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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_718_Библиотеки_им_академика_М_И_Перельмана
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inferior border - by the arcuate pubic ligament, lig. arcuatum pubis. The sacrum and iliac
bones form the sacroiliac joint, articulatio sacroiliaca.
¾ The osteal walls add to two ligaments: lig. sacrospinale going from the sacrum to the
ischial spine and lig. sacrospinale going to the ischial tuberosity. The ligaments close the
greater and lesser sciatic notch forming the greater and lesser sciatic foramen.
¾ Hip bones have different structures in males and females: the female pelvis is broader; its
inferior outlet is larger in size. These dimensions are necessarily considered in obstetric
practice because normal delivery depends on them much.
Fig.162: Differences between male and female pelvis.
Source [162].
The differences between male and female pelvis (Table 17):
Bony pelvis Male (Android) Female (Gynecoid)
1. General structure. Thick and heavy. Thin and light.
2. Greater (False) pelvis. Deep. Shallow.
3. Lesser (true) pelvis. Narrow and deep.
4. Pelvic inlet (superior
pelvic aperture).
5. Pelvic outlet (inferior
pelvic aperture).
6. Pubic arch and
suprapubic angle.
7. Obturator foramen. Round. Oval.
8. Acetabulum. Large. Small.
Tapering.
Narrow.
Heart shaped.
Comparatively small. Comparatively large.
Narrow (<700). Wide (>800)
Wide and shallow.
Cylindrical.
Wide.
Oval or rounded.
¾ The lateral walls of the lesser pelvis contain the parietal muscles: m. piriformis and m.
obturatorius internus.
¾ M. piriformis arises from the sacral anterior surface lateral to the pelvic sacral foramina
and exits into the gluteal region through the greater sciatic foramen. Above and under the
muscle, there is fissure-like supra and infrapiriform foramen, foramen supraet
infrapiriforme.
¾ The superior gluteal neurovascular fascicle directs into the gluteal region from the lesser
pelvic cavity through the suprapiriform foramen; the sciatic nerve, posterior cutaneous
nerve of thigh, the inferior gluteal neurovascular fascicle and the genital neurovascular
fascicle go through the infrapiriform foramen.
150
¾ M. obturatorius internus arises from the internal surface of the anterolateral wall of the
pelvis and the obturator membrane. At the superior border of the obturatorius internus
muscle, there is the deep foramen of the obturator canal; through this foramen, the obturator
neurovascular fascicle exits from the lesser pelvic cavity upon the anterointernal surface
of thigh. The muscle passes into the gluteal region through the lesser sciatic foramen. The
genital neurovascular fascicle also passes through this foramen from the gluteal region into
the ishcio-anal fossa.
¾ Muscles and bones of the lateral walls of the lesser pelvis are lined with the parietal pelvic
fascia, fascia pelvis parietale - a part of fascia endopelvina, the continuation of fascia
endoabdominalis. Beside m. obturatorius internus, this fascia is known as fascia
obturatoria.
¾ The lesser pelvis cavity floor is formed by the pelvic diaphragm, diaphragma pelvis and
partially the urogenital diaphragm, diaphragma urogenitale.
Fig.163: The lesser pelvis.
Source [163].
¾ The pelvic diaphragm is formed by the levator ani muscle, m. levator ani, the ischio-
coccygeus muscle (m. coccygeus) and the superior and inferior fasciae of the pelvic
diaphragm, a part of fascia endopelvina.
¾ Mm. pubo-anales envelope the rectum from the sides and posteriorly. When they contract,
the rectum walls are pulled up and thrust anterior playing an important part in continence
function, i.e., ability to control one's bowels, feces and flatus
¾ M. pubococcygeus and m. iliococcygeus attach posteriorly to corpus anococcygeum (the
anococcygeal ligament, lig. anococcygeum) and to the coccyx.
¾ The anteromedial fascicles of m. levator ani do not contact with one another, and between
them one can see the superior surface of the second, urogenital diaphragm - diaphragma
urogenitale; it consists of the perineal membrane, the deep transverse perineal muscle and
the external urethral sphincter.
¾ The urogenital diaphragm is situated in the angle between the inferior branches of pubic
bones (for details see the section 'Perineal topography').
151
Fig.164: Muscles of the lateral pelvic wall and the pelvic diaphragm.
Source [164].
The lesser pelvis cavity has three parts (divisions):
1-The superior - peritoneal, cavum pelvis peritoneale.
2-The middle - subperitoneal, cavum pelvis subperitoneale.
3-The inferior - subcutaneous or perineal, cavum subcutaneum s. perinale.
This division is done in relation to m. levator ani:
1.The subcutaneous division is situated lower to the muscle.
2.The subperitoneal division - right above the muscle.
3.The peritoneal one - still more above. The peritoneal division includes parts of the walls of pelvis
and organs coated with the peritoneum
152
The female pelvis divisions:
I - peritoneal division;
II - subperitoneal division;
III - perineal division.
1.Peritoneum viscerale.
2.Uterus.
3.Fascia visceralis.
4.Peritoneum parietale.
5.Fascia parietalis.
6.m. obturatorius internus.
7.Arcus tendineus m. levatoris ani.
8. a. iliaca interna.
9. m. levator ani.
10. ureter.
11.fascia obturatoria.
12.fascia inferior diaphragmae pelvis.
13 - tuber ischiadicum.
14 - tela subcutanea.
15 - fossa ischioanale.
16 - membrana perinei.
17 - fascia superior diaphragmae pelvis.
18 – vagina.
Fig.165: Female pelvis divisions. Source
[165].
Peritoneum continuation through the female pelvis in the parasagittal section.
1.ureter.
2. tuba uterina.
3. ovarium.
4. lig. ovarium propriae.
5. lig. teres uteri.
6. lig. Latum.
7. ramus superior ossis pubis.
8. ramus inferior ossis pubis.
9. m. ishiocavernosus.
10. crus clitoridis.
11. labia minora.
12. labium majus.
13. m. sphincter ani externus.
14. m. transversus perinea profundus.
15. diaphragm pelvis (m. levator ani).
16. vagina.
17. vesica urinaria.
18. ureter.
19. rectum.
20. excavatio vesicouterina.
21. peritoneum.
22. excavatio rectouterina
.
Fig.166: Peritoneal continuation through the
female pelvis.
Source [166].
153
Peritoneal continuation through the male pelvis (the red line - visceral peritoneum, the blue
line - parietal peritoneum):
1. mesocolon sigmoideum.
2. rectum.
3. excavatio rectovesicalis.
4. vesica urinaria.
5. plica transversalis peritonei.
6. ileum.
7. omentum majus.
Fig.167: Peritoneal continuation through the
male pelvis.
Source [167].
Cellular spaces:
¾ The parietal and the visceral pelvic fascia form a group of cellular spaces of the lesser
pelvis - visceral and parietal ones.
¾ Visceral cellular spaces are interstices between a wall of an organ and the visceral fascia;
they contain a more or less solid layer of adipose tissue, vessels and nerves running to an
organ. Relative to an organ surrounded by the visceral fascia, they distinguish the
paravesical, paraprostatic, paravaginal, paracervical, and pararectal visceral cellular space.
The largest is the visceral fascia of the prostate and of the rectum; it is known as the capsule
for this organ.
¾ The lesser pelvis organs take the median position and do not contact the pelvic walls
directly - they are separated by cellular layers of the parietal spaces.
¾ Parietal spaces are situated between parts of the parietal fascia and the visceral fascia of
the organs.
¾ There are four parietal cellular spaces in the subperitoneal division of the female lesser
pelvis: one retropubic (prevesical), two lateral and one presacral (retrorectal). In males,
they mark one more, retrovesical space.
¾ All these spaces are practically considered as places of probable localization of suppurative
processes in the lesser pelvis.
¾ The rectum with its fascia and the presacral space are separated of all the rest by the
Denonvillier-Salitschev's fascia going frontally (in males, it is named the recto-prostatic,
fascia rectoprostatica; in females it is known as the rectovaginal, fascia recto-vaginalis).
This fascia (septum) by its lateral borders partly interlaces into the visceral rectal fascia,
partly fuses with the fascial capsule of the internal iliac vessels and along with the capsule
accretes to the parietal (presacral) fascia near the sacroiliac joint.
154
The cellular spaces of the female pelvis in the horizontal section:
1. spatium lateralis pelvis;
2. spatium retropubicum (prevesicalis);
3. umbilicalis (pars obliterans);
4. spatium paravesicale;
5. vesica urinaria;
6. symphysis;
7. fascia diaphragmatica urogenitalis superior;
8. fascia parietalis pelvis;
9. m. obturatorius internus;
10. fascia visceralis vesicalis;
11. the lateral fascial valve from the urinary bladder
visceral fascia;
12. canalis obturatorius;
13. fascia visceralis cervicis uteri et vaginae;
14. vagina;
15. Denonvillier-Salitschev’s fascia rectovaginalis
16. a., v. iliaca interna;
17. fascia visceralis recti
18. spatium pararectalis
19. rectum
20. sacrum
21. spatium presacralis (retrorectalis)
22. m. piriformis
Fig.168: The cellular spaces of the female
pelvis in the horizontal section.
Cellular spaces of the lesser pelvis in the sagittal section:
1. fascia superficialis;
2. tela subcutanea;
3. m. rectus abdominis;
4. fascia transversalis;
5. fascia vesicoumbilicalis;
6. peritoneum parietale;
7. spatium retropubicum;
8. symphysis;
9. fascia visceralis vesicae urinariae;
10. clitor;
11. diaphragma urogenitale;
12. orificium externae urethrae;
13. vagina;
14. membrana perinei;
15. centrum tendineum perinei;
16. anus;
17. fascia rectovaginalis [Denonvillier];
18. fascia visceralis vaginae et uteri;
19. m. levator ani;
20. fornix vaginae posterior;
21. fascia presacralis;
22. spatium presacralis;
23. fascia visceralis recti;
24. excavatio rectouterina.
Fig.169: Cellular spaces of the lesser pelvis in
the sagittal section.
155
Source [168].
Source [169].
The retropubic (prevesical) cellular space, spatium retropubicum:
¾ This space is frequently named prevesical (spatium prevesicale) or the Retzius space.
¾ In accordance with general disposition this space is situated between the parietal fascia and
the visceral fascia of the urinary bladder.
¾ The posterior wall of this space is the anterior lamina of the visceral fascia of the urinary
bladder; the lamina, uniting with the superior part of the fascia near the anterosuperior
surface of the bladder, forms a triangular duplication going up to the umbilicus. This part
of the fascia is known as fascia vesicoumbilicalis. By sides it is limited by fascial capsules
of the obliterated part of umbilical arteries. On the posterior side of the anterior abdominal
wall over these arteries the peritoneal plicae umbilicales media-les are formed; they were
described in the previous chapter.
¾ The anterior wall is the parietal fascia: inferior of the umbilicus, it is the transverse fascia
of abdomen passing down into the fascia covering the posterior surface of pubis.
Fig.170: Retropubic and retrorectal spaces.
Source [170].
¾ Lateral walls are formed by the so-called lateral valves - the place where the fascia of
umbilical arteries attaches to the parietal fascia of the lateral pelvic wall. As a rule, these
valves attach posterior of the obturator foramen but anterior of the deep ring of the inguinal
canal, so that the obturator canal opens into the retropubic space while the inguinal canal into the lateral space. The lateral valves separate the retropubic space of the lateral spaces.
¾ The inferior wall of the retropubic space as well as of the entire subperitoneal layer is the
pelvic diaphragm and partially the superior surface of the urogenital diaphragm where the
medial fascicles of m. levator ani do not slide with each other.
¾ Along the inferior wall of the space, Musculo-fibrous ligaments go - the pubovesical, ligg.
pubovesicalia, and in males the puboprostatic, ligg. puboprostaticum as well.
¾ The contents of the retropubic space are adipose tissue, the vesical and the prostatic venous
plexus and inferior urovesical arteries.
¾ When bones and urinary bladder are broken, blood and urine congest in the retropubic
space; as a result, serious phlegmons develop. Undue delay in opening and draining of a
phlegmon may let the process spread to the thigh through the obturator canal, through a
threshold between the pelvic and urogenital diaphragms into deep perineal layers and into
the lateral parietal spaces.
156
The retrovesical cellular space (spatium retrovesicale):
¾ The anterior wall of this space, which is described only in males, is the prostate and the
subperitoneal part of the posterior wall of the urinary bladder, both structures enclosed into
proper visceral fasciae.
¾ The posterior wall is the Denonvillier-Salitschev's fascia (fascia retroprostatica) which has
been described earlier.
¾ Laterally the space is limited by the rectovesical muscles, mm. rectovesicales with
musculofibrous structure.
¾ The floor of the retrovesical space is formed by medial parts of the pelvic diaphragm.
¾ The superior wall is the parietal peritoneum of the rectovesical pouch.
¾ The space contains terminal parts of the ureters, deferent ducts with their ampullae as well
as seminal glands (vesicles), loose cellular tissue and the posterior part of the prostatic
venous plexus.
¾ Pio-inflammatory processes may spread from the retrovesical space into the inguinal canal
region along the ductus deferens, into the lateral and further retroperitoneal cellular space
along the ureters.
The presacral (retrorectal) cellular space (spatium retrorectale):
¾ The anterior wall of this space is the visceral fascia of the rectum (the Amussat’s capsule).
¾ The posterior wall is formed by the presacral fascia and the sacrum.
¾ The lateral walls separating the presacral space from the lateral ones are the fascial capsules
of the internal iliac vessels and lateral areas of the Denonvillier-Salitschev’s fascia.
¾ The inferior wall is formed by the pelvic diaphragm (m. levator ani et m. ischiococ-cygeus)
with its fascia.
¾ There is no superior wall of this space; it continues on right into the retroperitoneal space.
¾ Besides of adipose tissue, the presacral space contains superiorly a., v. rectalis superior, a.,
v. sacralis mediana, the sacral part of the sympathetic trunk with nn. splanchnici sacrales
branching off from it, plexus hypogastricus superior, nn. splanchnici pelvini from the
parasympathetic centers of the sacral part of the spinal cord, and sacral lymph nodes, nodi
lymphoidei sacrales.
¾ Pio-inflammatory processes may spread up into the retroperitoneal cellular space; below it
is enclosed by the pelvic diaphragm (m. puborectalis et m. pubococcygeus - parts of m.
levator ani).
Lateral cellular spaces, (spatia lateralia dextrum et sinistrum):
¾ The anterior wall is the lateral fascial valve going from the visceral fascia of the urinary
bladder to the parietal fascia.
¾ The posterior wall is the fascial capsule of internal iliac vessels that attaches to the parietal
(presacral) fascia.
¾ The lateral wall is the parietal fascia coating the lateral pelvic walls.
¾ The medial wall is the tendinous arch of pelvic fascia and the visceral fasciae of the organs.
¾ The inferior one is the pelvic diaphragm.
¾ The superior wall is the parietal peritoneum passing from the walls onto the organs of the
lesser pelvis.
¾ In the lateral cellular spaces, there are: blood vessels (internal iliac arteries and veins and
their branches), venous plexi of the organs, lymphatic vessels and lymph nodes (along the
internal iliac arteries), obturator nerves, visceral nervous plexi, nervous trunks of the sacral
plexus, ureters, and deferent ducts (in males).
¾ In females, the cellular tissue situated between the laminas of the broad ligament of uterus,
ligamentum latum uteri passes on directly into the cellular tissue of the lateral spaces. This
part of the lateral space is known as the parametrium - the periuterine cellular space; it is
157
not limited from the lateral space. Two lateral parametria and one anterior are marked in
this space.
¾ The lateral parametrium adjoins to the cervix of uterus medially and fuses with the parietal
cellular tissue of the greater pelvis laterally along the lesser pelvis wall. In the lateral
parametrium, near the cervix of uterus, the uterine artery and the ureter crossing the artery
inferiorly and posteriorly are situated, and a little lower there is the uterine venous plexus.
¾ The precervical (anterior) parametrium is thin. Its cellular tissue separates the cervix of
uterus from the urinary bladder. Blood vessels of the lateral cellular space.
¾ The main arterial trunk supplying the organs of lesser pelvis with blood is the internal iliac
artery, a. iliaca interna. At the level of linea terminalis it branches off from the common
iliac artery and descends lateral of the rectum down to the greater sciatic foramen. The
fascial capsule for the artery and vein is connected with the visceral fascia of the rectum,
the Denonvillier-Salitschev's fascia and with the presacral fascia. At the level of the
superior border of the greater sciatic foramen a. iliaca interna splits into the anterior and
posterior trunk
Fig.171: Female pelvic cellular spaces. Source [171].
158
The Pelvic Splanchnic Nerves:
The PSNs join the inferior hypogastric plexus (IHP) at the lower medial edge of the coccygeus
muscle. Nerve bundles from S2, S3, and S4 spinal roots converge to form from 2 to 4 bilateral
larger nerve bundles of the PSN.
These nerves are responsible for the parasympathetic activity and nociception of the bladder, left
colon, sigmoid colon, and rectum, and are at risk during any radical pelvic surgery.
Fig.172: The Pelvic Splanchnic Nerves. Source [172].
159
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