraperi-
toneal approach?
4. What is the blood supply of the ureter and why, when
removing a kidney for transplantation, is it important to leave abundant connective tissue around the
ureter?
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