CLINICAL ANATOMY OF THE LUMBAR REGION AND OF THE

Lumbar region borders

● Superiorly - 12th rib
● Inferiorly - iliac crest
● Laterally - midaxillary
● Medially- spinous process

Layers
● Skin
● subcutaneous tissue
● Superficial fascia
● Fatty layer inferiorly
● Proper fascia
● Deep fascia that covers muscles

Branches of lumbar plexus -

● ilioinguinal
● Femoral
● Iliohypogastric
● Genitofemoral which divides into genital and femoral
● Obturator nerve
● Lateral cutaneous nerve of thigh
● Lumbosacral trunk - portion of 4th lumbar nerve

RETROPERITONEAL SPACE
Lumbar region is posterior abdominal wall. The borders of the lumbar region are composed of
superiorly-the twelfth rib, inferiorly the iliac crest, medialy spinous processes of the lumber
vertebrae, laterally midaxillary line.

Layers:
skin, subcutaneous fat, superficial fascia, fatty layer in the inferior region. It is the so-called
lumbogluteal fatty pillow, proper fascia, thoracolumbar fascia is a deep fascia. The muscles of the
lumbar region are divided into two basic groups (parts): medial and lateral.
Medial and lateral muscles
Lateral - 3 layers
1st layer-
latissimus Dorsi
External oblique
2nd layer-
Serratus posterior inferior
Internal oblique
3rd layer-
Transverse abdominis

Medially (deeply)-
● Quadratus lumborum
● Psoas major
● Erector spinae

Medially these muscles are lined by intra abdominal

fascia/transverse fascia
Anterior to this- retroperitoneal space

The muscles of the medial part:

The erector spinae muscle.
The left and right portion of the muscles lie in a trough on either side of the vertebral spines. The
trough is limited anteriorly by transverse processes and in the thoracic region by the portion of ribs
medial to their angles. The remainder of the muscle is enclosed by thoracolumbar fascia. The muscle
is supplied by muscular branches of the dorsal rami of spinal nerves.
Quadratus lumborum muscles.
This flat muscle lies immediately laterally to the upper part of psoas major. It is quadrilaterally-
shaped muscle that lies alongside the vertebral column. It extends from the lower border of the
twelfth rib and the tips of the lumbar transverse processes to the iliolumbar ligament which spans
the gap between the fifth lumbar transverse process and the iliac crest itself. The anterior and
middle sheets of the thoracolumbar fascia enclose the quadratus lumborum muscle. The anterior
sheet of this fascia is thickened above to form the lateral arcuate ligament and below to form the
iliolumbar ligament.

Psoas major muscle.

The psoas major muscle lies in the paravertebral gutter at the side of the bodies of the lumbar
vertebrae from the twelfth thoracic to the fifth lumber vertebrae. The fibers run downward and
laterally and leave the abdomen to enter the thigh by passing behind the inguinal ligament. The
lateral border of the psoas muscle converges with the inguinal ligament. These muscles share a
common attachment to the lesser trochanter of the femur.

The psoas is enclosed in a fibrous sheath that is derived from the lumbar fascia. The sheath is
thickened above to form the medial arcuate ligament. These muscles are supplied by the lumbar
plexus.

The muscles of the lateral part ie in three layers he first layer is composed of the lastissimus dorsi
and the external oblique muscles

Although the lumbar part of the thoracolumbar fascia is an integral part of the posterior abdominal
wall, it forms an important site of origin for muscles of the lateral and abdominal walls.

The muscles of lateral part

1st layer-
Latissimus dorsi
is a large flat muscle. It’s origin extends from the lower six thoracic spines, the lumbar spines, the
sacral spines the iliac crest by means of the thoracolumbar fascia to which it is attached. It is
supplied by the thoracodorsal nerve from the posterior cord of the brachial plexus.

The external oblique muscle

having an oblique, free posterior border that extends from the up of the twelfth rib to the midpoint
of the iliac crest. The fleshy fibers fan out downward and medially over the anterior abdominal wall.

2nd layer-
The serratus posterior inferior
is a thin flat muscle that arises from the upper lumbar an lower thoracic spines. It's fibers pass
upward and laterally and are inserted to the lower ribs.

The internal oblique muscle

lies deeper than the external oblique one. It arises from the thoracolumbar fascia, the anterior two-
thirds of the inguinal ligament. It forms the floor of the lumbar triangle and has a triangle between it
an serratus posterior inferior. This is the "superior lumber triangle" Lesgaft-Grunfeld.
The triangle is formed by serratus posterior inferior superiorly, internal oblique muscle inferiorly and
by the erector spinal muscle – medially. The floor of this triangle is formed by aponeurosis
transverus abdominis muscle

The third layer is composed of the transverse abdominis muscle. It lies deep to the internal oblique,
and its fibers run horizontally forward It arises form the deep surface of the costal margin, the
thoracolumbar fascia, the anterior two-thirds of the medial margin of the iliac crest and the outer
half of the inguinal ligament.

Subcostal nerve, artery and vein pierce posterior aponeurosis of the transversus abdominis muscle
in triangle Legaft-Grunfeld and continue anteriorly between internal oblique and transvesus
abdominis muscle

Lumbar triangle Pti and superior lumbar triangle Lesgaft-Grunfeld are weak points of the lumbar
region where can be spread phlegmons from the retroperitoneal fat and seldom lumbar hernia.

3rd layer-
Transverse abdomins

Lumbar triangle (Petit’s)

is formed by a free posterior border of the external oblique muscle- laterally, and by a free border of
the latissimus dorsi-medially and the iliac crest – from below that is the foundation of the triangle.

The second layer is composed of the serratus posterior inferior muscle and internal oblique muscle.

Retroperitoneal space
Ant- parietal peritoneum of post abdominal wall
Post- intra abdominal/transverse fascia

Layers (all together- from Post to ant)

1. Intra abdominal fascia
2. Proper retroperitoneal fat
3. Posterior layer of renal fascia
4. Perirenal fat - continues as parauretic
5. Ant layer of renal fascia
6. Pericolic fat
7. Toldi's fascia/Retrocolic
3 layers of fat (from Post- anterior)
● Proper retroperitoneal fat - lies between intra abdominal fascia
(post) and posterior layer of renal fascia (anterior to it)
● Perirenal fat (enclosed by renal fascia), paruretic
● Pericolic fat - between anterior layer of renal fascia and parietal
peritoneum - TOLDI's fasci/Retrocolic fascia (behind ascending
colon)

Fascia
Retroperitoneal fascia
Retrocolic
Endoabdominal

Content - Organs, vessels and nerves

● Organs
● Kidneys ureters suprarenal glands pancreas posterior part of
ascending and descending colon descending ascending and
horizontal part of duodenum

Retroperitoneal space - plexus

● Plexus
● Aortic plexus
● Lumbar plexus
● Sympa trunk

Great vessels

Inf vena cava tributaries -

● Short hepatic vein
● Right gonadal vein (left gonadal vein enters left renal vein)
 ● Inferior phrenic vein and lumbar veins
● 2 renal veins

Abdominal aorta branches

3 divisions
1.For organs paired branches-
● Renal - right and left renal artery
● Middlesuprarenal
● Gonadal going to testis/ovary

2.For viscera unpaired

● Celiac trunk - T12/L1
● Superior mesenteric L2
● Inferior mesenteric L3

3.Branches going to body wall-

● Inferior phrenic arteries
● 4 pairs of lumbar segmental arteries

Terminal branches
● 2 Common iliac arteries
● Median sacral arteries

Kidney -

either side of vertebral column T11-12 - L2/3

● 2 surfaces- anterior and posterior
● 2 poles- Superior and Inferior
● 2 borders lateral convex and Medial concave
 ● Lies in perirenal fat (enclosed by retroperitoneal fascia)
Hilus-
vertical slit on the medial concave border (at L1)
CONSISTS OF-
Renal vein, 2 branches of renal arteries, renal pelvis and ureter, renal
artery 3rd branch
Perirenal fat encloses kidney
Perirenal fat enclosed by renal fascia

Layers of kidney -
● Closest- fibrous capsule - renal capsule - attached to contex

● Perinephric fat/perirenal fat - covering kidney+Suprarenal glands

● Renal fascia - extends medially and wraps the great vessels like IVC

Syntopy of kidney
● Right kidney is lower than left kidney (cause of right lobe of liver)
● Anteriorly to left kidney - stomach, spleen and tail of pancreas

● Anterior to right kidney - right lobe of liver & descending part of

duodenum sits in front of it medially

● Hilus region of left kidney- pancreas

● Hilus region of right kidney- duodenum

● Anterior to Lower pole of left kidney - left colic flexure/splenic

flexure
 ● Anterior to Lower pole of right kidney- hepatic flexure/right colic
flexure

● Left Lower pole of kidney- covered with peritoneum

● On the right too- lesser area covered with peritoneum
● Small intestine lies in front of both

LIGAMENTS of Kidney - Hepatorenal, Duodenorenal, Splenorenal

(near tail of pancreas)

Pedicle of kidney - consists of vein, artery and ureter/renal pelvis,

sympathetic nerves and lymph vessels.

Suprarenal glands - located on medial side of Upper superior pole of

kidneys

Blood supply - branches of inferior phrenic and renal arteries from

suprarenal branches of the aorta.
Blood drains to the inferior vena cava on the right and to the left renal
vein on the left

Covered by anterior layer of renal fascia (covered by renal fascia) -

perirenal fascia (just tell it)

Ureter
Located in Post abdominal wall
Behind the peritoneum
3 constrictions
First- where renal pelvis joins ureter
Second - crosses pelvic brim ; genitofemoral nerve- compression of the
nerve shows irradiation of pain to external genitalia and femur in
nephrolithiasis if the stone stops before second constriction - clinical
importance

Third - pierces the bladder wall

Arteries - renal artery- Superiorly

Branches of common iliac
Vesical artery- Inferiorly

Nephrectomy operation-

The 2 accesses/incisions are-

● Lumbar subtotal approach by Fludoolov- (incision performed on

skin) STARTS at angle between 12th rib and lateral border of
Erector spinal muscle to downwardly to a curved line between 12th
rib and iliac crest at the level of umbilicus and can be extended
forwards to the lateral border of the rectus muscle

● Bergmen-Israel - begin incision from bisector of angle of 12th rib

and lateral border of erector spinae muscle and is carried
downwards and forwards in a curved line between the 12th rib and
iliac crest.

It ends at the Ant wall- 4-5cm above ant sup iliac spine at iliac
crest
Difference Between Fludoolov and Bergman - READ THE LINES IN BOLD

The retroperitoneal space

is located between anteriorly - parietal peritoneum of the posterior abdominal wall and posteriorly -
intra-abdominal fascia or transversalis fascia.

Beneath the muscles of the medial and lateral parts of the posterior abdominal wall lies a thin layer
of transversalis fascia, which covers the deep surfaces of transversus abdominis quadratus
lumborum and psoas major muscles. This fascia is called according to the name of the muscle, which
it covers. For example, psoas fascia, quadratus fascia, transversal fascia are parts of the intra-
abdominal fascia

Retro fat
The retroperitoneal fat lies in three layers.

Beneath the transversal fascia, counting from the back forward, there is the first layer of the
retroperitoneal fat, which is called proper retroperitoneal. It is immediate continuation of the
extraperitoneal fat.

Retro fat wall

The walls of this fat layer are composes of:

anteriorly - retroperitoneal fascia and renal fascia, it's posterior layer posteriorly - transversalis
fascia: superiorly – diaphragm; inferiorly - fat layer becomes pelvis fat.

Pus spreading
The ways of pus spreading from retroperitoneal fat

are the following upwards pus can reach the diaphragm, there is a wear Point of the diaphragm,
called lumbar -costal triangle Bohdaleck and where pus can spread into thoracic cavity ; Pus can pass
through triangle Pti to lumbar region; pus can pass trough triangle Lestagt-Grunfeld to the lumbar
region under the latissimus dorsi muscle: downwards: pus can get into the pelvic tat; forward pus
can get into the extraperitoneal fat of preperitoneal fat as it is sometimes called

In front of proper retroperitoneal fat there is retroperitoneal fascia. It arises from the point of the
passage of parietal peritoneum from the lateral abdominal wall to the posterior abdominal wall and
reaches the lateral border of the kidney. Here it divides into two sheets or layers of the renal fascia
anterior and posterior. The renal fascia surrounds the perirenal fat and encloses the kidneys.
Anterior layer (sheet) encloses the suprarenal glands. Below of the kidneys retroperitoneal fascia
surrounds parauretric fat and encloses the ureters.

The second layer of the retroperitoneal fat is composed of perirenal fat (pararenal) and parauretric
fat. They are closed fat spaces (layer) posterior layer of the renal fascia, is connected in the left aorta
and in the right with inferior vena cava.

Anterior of anterior layer of the renal fascia there is the third layer of the retroperitoneal fat, the so-
called pericolic fat. The walls of this layer are composed of anteriorly - peritoneum of the posterior
abdominal wall and retrocolic fascia Toldi; posterior – retroperitoneal fascia and anterior layer of the
renal fascia; superiorly - transvers mesocolon: inferiorly in the parietal left-cecum, in the right
sigmoid mesocolon.

The retrocolic fascia Toldi arises (begins) from the point of the passage of parietal peritoneum from
the posterior wall to the ascending colon on the right and to the descending colon on the left. It
covers posterior walls of the ascending colon and the descending colon.

Pus can get from the right to the left and in the pericolic fat. Let's take down this material in the
form of a table.

The retroperitoneal space contains organs, blood vessels, lymph vessels and nerves. The organs of
the retroperitoneal space are: kidneys, ureters, Suprarenal glands pancreas. Posterior walls of the
ascending colon and descending colon, descending. horizontal and ascending parts of the
duodenum.

The vessels of the retroperitoneal space are: the abdominal aorta and it's branches the inferior vena
cava and it’s branches.

The nerves of the retroperitoneal space are the sympathetic trunks, aortic plexuses and lumbar
plexus and it’s branches

Lymph vessels of the retroperitoneal space are the thoracic duct, cisterna chili the intestinal trunk,
the right and left lumbar trunks and lymph nodes.

Kidney removal- Nephrectomy

Indication: renal damage with gunshot wounds, severe trauma, hydronephrosis, pionephrosis,
nephrolithiasis, malignant tumors, etc.

Before the operation it is essential to make sure in the existence of the second kidney, and establish
its functional capacities

The patient is lying on the healthy side with a sandbag under it. The lower limb is bent in the joints
of pelvis and knee on the healthy side, while it is stretched on the diseased one.

Anaesthetization-endotracheal narcosis.
Operation techniques: During the renal tumors, in case of extensive renal trauma, especially for
combined injuries of the organs located in the abdominal and renal cavity the most rational is
Fyodorov's incision, in which extraperitoneal and transperitoneal approaches towards the kidney are
combined.

Extraperitoneal approach is mostly carried out by Bergman-lsrael's incision.

According to the layers there are incised:

1. The skin with its subcutaneous tissue and fascia;

2. The lattisimus dorsi muscle and the external oblique muscle of abdomen;

3. Serratus posterior inferior muscle and the internal oblique muscle of abdomen;

4. Transverse muscle of abdomen.

Here must be spared subcostal and iliofemoral nerves which runs along the lower border of the
twelfth rib on the transverse muscle, and supplying parts of the abdominal muscles. Along with the
transverse muscle they are crossing the transverse fascia, and opening the posterior part of
retroperitoneal space. In order to avoid the damage of abdominal cavity and colon, parietal
peritoneum is moved forward and upward by swab. In case of incidental damage of peritoneum or
pleura the incision is immediately closed by Catgut continuous stitch and the operation goes on.

Since the retroperitoneal fatty tissue is disconnected, posterior renal fascia is incised, its edges are
stretched aside by the hook, and they began to separate dully (with fingers) and successively the
rear surface of kidney, lower pole, frontal surface and upper pole from fatty capsule.

The separation or the kidney from fatty capsule is complicated in case of existing cicatrixes there.
This manipulation represents one of the most difficult and responsible situation during the
operation. The possibility of the existing additional renal arteries should be taken into the
consideration, and t they are damaged, there develops the bleeding which is very hard to stop.

In order to avoid this problem, the additional arteries should be found and knotted in advance.

The separated kidney is raised high in the wound by hand. By means of swab the front and rear
surfaces of the kidney are cleaned carefully from fatty tissue. Ureter is separated and it is as deeply
knotted as possible by two ligatures of the hard Catgut. Ureter is incised between the ligatures and
its stump is treated with iodine. Renal blood vessels are knotted by two ligatures of silk thread. The
distance between the ligatures is 1sm. It is also possible to knot the renal artery and vein together.
In case of separate knotting, the very first is knotted the artery and then -the vein. At the hilus of the
kidney the Fyodorov's forceps is placed on the blood vessels, while the clip is put on between the
ligatures and forceps. The blood vessels are crossed between Fyodorov's forceps and the clip, the
kidney is removed. The clip is lessened carefully without removing it. If the bleeding does not begin,
it means that the blood vessels are well knotted and the clip is removed. The ends of the ligatures
are cut. The kidney bed is carefully inspected. The reliable hemostasis is also carried out. After that
the drainage is introduced in the kidney bed.

The sandbag is taken out of the patient and the closure of the incision is begun. The muscles are
sewed by large Catgut knotted stitches, while the skin is sewed by silk sparse stitches. The drainage
is brought out in the rear corner of the wound. It will be removed in five days after the operation.
Surgical approaches to the ureter
1. The upper third of the ureter, including the pelvi-uretic junction, can be exposed through a
posterolateral, subcostal or lumbotomy incision.

2. The middle third of the ureter lies in the iliac fossa and is usually exposed through a muscle cutting
incision. The incision, centered on Mc Burney's point, extends from the midaxillary line posteriorly to
the lateral edge of the rectus sheath anteriorly

3. The pelvic part of the ureter can be exposed through a low paramedian incision, a low oblique
incision above and parallel to the inguinal ligament or a transverse suprapubic incision.

4. Transvaginal approach to the pelvic through the lateral fornix of the vagina has been described for
the removal of stones from the lower part of the ureter in women.

Uretrolithotomy.
In this procedure the stone is removed through an incision in the ureter The incision in the ureter
may be repaired with absorbable sutures which do not penetrate the mucosa.

Injuries of the ureter. The ureter is more likely to be injured during pelvic operations, especially
those on the uterus, than by road traffic accidents, falls or perforating wounds

Incomplete tears may be loosely sutured witn tine absorbable sutures that do not penetrate the
mucosa. Complete tears are treated it possible by an end-to-end anastomosis using absorbable
sutures. diminishing the risk of stricture by spatulating the cut ends of the ureter before suturing.
Each end of the ureter is spatulated. This result in a wide oblique anastomosis which is carried out
with interrupted sutures over a ureteric split.

CLINICAL ANATOMY OF THE PELVIC CAVITY

Pelvic outlet borders
● Post-coccyx
● Ant- pubic arch
● Lateral - ischial tuberosities

Pelvic inlet borders

● Post - sacral promontory
● Laterally - iliopectineal lines
● Anteriorly- pubic Symphysis

Parietal muscles that line wall of pelvic cavity -

● Piriformis
● Obturator internus
● Levator ani
Pelvic diaphragm is formed by 2 muscles -
● Levator ani and small coccygeus muscles

Pelvic Fascia

Divides into Parietal and Visceral-

Parietal covers walls of pelvis.
It forms arcus tendinous on boundary between superior half of obturator
internus muscle and levator ani.

The pelvic fascia is formed by 2 ligaments (puboprostatic and

pubovisceral ligaments) between the pubic Symphysis and urinary
bladder in female.

Parietal muscles of pelvic region- Obturator internus

Visceral pelvic fascia covers all the pelvic viscera.

Pelvic viscera borders -

Anteriorly - pubic bones
Posteriorly- sacrum & coccyx
Laterally- sagittal plates

Neurovacular bundles -
Plexus of pelvic region-
Sacral plexus
Lumbosacral trunk
MAIN ARTERY OF PELVIC REGION- INTERNAL ILIAC ARTERY

The pelvic is composed of four bones:

the two innominate bones or hip bones from the lateral and anterior walls, and the sacrum and the
coccyx form the back wall. The pelvic is divided into two parts by the pelvic brim. Above the brim is
the false pelvis or greater pelvis, which forms part of the abdominal cavity. Below the brim is the
true pelvis or lesser pelvis. The true pelvis is a bowl-shaped structure that contains and protects the
lower parts of the intestinal and urinary tracts and the internal organs of reproduction. The true
pelvis has an inlet, an outlet and a cavity.

The pelvic inlet, or pelvis brim, is bounded posteriorly -by the sacral promontory, laterally - by the
iliopectineal lines, and anteriorly - by the symphysis pubis.

The pelvis outlet is bounded posteriorly by the coccyx, laterally by the ischial tuberosities, and
anteriorly by the pubic arch. Laterally there are the sciatic notches. The sciatic notches are divided
by the sacrotuberous and sacrospinous ligaments into the greater and lesser sciatic foramens.

The pelvic cavity lies between the inlet and the outlet. It is a short, curved canal, with a shallow
anterior wall and a much deeper posterior wall.

The walls of the pelvic are formed by bones and ligaments that are partly lined with muscles
covered with fascia and parietal peritoneum. The pelvis has anterior, posterior and lateral walls and
it also has an inferior wall of floor.

The piriformis muscle arises the front of the lateral masses of the sacrum and leaves the pelvis to
enter the gluteal region by passing laterally through the greater sciatic foramen. It is inserted into
the upper border of the greater trochanter of the femur.

The obturator membrane is a fibrous sheet that almost completely closes the obturator foramen,
leaving a small gap, the obturator canal for the passage of the obturator nerve and vessels as they
leave the pelvis to enter the thigh.

The sacrotuberous ligament is strong and extends from the lateral part of the sacrum and coccyx
and the posterior inferior iliac spine to the ischial tuberosity. The sacrospinous ligament is strong
and triangular in shape. It is attached by its base to the lateral part of the sacrum and coccyx and by
its apex to the spine of the ischium. The two ligaments convert the greater and lesser sciatic notches
into foramen, the greater and lesser sciatic foramens.

The obturator internus muscle arises from the pelvis surface of the obturator membrane and the
adjoining part of the hip bone. The muscle fibers converge to a tendon, which leaves the pelvis
through the lesser sciatic foramen and is inserted into the greater trochanter of the femur

The floor of the pelvis supports the pelvis viscera and is formed by the pelvic diaphragm and the
urogenital diaphragm.

The pelvic diaphragm is formed by the important levatores ani muscles and the small coccygeus
muscles and their covering fascias.

The levator ani is the important muscle and the integrity of the pelvis floor depends upon its
function. It is particularly liable to damage during difficult deliveries and this damage may be
followed by urinary incontinence prolapse of the bladder, and prolapse of the uterus through the
vagine. The muscle has a linear origin from the pelvic wall. This origin starts anteriorly on the inner
aspect of the body of the pubis, extends across the surface of the obturator fascia from an overlying
condensation of the pelvic fascia called the arcus tendineus and terminates at the spine of the
ischium where its most posterior fibers lie parallel with the lower coccygeus. The levator ani can be
described in two parts according to the origin of their fibers. Those fibers arising from the pubis are
known an pubococcygeus and those from the arcus tendindeus and the spine of the ischium as
iliococcygeus. The coccygeus muscle is a small muscle that arises from the spine of the ischium and is
inserted into the lateral margin of the lower sacrum and coccyx.

The urogenital diaphragm lies below the anterior part of the floor and the genital hiatus between
the medial margins of the levator ani muscles. The diaphragm consists of a layer of striated muscle
sandwiched between two fascial layers. 1The deep layer or superior fascia of the urogenital
diaphragm is an insubstantial layer which blends posteriorly with the perineal body and perineal
membrane. The muscular layer consists of the deep transverse perineal muscles The more
superficial fascial layer is known as the inferior fascia of the urogenital diaphragm, or more
commonly the perineal membrane.

The Pelvic Fascia

The pelvic fascia is the continuation of the endoabdominal fascia below the pelvic brim. The pelvic
fascia may be divided into the parietal and visceral layers.

The parietal pelvic fascia

lines the walls of the pelvis. It is formed arcus tendineus on boundary between the superior half of
the obturator internus muscle, from which the fibers of the levator ani arise. The pelvic fascia is
formed the two ligaments between the symphysis pubis and the urinary bladder in the female. They
are puboprostatic and pubovesical ligaments, respectively.

The visceral pelvic fascia

covers all the pelvic viscera.

The pelvic fascia is formed the two sagittal plates in passage from walls to pelvic organs. They spread
between the pubic bone and the sacrum. Thus the pelvic viscera are located into space, which is
limited anteriorly by the pubic bones, posteriorly by the sacrum and the coccyx and laterally- by the
sagittal plates. This space is divided into two parts anterior and posterior by septum, which is located
in frontal plane between the peritoneum and the urogenital diaphragm. This septum is called the
peritoneoperineal aponeurosis Dennonviller. The peritoneoperineal aponeurosis separates the
rectum from urinary bladder and the prostate the male.

The anterior parts of space in the male contains the urinary bladder, the prostate, the seminal
vesicle and ampulla of vas deferens. The anterior part of space in the female contains the urinary
bladder and vagina.

The posterior part of space contains the rectum in the male and female. The peritoneoperineal
aponeurosis Dennonvillier separates the rectum from the vagina. The fascial sheath of some pelvic
organs were described as capsules. The fascial sheath of the prostate is called capsule Pirogov-
Retziy. The fascial sheath of the rectum is called capsule Amuse. The organs of the pelvic cavity are
separated from the walls by fat spaces.
The relation of the peritoneum to pelvic viscera.
The peritoneum is formed the transverse vesical fold in passage from the anterior abdominal wall to
the superior wall of the urinary bladder. Further in the male the peritoneum covers part of the
lateral and posterior wall of urinary bladder and the medial borders (margins) of the ampullas of vas
deferenses and the apexes of the seminal vesicle. Then, the peritoneum passes on rectum, forming
the recto-vesical pouch. Laterally this pouch is limited by the recto-vesical folds of the peritoneum
which pass in sagittal direction from the urinary bladder to the rectum. The recto-vesical pouch
contains the coils of small intestine in norm, but it may contain the blood, the pus, the exudate in
pathology, plexuses drain into the internal iliac veins. The pelvic venous plexuses also communicate
with the external and internal vertebral plexuses These communications play an important part in
the spread of disease from the pelvis. It should also be remembered that the middle rectal veins
communicate with the superior rectal veins which form part of the portal venous system.

Nerves of the Pelvis

the sacral plexus lies on the posterior pelvic wall in front of the piriformis muscle. It is formed the
from the anterior rami of the fourth and fifth lumbar nerves and the anterior rami of the first
second. Third and fourth sacral nerves. Note that the contribution from the fourth lumbar nerve
joins the fifth lumbar nerve to form the lumbosacral trunk.

The lumbosacral trunk passes down into the pelvis and joins the sacral nerves as they emerge from
the anterior sacral foramen.

Branches

1.Branches to the lower limb that leave the pelvis through the greater sciatic foramen: the sciatic
nerve (L4 and 5, S1, 2 and 3) is the largest branch of the plexus and the largest nerve in the body the
superior gluteal nerve, which supplies the gluteus medius and minimus and the tensor fascia lata
muscles the inferior gluteal nerve which supplies the gluteus maximus muscle, the nerve to the
quadratus femoris muscle, which also supplies the inferior gemellus muscle; the nerve to the
obturator internus muscle, the posterior cutaneous nerve of the thigh which supplies the skin of the
back of the thigh.

2.Branche to the pelvic muscles, pelvic viscera and perineum the pudendal nerve (S2, 3 and 4) which
leaves the pelvis through the greater sciatic foramen and enters the peritoneum through the lesser
scatic foramen the nerves to the piriformis muscle: the pelvic splanchnic nerves. These constitute
the sacral part of the parasympathetic system and arise from the second, third, and fourth sacral
nerves. they are distributed to the pelvic viscera.

3. The perforating cutaneous nerve, which supplies the skin of the lower medial part of the buttock.

The obturator nerve is branch of the lumbar plexus emerges from the medial border of the psoas
muscle in the abdomen and accompanies the lumbosacral trunk down into the pelvis. crosses the
front of the sacroiliac joint and runs forward on the lateral pelvic wall in the angle between the
internal and external iliac vessels. On reaching the obturator canal (that is, the upper part of the
obturator foramen, which is devoid of the obturator membrane), it splits into anterior and posterior
divisions that pass through the canal to enter the adductor region of the thigh

The pelvic part of the sympathetic trunk is continuous above, behind the common vessels, with the
abdominal part. It runs down behind the rectum on the front of the sacrum medial to the anterior
sacral foramen. The Sympathetic trunk has four or five segmental arranged ganglia. Below the two
trunks converge and finally unite in front of the coccyx.

The pelvic splanchnic nerves constitute the parasympathetic part of the autonomic nervous system
in the pelvis. Some of the parasympathetic fibers ascend through the hypogastric plexuses and
thence via the aortic plexuses to the inferior mesenteric plexus. The fibers are then distributed along
branches of the inferior mesenteric artery to supply the large bowel rom he left colic flexure to the
upper hall of the anal canal.

The superior hypogastric plexus is situated in front of the promotory of the sacrum. it divides
inferiorly into right and left hypogastric nerves. The plexus is formed as a continuation of the aortic
plexus and from branches of the third and fourth lumbar sympathetic ganglia. it contains
sympathetic and sacral parasympathetic nerve fibers and visceral afferent nerve fibers.

The inferior hypogastric plexus lies on each side of the rectum the base of the bladder and the
vagina. It’s formed from a hypogastric nerve (part of the superior hypogastric plexus) and from the
pelvic splanchnic nerve. It contains postganglionic sympathetic fibers. pre and postganglionic
parasympathetic fibers, and visceral afferent fibers Branches pass to the pelvic viscera via small
subsidiary plexuses.

Lymphatic drainage in the pelvis. The lymphatic drainage of an organ in the pelvis is closely related
to that organs blood supply whether this is from, a branch of the internal iliac artery or directly from
the aorta. In the pelvis. lymphatic vessels also follow the fascial and peritoneal coverings of organs
which reach the iliac fossas and hence the nodes around the external iliac vessels. Groups of
lymphatic nodes are found around the internal external and common iliac arteries and along the
aorta. Additional nodes are found in the hollow of the sacrum. Connections between these groups,
however, allow the spread of lymph and therefore tumours from one organ or group to another in
an unpredictable manner. It must also be realized that many pelvic structures extend into the
perineum where the lymphatic largely to inguinal lymph nodes Beaning these facts in mind. the
common lymphatic drainage of the pelvic organs listed in chart may be more easily understood.
The Fat Spaces of the Pelvis.
All fat spaces may be divided into two parts parietal and visceral. The parietal tat spaces of the pelvis
are the two lateral spaces, the retropubic space and the retrorectal space.

The visceral fat spaces are paravesical space, the perimetric space, the paravaginal space the
perirectal space

The retropubic space may be divided into two parts by the previsceral fascia. They are the prevesical
space is located between the pelvic fascia - anteriorly and the prevesical fascia - posteriorly. The
preperitoneal space is located between the prevesical fascia - anteriorly and the peritoneum –
posteriorly.

The hematoma in fractures of the pelvis may occur the prevesical space. The urinary infiltration may
occur here injures of the bladder. The urinary infiltration may spread upwards along the
preperitoneal (extraperitoneal) fat of the abdominal wall in damage of the prevesical fascia.

The lateral spaces are communicated with retroperitoneal fat space, fat of the adductor region of
the thigh through obductor canal of the gluteal region through the infrapiriformis foramen along
inferior gluteal vessels and nerve and the sciatic nerve.

The retrorectal space is located between the ampulla of rectum and its capsula – anteriorly and
sacrum and pelvic fascia – posteriorly. The levator ani muscle and its fascia are limited this space
below. Above this space is communicated with retroperitoneal fat space.

The perimetric space is located between the layers of the broad ligaments. The fat of the perimetric
space below reaches to pelvic diaphragm, above it is communicated with the retroperitoneal fat,
laterally it is communicated with lateral space fat of the gluteal region.
The ways of pus spreading from the perimetric fat in parametritis are the following: upwards pus can
reach the retroperitoneal fat, laterally and posteriorly pus can pass through the infrapiriformis
foramen to the fat or the gluteal region, pus can pass through the inguinal canal along the round
ligament to the anterior abdominal wall pus can pass through the vessels lacuna to the fat of the
femoral triangle, pus can pass through the obturator canal to the adductor region pus can pass
through the lessor sciatic along the internal pudenda vessels and pudendal nerve to the fat of the
ischiorectal fossa (or through the fibers of the levator ani muscle)

The Pelvic Organs

Structures entering the pelvis. The greater peritoneal sac of the abdominal cavity dips down into the
lesser pelvis and provides a partial covering of peritoneum for some of the organs contained in the
pelvic cavity This extension of the peritoneal cavity may contain abdominal structures such as the
small intestine, the appendix, the pelvic colon or the greater omentum, but these are
separated from the cavity by their own covering of visceral peritoneum .

The rectum
The rectum occupies a similar pelvic position in both sexes but its anterior relations differ
considerably. The rectum begins in front of the third sacral vertebra as a continuation of the sigmoid
colon. It is a Continuation of the mobile sigmoid colon but is itself and has no mesentery passes
downward, following the curve of the sacrum (anteroposterior flexure) and ends in front of the tip of
the coccyx by piercing the pelvic diaphragm and becoming continuous with the anal canal. These
flexures are located in sagittal plane. The curved course is itself sinuous in that the middle portion af
the rectum or ampulla shows bend to the left. The flexure is located in frontal plane. At the border
of the levator ani muscle it pierces the pelvic floor lo become the canal, This point is referred to as
the anorectal junction The upper one-third of the rectum is covered by peritoneum anteriorly and
laterally. The middle third is only covered anteriorly and the lower third has no peritoneal
relationship.

Beneath the peritoneum the three taeniae coli typical of the large intestine fuse again into a
continuous longitudinal muscle coat. The muscular coal of the rectum as arranged in the usual outer
longitudinal and inner circular layers of smooth muscle. The three taeniae coli of the sigmoid colon,
however, Come together, so that the longitudinal fibres form a broad band on the anterior and
posterior surfaces of the rectum. The mucous membrane of the rectum together with the circular
muscle layers, form three permanent folds called the transverse fold of the rectum. These folds are
semi-circular two are placed on the left rectal wall and one on the right wall.

Posteriorly, the rectum is related to the sacrum, the coccyx and the pelvic floor. The sympathetic
trunks lateral sacral vessels and lymph nodes also lie posteriorly. Between the upper part of the
rectum and the lateral pelvic walls lie mobile small bowel or pelvic colon in the pararectal fossa of
the pelvic parietal peritoneum.

Anteriorly, in the male the rectovesical pouch containing coils of small intestine separates the
rectum from the bladder. Below this the rectum is related to the bladder, the seminal vesicles and
the prostate without the intervention of peritoneum. These structures are embedded in visceral
pelvic fascia. In the female, the rectouterine pouch separates the upper part of the rectum from the
uterus and the posterior fornix of the vagina. Below the pouch the rectum is directly related to the
vagina. The posterior surface of the prostate in the male and in the female the posterior surface
(wall of the vagina are separated from the rectal ampulla by the aponeurosis or fascia of Denonviller
(rectovesical and retrovaginal septum).

The blood vessels of the rectum.

The rectum is primarily supplied by the superior rectal branch of the inferior mesenteric artery. It
enters the pelvis by descending in the root of the sigmoid mesocolon and divides into right and left
branches. These at first lie behind the rectum and then pierce the muscular coat and supply the
mucous membrane. They anastomose with one another and with the middle and inferior rectal
arteries.

The middle rectal artery is a small branch of the internal iliac artery.

The inferior rectal artery is a branch of the internal pudendal artery in the perineum. It anastomoses
with the middle rectal artery at the anorecta junction.

A rectal plexus of veins is drained by the superior rectal vein, a tributary of the inferior mesenteric
vein. The rectal plexus, which extends into the anal canal, is also drained by the middle and inferior
rectal veins. It is the longitudinally running venous channels of the rectal plexus that become dilated
to form haemorrhoids or piles. This conditions is common and inconvenient. However haemorrhoids
may also be a manifestation of portal obstructions because blood which is g from draining though
the superior rectal vein passes through middle and inferior recap vein to join the Systemic Venous
System. this is an example of a portocaval anastomosis.

The nerve Supply to the rectum is the sympathetic and parasympathetic nerves from the inferior or
hypogastric plexuses.

The examination of the rectum.

The anal canal and lower rectum may be palpated by a finger inserted into the anal canal this simple
procedure should form part of every full physical examination in addition to the anal and rectal wall
it allows the prostate to be felt in the male. In the female, rectal examination provides an alternative
to vaginal examination, particularly during a delivery when the degree of dilatation o the uterine
cervix may be estimated.

Pathological conditions of the seminal Vesicles and ovaries and other pelvic disease may also be
detected in this manner. The rectum can be Viewed directly with the proctoscope examination may
be extended to the sigmoid colon with the sigmoidscope. The anteroposterior flexure of the rectum,
as it follows the curvature of the sacrum and coccyx, and flexure in frontal plane must be
remembered when one is passing a Sigmoidoscope, to avoid causing the patent unnecessary
discomfort.

Partial and complete prolapses of the rectum through the anus are relatively common Clinical
condition. In partial prolapse the rectal mucous membrane and submucous coat proteude for a short
distance outside the anus. In complete prolapse the whole thickness of the rectal wall proteudes,
through the anus. In both conditions, many Causative factors may be involved. However, damage to
the levators ani muscles as the result of childbirth and poor muscle tone in the aged are important
contributing factors. A Complete rectal prolapse may be regarded as a sliding hernia through the
pelvic diaphragm.
Pelvic viscera in the male

The rectum, sigmoid colon, and terminal coils of ileum occupy the posterior part of the pelvic cavity
in both sexes.

Ureters. The course of the ureters has been followed from the kidney over the posterior abdominal
Wall to pelvic brim. Each crosses the brim beneath the peritoneum covering the bifurcation of the
common iliac artery. Each ureter then runs down the lateral wall of the pelvis in front of the internal
iliac artery to the region of the ischial spine and turns forward to enter the lateral angle of the
bladder. In its pelvic course the ureter is crossed anteriorly (superiorly) by the ductus deferens.

The innervation of the ureter is of some interest. Although supplied by both sympathetic and
parasympathetic nerves the, nature of the motor supply to the thick muscular wall of the ureter is
unclear. What is certain is that this undergoes peristalsis and spasm of the muscle, usually to the
presence of a stone produces acute pain. This is referred to the skin innervated by the last two
thoracic and first two lumbar spinal cord segments. Typically, the pain starts in the loin and radiates
toward the scroturm and penis or to the labium majus.

The urinary bladder or vesica urinaria is a highly distensible muscular organ which, when empty, lies
in the pelvis and rests on the symphysis pubis and the floor of the pelvis, It is partially covered by
peritoneum (mesopertorneal) its muscular walls are of smooth muscle and is lined by transitional
epithelium. A lining layer that can adapt to the large changes in its volume. As it filled with urine
from the ureters, It enlarges upward into the abdominal cavity stripping peritoneum off the anterlor
abdominal wall as t ascends. In cases of prostatic obstruction to the flow of urine from the bladder, it
may extend to the umbilicus. The absence of peritoneum over its anterior aspect allows
percutaneous surgical drainage of the bladder above the pubis. In the infant the pelvic cavity is very
flat and shallow and bladder normally occupies an intraabdominal position.

The empty bladder Is pyramidal in shape, having an apex; a base, and a superior and two
inferolateral surfaces, it also has a neck. The apex of the bladder lies behind the upper margin of the
Symphysis pubis. To the apex of the pyramid is attached the median umbilical ligament a remnant of
the urachus.

The base, or posterior surface of the bladder is triangular in shape. At the two superior angles of the
base, the ureters enter the bladder and at the inferior angle, the urethra leaves it. It is here that the
smooth muscle of the bladder wall becomes circularly arranged the commensequent of the urethra
and forms the sphincter vesicae. The two vasa deferentia lie side by side on the posterior Surface of
the bladder is covered by peritoneum, which forms the anterior wall of the rectovesical pouch. The
lower part of the posterior surface is separated from the rectum by the vasa deferentia, the seminal
vesicles, and the rectovesical fascia or aponeurosis of Denonvillier.

The superior surface of the bladder is complete by covered with penitoneum and is related to
intraadbominal contents (usually coils of ileum or sigmoid colon). This is reflected on either side into
the paravesical fossas and onto the upper par of the base where it forms the anterior wall of the
rectovesical pouch.
The infrolateral surfaces are related in front to the retropubic pad of fat and pubic bones. More
posteriorly, they lie in contact with the obturator internus muscle above and the levator ani muscle
below.

The neck of the bladder lies inferiorly and rests on the upper surface of the prostate. Here the
smooth muscle fibers of the bladder wall are continuous with those of the prostate. The neck of the
bladder is held in position by the puboprostatic ligaments in the male and the pubovesical ligaments
in the female These ligament5 are thickenings of the pelvic fascia.

The interior of the bladder. The bladder can be disternded with water and examinated directly using
a cystoscope.

The mucous membrane of the greater part of the empty bladder is thrown into folds, but these
disappear when the bladder is full. The area of mucous membrane covering the internal Surface of
the base of the bladder s referred to as the trigone (lieto). Here the mucous membrane is always
smooth even when is empty because the mucous membrane over the trigone is firmly adherent to
the underlying muscular coat. The superior angles of the trigone correspond to the openings of the
ureters and its inferior angle, to the internal urethral orifice.

The ureters pierce the bladder wall obliquely and this provides a valve like action which prevents a
reverse flow of urine the kidney as the bladder fills.

The trigon is limited above by a muscular ridge, which runs from the opening of one ureter to that of
the other and is know as the interuretic ridge. The uvula vesicae is a small elevation situated
immediately behind the urethra orifice that is produced by the underlying median lobe of the
prostate.

The mucous membrane of the bladder, the two ureteric orifices, and the urethral meastus can easily
be observed by means of a cystoscope. With the bladder distened with fluid, an illiminated tube
fitted with lenses is introduced into the bladder through the urethra. Over the trigone the mucuous
membrane is pink and smooth, but is thrown into folds else where The ureteric orifices are slitlike
and eject a drop of urine intervals of about 1 minute. The interureteric ridge and uvula vesicae may
be recognized easily.

The muscular coat of the bladder is composed of smooth muscle and s arranged as three layers of
interlaing bundles known as the detrussor muscle. At the neck of the bladder the circular component
of the muscle coat s thickened to form the sphinctar vesiae. The bladder is supplied by the Superior
and inferior vesical branches of the internal iliac arteries. Veins which drain a vesical venous plexus
which communicates below with the prostatic plexus it is drained into the internal iliac vein.

The lymph vessels from the bladder drain into the internal and external iliac nodes.

The bladder receives both motor and sensory innervation. The motor fibres are both
parasympathetic and sympathetic. The Parasympathetic fibres are motor to the smooth muscle of
the bladder wall or detrusor muscle, but inhibit the sphincter vesicae. The sympathetic fibres on the
other hand are said to be inhibitory to the detrusor muscle and motor to the sphincter vesicae. The
sensory fibers give rise to the conscious sensation of a full bladder and also pain resulting from
disease. The fact that these pain fibers return to both sacral and lumbar segments of the cord makes
in difficult to surgically eliminate the intractable pain of terminal disease in this region.

Pelvic Viscera in the Female

The rectum, sigmoid colon and terminal coils of ileum occupy the posterior part of the pelvic cavity.

Ureter crosses the pelvic inlet in front of the bifurcation o the common iliac artery. It its pelvic
course the ureter is crossed the uterine artery two time. It runs downward and backward in front of
the internal iliac artery and behind the ovary (here the ureter crosses the uterine artery first time:
ureter anteriorly, the uterine artery posteriorly), until it reaches the region of the ischial spine. lt
then turns forward and medially beneath the bas of the broad ligament where it is crossed by the
uterine artery (second time uterine artery - anteriorly, ureter – posteriorly). This later relationship is
of extreme importance, for it is possible to damage the ureter when the uterine artery is ligated
prior to removal of the uterus during a hysterectomy. The ureter then runs forward, lateral to the
lateral fornix of the vagina to enter the bladder.

Urinary bladder. As in the male. the urinary bladder is situated immediately the pubic bones.
Because of the absence of the prostate, the bladder lies at a lower level than in the male pelvis, and
the neck rests directly on the upper surface of the urogenital diaphragm. The close relation of the
bladder to the uterus and the vagina is of considerable clinical importance The apex of the bladder
lies behind the symphysis pubis. The base, or posterior surface, is separated by the vagina from the
rectum. The superior surface is related to the uterovesical pouch of peritoneum and to the body of
the uterus. The inferolateral surfaces are related in front to the retropubic pad of fat and the pubic
bones. More posteriorly, they lie in contact with the obturator internus muscle above and the
levator ani muscle below The neck of the bladder rests on the upper surface of the urogenital
diaphragm.

The female urethra, which is only about 4.0 cm in length runs from the neck of the bladder through
the floor of the pelvis and perineal membrane to open into the vestibule just anterior to the opening
of the vagina. Over its course it is firmly bound ta the anterior wall of the vagina.