Search

Study Objective: To demonstrate the importance of being familiar with the anatomy of the endopelvic fascia as seen by laparoscopy to perform safe laparoscopic hysterectomies., Design: Combination of surgical videos and design diagrams., Setting: Compiled high-definition surgical videos from the Galaxy Care Laparoscopy Institute, Pune, India. These videos clearly demonstrate the anatomy of the endopelvic fascia and describe tips to avoid damage to the major structures, including the major vessels, ureter, bowel, bladder, and endopelvic fascia. The laparoscopic view of the anatomy with the current camera system is an excellent tool to demonstrate and teach pelvic anatomy, which can be applied to surgical principles in difficult benign and oncological cases., Intervention: We used a total laparoscopic approach to demonstrate the fasciae that were seen during various types of hysterectomies. The video shows the following: (1) the posterior leaf of the broad ligament was opened until it reached the apex of the uterosacral ligament; (2) the anterior leaf of broad ligament was opened until it reached the vesico-uterine peritoneal reflection; (3) the principles of bladder dissection; (4) the pubocervico-vesical fascia and its relevance to bladder dissection; (5) the relevance of the anatomy of the uterine artery, vein, and ureter with endopelvic fascia within the leaves of the broad ligament; (6) Denonvillier's fascia dissection technique for dissection of the rectum away from the vagina; (7) the anatomy of the vesicocervical ligaments, forming the ureteric tunnel; (8) the dissection principles of lateralizing the ureter in the retrovesical region; (9) the endopelvic fascia reflection, which continued caudally, covering the pelvic floor; and (10) the relevance of the anatomy of the endopelvic fascia and the stress urinary incontinence treatment technique., Conclusion: Understanding the anatomy of the fasciae of the pelvis helps to create avascular planes and is crucial for performing safe hysterectomies., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

The objective of this study was to evaluate the influence of vascular architecture of broad ligament of the uterus on fetal and placental development in gilts. Fifteen gilts DB-90 (DanBred) were divided into three groups according to gestational age at slaughter (50, 80, and 106 days). After slaughter, fetuses and placentas were collected, weighed, and measured. The uterine arterial system was detached by latex repletion for quantification of the number and diameter of the terminal vessels in different regions of the uterine horns (apex, middle region, and base). Fetal and placental measurements were statistically analyzed and correlated with the number and diameter of arteries in each uterine segment. No correlation was observed (P > 0.10) between the number and diameter of arteries destined to the uterus with the number or weight of fetuses or placental weight in any gestational group. It was observed (P < 0.05) that more vessels destined to the medium region of the uterine horns, independent of the gestational age or uterus side. At the 80th day of gestation, fetuses located at the base of the uterus have (P < 0.05) smaller cephalic and thoracic perimeters. It was concluded that there were differences in vascularization of broad ligament that irrigates the different uterine segments, but this was not sufficient to influence the development of fetuses in gilts. The middle region of the uterine horns was the segment with a greater number of vessels, regardless of gestational age., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Our objective was to concomitantly assess distribution of lymphatic and nerve structures in the parametrium., Methods: Twenty hemipelvises from ten fresh cadavers were dissected to differentiate between, three different parts of the parametrium: the lateral parametrium, the proximal and the distal part of the posterior parametrium. Histologic and immunofluorescence analyses of nerve and lymphatic structures were performed using NSE and LYVE-1 staining, respectively. The percentage of structures was independently scored as 0 (0%), 1 (1-20%), 2 (20-50%), 3 (50-80%), 4 (>80%)., Results: The lateral parametrium and the proximal part of the posterior parametrium contained both nerve (scored 2.25 and 2.50, respectively) and lymphatic (scored 2.50 and 2.00, respectively) structures. The distal part of the posterior parametrium also contained numerous nerve structures (scored 2.00) but lymphatic structures were rare (scored 0.88). No difference in nerve distribution was found according to the parts of parametrium while a significantly lower distribution of lymphatic vessels was observed in the distal part of the posterior parametrium (p=0.03)., Conclusion: The distal part of the posterior parametrium is of high nerve density and low lymphatic density raising the issue as to whether it should be removed during radical hysterectomy., (© 2013.)

Introduction and Hypothesis: Pelvic organ prolapse (POP) affects one third of women of all ages and is a major concern for gynecological surgeons. In pelvic reconstructive surgery, native ligaments are widely used as a corrective support, while their biomechanical properties are unknown. We hypothesized differences in the strength of various pelvic ligaments and therefore, aimed to evaluate and compare their biomechanical properties., Materials and Methods: Samples from the left and right broad, round, and uterosacral ligaments from 13 fresh female cadavers without pelvic organ prolapse were collected. Uniaxial tension tests at a constant rate of deformation were performed and stress-strain curves were obtained., Results: We observed a non-linear stress-strain relationship and a hyperelastic mechanical behavior of the tissues. The uterosacral ligaments were the most rigid whether at low or high deformation, while the round ligament was more rigid than the broad ligament., Conclusion: Pelvic ligaments differ in their biomechanical properties and there is fairly good evidence that the uterosacral ligaments play an important role in the maintenance of pelvic support from a biomechanical point of view.

The fascia pelvis parietalis (FPP) or endopelvic fascia is a well-known structure, but few studies described the detailed histological architecture, including the composite fiber directions. We hypothesized a gender-specific fiber architecture corresponding to the functional demand. For the first step to examine this hypothesis, we investigated specimens from 27 adult cadavers (10 males and 17 females) and 11 midterm fetuses (five males and six females) using immunohistochemistry and aldehyde-fuchsin staining. The adult female FPP was a solid, thick monolayered structure that was reinforced by abundant elastic fibers running across the striated muscle fibers, but it contained little or no smooth muscles (SM). In contrast, the male FPP was multilayered with abundant SM. In midterm fetuses, SM originated from the inferior part of the bladder and extended inferiorly along the gender-specific courses. Thus, we found a clear intergender difference in FPP architecture. However, the functional significance remained unknown because the basic architecture was common between nulliparous and multiparous women. Rather than for meeting the likely mechanical demands of pregnancy and vaginal delivery, the intergender difference of the FPP seemed to result from differences in the amount and migration course of bladder-derived SM as well as in hormonal background., (Copyright © 2010 Wiley-Liss, Inc.)

Objective: To perform vaginal hysterectomy and adnexectomy without laparoscopic assistance in women with ovarian endometriosis by accessing the posterior cul-de-sac via the posterior uterocervical-broad ligament space., Method: The author identified the posterior uterocervical-broad ligament space as a surgical window while reviewing his experience at accessing the pouch of Douglas in 40 women in whom vaginal hysterectomy without laparoscopic assistance was performed for ovarian endometriosis. He then used this window in 102 women to remove the adnexa vaginally during vaginal hysterectomy, also without laparoscopy., Results: This new technique was successful in 98 women, with no major complications, but 4 of the first 50 required laparotomy to complete the surgery., Conclusion: This new approach allows experienced surgeons to treat women with endometrial ovarian cysts by removing the adnexa vaginally during vaginal hysterectomy without laparoscopy, and complete the surgery abdominally or laparoscopically when necessary.

The peritoneum was examined for the existence of a vaginal ring and the round ligament of the uterus was dissected through the inguinal region in eleven embalmed adult female cats. In all cats, there was no evidence of a peritoneal evagination into the inguinal canal. There was no vaginal ring and no vaginal process. The round ligament of the uterus passed through the inguinal canal and disintegrated in the fascia a short distance beyond the superficial inguinal ring.

Objectives: To clarify the anatomy of the vesico-uterine ligament (VUL), we meticulously separated the VUL under magnification (x2.5) during Okabayashi's radical hysterectomy., Methods: Fifty-nine patients (TNM nomenclature: pTIb: 39, pT2a: 5, pT2b: 7, after trans-arterial anticancer-drug infusion treatment for the cervical cancer: 8) underwent this meticulous operation. Blood loss was recorded at two separate time points: during the separation of the VUL and after removal of the uterus., Results: After complete separation of the uterine artery and superficial uterine vein from the ureter, we could identify the genuine connective tissue of the anterior leaf of the VUL in which we isolate and divide a distinct bundle of blood vessels: the cervicovesical vessels that cross over the ureter from the bladder to the cervix. The remaining tissues in the anterior leaf is only avascular connective tissue. The posterior leaf of the VUL is the tissue residing under the ureter connecting the posterior wall of the bladder and the lateral cervix/upper lateral vagina. In the connective tissues, we identified the middle and inferior vesical veins connecting with the deep uterine vein. The division of these veins could separate the urinary bladder with ureters completely from the lateral cervix and upper vagina. The mean blood loss during the separation of the VUL was 20+/-10 g (N=59) and after radical hysterectomy was 189+/-91.6 g (N=59)., Conclusion: A precise network of blood vessels in the VUL is identified. The knowledge of this anatomy is important to perform radical hysterectomy.

The broad ligament is a double fold of peritoneum forming a mesentery for the human female genital tract. We investigated the anatomy of the broad ligament in different species and its hormonal regulation to determine if it had a role in gonadal positioning. The medical and veterinary literature was reviewed for descriptions of broad ligament anatomy and development. In addition, four adult female rats were dissected to compare the macroscopic anatomy of the broad ligament with any homologous structures in the male (n = 2). Detailed review was made of human males with persistent Müllerian duct syndrome (PMDS) and of bovine freemartin calves to determine the effect of abnormal hormonal environments on broad ligament development. Human and veterinary texts show variable broad ligament development between species, most being consistent with the size and shape of the uterus and uterine tubes. The broad ligament in adult female rats is a simple peritoneal fold and is homologous with the mesentery of the testis and vas deferens in males. Patients with PMDS and bovine freemartins have a broad ligament with intermediate anatomy. In PMDS the broad ligament is elongated and narrow, and not attached to the pelvic wall. The broad ligament is the mesentery of the genital ducts, and its anatomy varies with the degree of Müllerian duct fusion. The absence of a human male homologue is unusual, as the genital mesentery persists in male rodents. Apparent lack of a male homologue in the human may relate to obliteration of the processus vaginalis. The variable development of the broad ligament in pathological conditions is consistent with a role for steroid hormones in its development., (Copyright 2004 Wiley-Liss, Inc.)

This investigation was aimed at the evaluation of the shape and myoarchitectonic of of lymphangions in the uterine broad ligament in humans and albino rats. The lymphangion length and width was evaluated with further lymphangion volume determination, and number of myocytes in the muscular cuff was counted in the preparations containing 100 collector lymphatics obtained from 30 women aged 25-40 years and in 100 similar vessels taken from female albino rats. Most of lymphangions in the uterine broad ligament were found to have ellipsoid shape. In the rat, the lymphangions are longer and narrower with lesser volume and myocyte content in the muscular cuff, than those in humans. Short and round lymphangions with more transverse orientation of myocytes are often present close to ovary. In the angle between the uterus and the uterine tube (uterine horn in rat), single large lymphangions of collector or collector-distributive types with many processes are found. The correlation between uterine broad ligament lymphangion shape, structure and myoarchitectonic of their muscular cuffs with their location and relative width was observed.

The distribution of oviductal lymphatic vessels in the bovine mesosalpinx and bursa ovarica, and their communications with other lymphatics in the uterine broad ligament were examined after exposition of all lymphatic pathways with varicoloured microfil and/or ink-gelatin mixture. However, filling of the lumen of the oviductal infundibulum lymphatics was difficult or impossible because of its slender walls. Lymphatics of the isthmus and ampulla with short precollectors formed branches 1.5-2.0 cm long on both sides: dorsal and ventral of the uterine broad ligament. Collectors with slender and long lymphangions, visible after filling their lumen, encircled the alymphatic area in the parainfundibullar mesosalpinx. The greatest number of lymphatic branches, which originated from the paraisthmal part of the oviductal ampulla were observed in the subovarian area. The characteristic feature was their immediate proximity with uterine and oviductal arterial vessels. Subsequent studies have provided convincing evidence that there are direct connections of lymphatics leaving the oviduct and ovarian sac with lymphatics emerging from the uterus and ovary (after bilateral filling of lymphatics pathways in the whole broad liagment of the uterus). The performed investigations showed particularly characteristic feature in the cow--mixing lymph leaving various reproductive organs in the area of the right and left ligament--before two long collector branches reach the nearest lymphatic node/-s.

Localization and morphological features of lymphatic vessels leaving tissues of uterine horns and running through the broad ligament area were studied in mature cows after filling the lumen of the each lymphangion with varicoloured masses, mainly Microfil. The study has revealed that each branch of the lymphatic vessels emerged from both sides of the uterus and then formed double-layered networks, dorsal and ventral in the area of the mesometrium. The lymphatic branches under the uterus are very numerous and consist of enlarged precollector lymphangions. At the level of the ovary, the branches of vessels in both layers interweave each other forming the common pathway suggesting that lymph leaving the bovine uterus can be mixed in branches which are formed by elongated lymphangions running to lymphatic nodes.

Objective: To determine the optimal site in the uterosacral ligament for suspension of the vaginal vault with regard to adjacent anatomy and suspension strength., Methods: Fifteen female cadavers were evaluated between December 1998 and September 1999. Eleven hemisected pelves were dissected to better define the uterosacral ligament and identify adjacent anatomy. Ureteral pressure profiles with and without relaxing incisions were done on four fresh specimens. Suture pullout strengths also were assessed in the uterosacral ligament., Results: The uterosacral ligament was attached broadly to the first, second, and third sacral vertebrae, and variably to the fourth sacral vertebrae. The intermediate portion of the uterosacral ligament had fewer vital, subjacent structures. The mean +/- standard deviation distance from ureter to uterosacral ligament was 0.9 +/- 0.4, 2.3 +/- 0.9, and 4.1 +/- 0.6 cm in the cervical, intermediate, and sacral portions of the uterosacral ligament, respectively. The distance from the ischial spine to the ureter was 4.9 +/- 2.0 cm. The ischial spine was consistently beneath the intermediate portion but variable in location beneath the breadth of the ligament. Uterosacral ligament tension was transmitted to the ureter, most notably near the cervix. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure., Conclusion: Our findings suggest that the optimal site for fixation is the intermediate portion of the uterosacral ligament, 1 cm posterior to its most anterior palpable margin, with the ligament on tension.

Ten women had endometriosis and pelvic peritoneal defects of the posterior leaf of the broad ligament, with the consistent finding of medial displacement of the ureter toward the uterosacral ligament. Ureterolysis at the time of surgery revealed the underlying course of the ureter and its proximity to the uterosacral ligament, making it susceptible to surgical injury. It is important for surgeons to be aware of this anatomic alteration associated with these specific peritoneal defects.

The broad ligament containing uterine, paraovarian, and oviduct lymphatics was examined in the pig in various phases of the estrous cycle using light, scanning and transmission electron microscopy. The architecture of these regions differed and was independent of the lymphangions of the precollector and collector lymphatic vessels. Lymphangions were separated from mesothelium by connective tissue and/or muscle layers; however, in the vicinity of the thin walled paraovarian sac, large lymphangions were often compressed between two epithelial layers. Numerous lymphatic lacunae were in direct contact with the peritoneal and paraovarian sac cavities. The mesothelial lining of the broad ligament and the external and internal epithelium of the pig paraovarian sac displayed two distinct cell types. Only smaller cuboidal cells with prominent microvilli extended above the lymphatic endothelium. The surfaces of these cells were discontinuous and showed: 1) lymphatic stomata, 2) small pores or fenestrae, 3) a superficial network of epithelial-free communications with underlying connective tissue to the paraovarian sac in the postovulatory period independent of the lymphatic vasculature, and 4) endothelial (instead of epithelial) cells with crevice-like discontinuities in large portions of the internal sac surface during the follicular phase of estrus. Numerous lymphatic stomata had orifices composed of flattened cuboidal cells while lymphatic endothelial cells were characterized by macula or zonula adherent connections formed within rims of various sizes (up to 50 microns in diameter). During estrus, there were circular (0.5-2.0 microns) and irregular (to 10 microns) interendothelial openings in stomatal orifices with migrating cells. These morphologic findings suggest that absorption and passage of fluid, particles and cells between cavities and the lymphatic lumen in areas of the paraovarian lymphatic plexus in the pig is feasible.

We examined the immunohistochemical staining characteristics of S-100 protein in the vessels of the broad ligament of the swine uterus. The endothelial cells of arterial vessels, lymphatics and blood capillaries as well as nerve fiber bundles showed S-100 protein positivity. In contrast, the endothelial cells of veins did not react for the S-100 antiserum. Immunoreactivity for S-100 protein in the endothelial cells of lymphatics did not consistently demonstrate strong staining intensity. Accordingly, we filled lymphatics with colored gelatin before immunohistochemical staining to facilitate identification of lymphatics under light microscopy. Numerous arterioles and capillaries (of which the endothelial cells were immunopositive for S-100 protein) in the lymphatic walls, especially those in the paraovarian vascular plexus, support the existence of a microvascular arterio-arterial rete mirabile network.

The aim of the study was to perform uterus measurements in order to demonstrate variability of size, shape and proportions of each part of uterus. Topography, shape and dimensions of the uterine artery and its organic branches were also analyzed. The main part of the study was to analyze the arterial system in the walls of the human uterus. The study has been performed in order to find correlation between anatomic variety and age, and obstetric history of the investigated females. Internal genital organs taken at autopsy from 105 female cadavers (only unchanged pathologically) aged from 3 to 85, underwent evaluation (Table 1). Material consisted of 8 non menstruating girls, 30 nulliparas (20 premenopausal and 10 postmenopausal) and 67 multiparas (32 and 35, respectively). During postmortem examination topography of the origin sites of the uterine artery originating from the internal iliac artery, its diameters and its position towards ureter have been estimated. External measurements of the uterus have been performed. After excision of the uterus, uterine arteries have been injected with radiologic contrast medium. Radiography of the uterus has been taken using roentgenographic apparatus for structural research, and then arrangement of the uterine arteries in myometrium and their organic branches have been assessed. Uteri have been sectioned horizontally, and finally enlarged radiographs of each layer have been taken to estimate the arrangement of vessels at different levels of the myometrium. Fractionation itself made accurate measurements of the walls of the uterus possible at different levels. It has been stated that shape and size of the uterus changed considerably during the whole individual's life. Changes occurred not only within time, but they were connected with motherhood as well. Variability of the external dimensions of the uterus was always closely connected with variability of the uterus wall's thickness at different levels. Angiographic studies revealed that uterine arteries were present in every case, on both sides, regardless of the age and obstetric history. Topographic investigations proved that the vessels always crossed the ureter superficially on both sides. Considering each of the three segments of the uterine artery, it was stated that the length of the descending part of the vessel varied only within age, while the transverse and ascending parts were elongated within age and also after pregnancies. The number of the uterine artery branches running towards the body and cervix of the uterus was significantly variable and depended not only on age, but on pregnancies as well. Radiographic analysis revealed that connections between uterine vessels on both sides of the same uterus were not constant. Their absence was associated with the presence of the hypovascular, or even avascular zone in the medial part of the fundus and body of the uterus. This situation was evident at any age, regardless of the obstetric history. Artery of the fundus uteri, which had been previously described in many studies, was a rarely existing vessel. In the investigated material no azygos uterine artery has been found. Microangiographic studies (Fig. 1-4) revealed that angioarchitectonics of blood vessels in consecutive layers of the wall of the human uterus at different levels was variable to a great degree. It has been stated that situation depended not only on age, but also on past pregnancies.

The authors used dissections of adult and fetal female cadavers to describe the meso uro-genito-rectum or visceral pelvic fascia, visceral prolongation of the parietal pelvic fascia. This meso uro-genito-rectum consists of two parts: 1 The anterior part: formerly the umbilico-prevesical aponeurosis, called the meso-bladder in this text. 2 The posterior part: the meso recto-vagina. While the meso-rectum was already well described using the term "rectal wing" or para-rectum, knowledge of the meso-vagina under the meso-cervix (or paracervix or Mackenrodt's cardinal ligament) was poorly defined, and concerning the following in particular: * its posterior prolongation by the meso-rectum, * its relations with the middle rectal pedicle (formerly the middle hemorrhoidal pedicle),* its helicoidal appearance when in anatomical position.

The lymphatics of the broad ligament were depicted in 24 pigs by multiple interstitial injections of latex into the ovary and subserosa of the mesometrial margin of the uterine horn. Two morphologically different networks of lymphatics emanating from the uterus and ovary were established. Ovarian lymphatics leave the hilus, invariably enter the parovarian plexus, lie superficially under the perimetrium of the mesovarium, and run a parallel course closely intertwined with the blood vessels in this region. Some lymphatics are thus located close to the branches of the ovarian artery and the utero-ovarian vein. Whereas the ovarian and uterine lymphatics in the swine are not directly connected, the uterine lymphatics enter the mesovarium and lie in close proximity to both the ovarian lymphatics and nearby blood vessels.

Falloposcopy combined with laparoscopy was performed in 11 women during the late follicular phase of spontaneous menstrual cycles, and a preovular follicle was confirmed to be present in each case. The fimbrial end of the tube and the ipsilateral ovary containing the preovular follicle were suspended in a fluid environment of 200 ml of lactated Ringer's solution which acted as a support medium for visualization of tubal mucus and facilitated the endoscopy procedure. As the falloposcope was passed through the fimbrial opening, it was observed to carry clear, elastic and filamentous strands of mucus material from within the distal tubal lumen in 4 of 11 procedures. As these mucus strands were carried on the tip of the falloposcope to touch the surface of the ovary containing the preovular follicle, they attached, on contact, in all cases. The fimbrio-ovarian mucus bridge created was quite strong and could be stretched for up to 7 mm before it detached from the ovarian surface. The mucus attachment appeared to be equally secure over the preovular follicle and adjacent ovarian surfaces. These fimbrio-ovarian mucus connections, which have a high affinity for ovarian surface attachment about the time of ovulation, may play an important role in securing tubal oocyte capture in humans.

Wertheim's radical operation aimed, by removing the parametrial tissue far from the tumour, to achieve margins free of disease. The paratissues contain the lymphatic channels draining the cervix. They run to the pelvic wall and are interspersed by lymph nodes scattered throughout the parametrium. If lymphadenectomy is to be curative then the entire parametrium must be removed. To this end the resection of the cardinal ligament was pushed to its limit by dissection directly at the pelvic wall. The surgical technique is guided by the anatomy of the pelvic fascia. The gaine hypogastrique lies just beneath the peritoneum and facilitates the opening of the paravesical space. The following are discussed: the condensations of the pelvic fascia; the composition of the cardinal ligament; the division into a venous, an arterial, and a neurovegetative root; and the anatomy of the connective tissue planes. The order in which the surgical steps are carried out is important. The paraspaces are opened first. The ureter is identified, and lymphadenectomy is performed. The rectum is dissected off the vagina, and the uterosacral ligaments are identified and removed. Only then is the vesico-uterine fold opened. The bladder is dissected off the vagina, and the anterior parametrium is clamped and divided. Now the cardinal ligament is completely exposed. The bladder, rectum and ureter have been mobilized so that the parametrium can be divided sharply directly at the pelvic wall, clipping the vessels step-by-step. The paracolpium is clamped and divided according to the proposed vaginal cuff. Thus, the entire lymphatic drainage can be removed. The value of this extension of radical abdominal hysterectomy lies especially in the treatment of large, voluminous tumours.