Review Article

Pelvic Retroperitoneal Dissection: A Hands-on Primer

Robert M. Rogers, MD, and Resad Pasic, MD*
From the Department of Gynecology, HealthCenter Northwest, Kalispell, Montana (Dr. Rogers), and Department of Obstetrics, Gynecology and Woman’s
Health, University of Louisville, Louisville, Kentucky (Dr. Pasic).

ABSTRACT This article is a personal perspective of female surgical pelvic anatomy and recommended surgical dissection techniques.
Journal of Minimally Invasive Gynecology (2017) 24, 546–551 Ó 2017 AAGL. All rights reserved.
Keywords: Anatomy; Millimeter by millimeter; Pelvis; Surgical skill

To become a competent surgeon, one must be able to
define the knowledge base and skill set of such a surgeon.
During training, the student surgeon must master the relevant
surgical and anatomic knowledge and be able to mimic the
motions of the experienced surgeon. The purpose of this
article is to define the qualifications of the competent surgeon
and the specific skills necessary to perform a safe and efficient
retroperitoneal surgical dissection in the female pelvis.
In 1995, independent of each other, Dr. Rogers in Mary-
land and Pennsylvania (with Drs. Harry Johnson, Alf Bent,
and Geoff Cundiff) and Dr. Pasic in Louisville, KY (with
Drs. Walter Wolfe and Ronald Levine) pioneered the teach-
ing of gynecologic surgery using unembalmed cadavers,
eventually joining talents in the late 1990s to teach prac-
ticing gynecologic surgeons the fundamentals of surgical
pelvic anatomy and gynecologic procedures in cadavers as
well as minimally invasive laparoscopic procedures. When
it became apparent that the students were not progressing
as expected, we reviewed the curriculum to discover what
was missing, what specifically needed to be taught, and
how to improve student proficiency.
We discovered that the missing link between knowledge
of surgical anatomy and becoming a competent surgeon at
the operating table is the skill of surgical dissection. The pur-
pose of surgical dissection is to expose the anatomic struc-
tures while safeguarding their structural and physiologic
Dr. Pasic has a research grant from Ethicon Endo and is speaker for Ethicon
Endo, Medtronic, and Olympus.
Corresponding author: Resad Pasic, MD, 550 S Jackson Street, Louisville,
KY 40202.
E-mail: paya@louisville.edu
Submitted January 13, 2017. Accepted for publication January 17, 2017.
Available at www.sciencedirect.com and www.jmig.org
1553-4650/$ - see front matter Ó 2017 AAGL. All rights reserved.
http://dx.doi.org/10.1016/j.jmig.2017.01.024
integrity by thinning the visceral connective tissues (endo-
pelvic fascia in the retroperitoneum) and any scar tissue in
which the anatomic structures are embedded and allowing
for continuous clear visualization of the field. The surgeon
must not cut, ligate, or coagulate any tissue that is not seen
or clearly understood. Bleeding must be minimal and imme-
diately controlled at the site. Dissection is deliberate and a
‘‘millimeter by millimeter’’ progression that ensures that
any injury to an anatomic structure, such as a ureter or bowel
serosa, is limited to 1 to 2 mm. Such injuries are easy to
repair, if necessary. When used ‘‘milliliter by millimeter,’’
these dissection techniques empower the student surgeon
to be confident and safe in his or her newfound skills.
The techniques of surgical dissection are best practiced on
the animal model and unembalmed cadavers. Currently, there
is no computer simulation program to practice true tissue
dissection. The techniques are simple yet very effective
when one concentrates and progresses in the dissection
‘‘millimeter by millimeter’’. Other techniques to be used
while implementing the ‘‘millimeter by millimeter’’ approach
include tenting of the tissues, small incisions, push-spread,
traction-countertraction, gentle ‘‘teasing’’ or ‘‘wiping’’ of
the tissue, and hydro/pneumodissection. The experienced sur-
geon uses these techniques instinctively without conscious
thought. The student surgeon must concentrate as he or she
learns to master these maneuvers and practice them in a delib-
erate manner until they become second nature.
Education Via Surgical Video or Live Surgery
When observing an experienced surgeon in the operating
room or on surgical video, it is crucial to listen, observe, and
focus. To do this, the student must be aware of two essential
aspects of any surgery: where in the pelvis the surgery is

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Rogers and Pasic. The Art of Surgical Dissection
taking place and what dissection techniques are being used.
Focusing on the specific skills and motions the experienced
surgeon uses to identify specific anatomic structures con-
tained within a small field of dissection as well as the
anatomic boundaries of that dissection field are crucial.
For example, the student witnesses the art of exposure via
tissue planes by using the push-spread technique, the trac-
tion and counter-traction technique, and by maintaining he-
mostasis. This allows the student to learn the core essence of
safe and efficient skills and how to grasp and guide instru-
ments to move and spread tissue [1,2].
Retroperitoneal Anatomy and Hands-on Dissection
The retroperitoneal landmarks within the female pelvis
alert the surgeon to key anatomic structures. The retroperito-
neal areas include the presacral area, the pelvic brim, the pel-
vic sidewall, and the parametrium (i.e., the base of the broad
ligament at the level of the cervicouterine junction [where the
ureter passes under the uterine vessels]). The retroperitoneal
spaces include the paravesical/paravaginal space, the retropu-
bic of Retzius, the vesicovaginal space, the pararectal space,
and the rectovaginal space (Fig. 1). The knowledge of surgical
anatomy is a 3-dimensional skill and must be mastered by
focused study and repetition through illustrations, videos, lec-
tures, cadaver dissections, and time in the operating room.
The Anatomy and Formation of the Pelvic Sidewall
At the pelvic brim laterally, overlying the sacroiliac joint is
the very important location of the entry of the anatomic struc-
tures that form the 3 layers of the pelvic sidewall [3]. Seen
through the peritoneum are the ovarian vessels in the infundi-
bulopelvic ligament, and, just under, the ureter passes over the
bifurcation of the common iliac artery into the internal and
external iliac arteries. Just under the arteries are the corre-
Fig. 1
A diagram of the avascular spaces. PV 5 paravesical space;
PR 5 pararectal space; RV 5 rectovaginal space.
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547
sponding veins, and under the veins the obturator nerve is
found exiting the medial edge of the psoas muscle. These
anatomic structures are not clearly seen at first because they
are embedded in fatty visceral connective tissue (areolar endo-
pelvic fascia), the surrounding tissue that must be thinned to
see these structures that appear to rotate 90 to form the 3 sur-
gical layers of the pelvic sidewall. The first layer of the pelvic
sidewall is the ureter on the parietal peritoneum (the ureteral
layer). The second surgical layer consists of the internal iliac
(hypogastric) artery and visceral branches (uterine, inferior
vesical, and superior vesical) (the visceral layer). These ves-
sels are embedded in visceral fascia (endopelvic fascia) along
with lymph channels and nodes, visceral nerves, and fatty
areolar tissue. The third layer includes the external iliac artery
and vein on the medial aspect of the psoas muscle and the
obturator nerve, artery, and vein on the anterior portion of
the obturator internus muscle (the parietal layer, Fig. 2).
This anatomic configuration then leads to the base of the
broad ligament (parametrium) where the ureter passes under
the uterine vessels. The surgical student must know that just
lateral to the cervicouterine junction the uterine artery and
vein trifurcate into the ascending, transverse, and descending
(vaginal) arteries and veins. This is important because during
a hysterectomy the area just next to the cervicouterine junc-
tion is vascular and potentially the source of hemorrhage.
Just as important, the surgeon must be aware that the ureter
courses under these vessels within 0.5 cm to 2 cm to the
side of the uterus and cervix in the undissected tissue.
The pelvic sidewall is frequently the site of surgical
dissection to positively identify the ureter when not clearly
visualized through the peritoneum during a hysterectomy,
Fig. 2
The dissected 3 layers (1–3) of the pelvic sidewall. The view is from the
patient’s right side. A 5 ureter; B 5 internal iliac artery; C 5 obliterated
umbilical artery; D 5 uterine artery; E 5 vaginal artery; F 5 uterine
vein; G 5 obturator artery; H 5 obturator nerve; I 5 external iliac
vein; J 5 external iliac artery; K 5 paravesical space; L 5 pararectal
space.
548
when excising sidewall endometriosis and scarring, when
excising an ovarian remnant, when excising a tumor, and
when removing lymph nodes from around the iliac vessels
and obturator areas.
Dissection Technique of the Pelvic Sidewall
When dissecting the pelvic sidewall, the surgeon starts at
the pelvic brim or lateral to the infundibulopelvic ligament
where there is no scarring or pathology. All dissection must
start from a clean, known anatomic area and proceed ‘‘milli-
meter by millimeter’’ by sharp dissection, with occasional
gentle ‘‘wiping’’ of the tissues, toward the area of the endome-
triosis, scarring, or tumor. Dissection is performed with 2
hands. In 1 hand during a laparoscopic or robotic procedure,
the grasper or coagulating forceps lifts the peritoneum and co-
agulates small capillary vessels during dissection. Monopolar
scissors or an ultrasonic instrument in the other hand cuts the
tissue and also coagulates the small capillary vessels. The
dissection is performed by creating traction and countertrac-
tion with 2 instruments, always applying force parallel to
the vital structures that are being dissected (Fig. 3). During
the dissection, the surgeon must expose, identify, and safe-
guard the vital structures (i.e., the ureter, external iliac artery
and vein, and obturator nerve and vessels, if necessary).
Pelvic Sidewall Dissection
The peritoneum lateral to the infundibulopelvic ligament
at the pelvic brim is tented away from the ureter and external
iliac vessels. The tenting of the peritoneum also thins the un-
derlying visceral connective tissues. The tented peritoneum
is then incised with a very small, superficial cut. In laparos-
copy, carbon dioxide gas insufflation gently enters the retro-
Fig. 3
The dissection and isolation of the ureter is performed by creating trac-
tion and countertraction with 2 instruments. The view is from the pa-
tient’s right side.
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Journal of Minimally Invasive Gynecology, Vol 24, No 4, May/June 2017
peritoneal cavity and helps the surgeon develop more
avascular planes. The tip of the scissors (handheld, laparo-
scopic, or robotic) are placed superficially under the incised
peritoneum and opened gently in the push-spread manner,
further thinning the visceral connective tissue surrounding
the external iliac vessels and the ureter (Fig. 4). Grasping
the edges of the incised peritoneum and gently pulling
apart, the traction-countertraction maneuver (Fig. 3) further
thins the visceral connective tissue so that the major vessels
and eventually the ureter can be readily visualized.
The dissection proceeds ‘‘millimeter by millimeter’’ par-
allel to the great vessels and the ureter. The arteries rhythmi-
cally pulsate with the heartbeat, the veins undulate with
respiratory efforts and intrapelvic pressure changes, and
the ureter vermiculates with peristalsis from time to time
when moving urine down toward the bladder. Each of these
motions is distinct and must be observed and learned.
As the dissection proceeds ‘‘millimeter by millimeter,’’
the embedded ureter and external iliac artery and vein may
be seen so that smaller blood vessels may be superficially
and safely coagulated away from these vital structures.
Maintaining hemostasis during dissection is a hallmark of
the competent surgeon so that the field remains visualized
at all times. With the first layer (ureteral) and the third layer
(the parietal layer consisting of the external iliac artery and
vein and the obturator artery, vein, and nerve) of the pelvic
sidewall positively visualized, the surgeon can superficially
ligate and coagulate tissue in the second surgical layer (the
visceral layer consisting of the internal iliac artery and
vein and their visceral tributaries and surrounding visceral
connective tissues) without causing harm to the patient.
However, the surgeon should continue to thin and move
any loose visceral connective tissue in order to conserve as
Fig. 4
‘‘Millimeter by millimeter’’ dissection by applying the push-spread
technique with laparoscopic scissors. The view is from the patient’s
right side.
Rogers and Pasic. The Art of Surgical Dissection 549

much of the visceral nerves in the area as possible because Fig. 5

fine visceral nerves usually cannot be seen. The second layer
The obturator space is dissected on patient’s right side. A 5 ureter;
of the pelvic sidewall is usually the layer involved with scar-
B 5 obliterated umbilical artery; C 5 obturator artery; D 5 obturator
ring and surgical pathology. If the ureter is involved, the sur-
nerve; E 5 external iliac vein.
geon must proceed carefully and parallel to course,
removing any scar tissue or endometriosis with cold scissors
and not electrosurgery near the ureter. Any injury close to the
ureter should be no more than 1 to 2 mm into the outer,
vascular coat. At this point, the surgeon should stop, achieve
hemostasis, and identify and assess the injury to the ureter.

The Surgical Spaces of the Female Pelvis: Anatomy and

Dissection Techniques
In this manner of ‘‘millimeter by millimeter’’ dissection, the
surgeon can easily follow the ureter to near the cervicouterine
junction where the ureter crosses under the uterine vessels.
Anterior and inferior to the cervicouterine junction and ureter
is the paravesical/paravaginal space. Posterior and inferior to
the cervicouterine junction and the ureter is the pararectal
space and then the rectovaginal space (Fig. 1). These spaces
are easily opened in an avascular manner using the push-
spread and traction-countertraction techniques to thin tissue.
by the iliococcygeus muscles of the levator ani, posteri-
Dissection of the Paravesical Space orly by the visceral fascial capsule surrounding the ante-
rior surface of the rectum, and anteriorly by the visceral
The paravesical space is found anterior to the base of the fascial capsule surrounding the posterior aspect of the va-
broad ligament and is bound medially by the bladder and gina. The rectovaginal septum is found just behind the va-
laterally by the obturator internus muscle fascia. The para- gina, somewhat adherent to it, and, yet, can be dissected
vesical space simply leads into the lateral portion of the away from it. This space is best approached by opening
space of Retzius (retropubic space). The space within the the peritoneum between the rectum and vagina and
paravesical space lateral to the obturator nerve is known as bluntly dissecting the space and pushing the rectum
the obturator space. The obturator nerve, obturator artery,
and vein (Fig. 5) are found in this space. From this region
above the level of the obturator nerve, the operating oncolo- Fig. 6
gist will harvest the obturator lymph nodes. The dissected paravesical and pararectal space on the patient’s right
side. A 5 retracted ureter; B 5 uterine artery; C 5 vaginal artery;
Dissection of the Pararectal Space D 5 internal iliac artery; E 5 obliterated umbilical artery;
F 5 obturator artery; G 5 obturator nerve; H 5 external iliac vein;
Posterior to the base of the broad ligament is the pararec- I 5 external iliac artery.
tal space, which is easily exposed by moving the ureter
medially toward the rectum, away from the internal iliac ar-
tery and vein and posterior to the origin of the uterine artery.
The anterior border of this space is the base of the broad lig-
ament. The lateral and medial borders are the internal iliac
artery and the rectum, respectively. This space also contains
the uterosacral ligament laterally as it passes posteriorly to-
ward the sacrum (Fig. 6). The uterine artery and vein and
vaginal artery and vein divide the pararectal space (poste-
rior) from the paravesical space (anterior). The dissection
of the pararectal space is essential to gain access to the rec-
tovaginal space in patients with rectovaginal endometriosis.

Dissection of the Rectovaginal Space

The rectovaginal space is bound superiorly by the cul-
de-sac peritoneum and the uterosacral ligaments, laterally

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550 Journal of Minimally Invasive Gynecology, Vol 24, No 4, May/June 2017

down, following the dictum that the fat belongs to the Fig. 7
rectum.
The space of Retzius. A 5 superior pubic rami covered by the Cooper
ligament; B 5 internal obturator muscle; C 5 bladder;
Dissection of the Retropubic Space D 5 pubocervical fascia.

The retropubic space (space of Retzius) is the areolar,

fat-filled potential anatomic space between the back of the
pubic symphysis and the bladder and from the pelvic
sidewall obturator internus fascia to the other obturator
internus fascia. The borders of the space of Retzius are
as follows: anteriorly, the back of the pubic symphysis;
laterally, the right and left obturator internus fasciae;
and posteriorly, the anterior peritoneal reflection from
the underside of the anterior abdominal wall to the
dome of the bladder and the internal iliac artery and
vein enveloped in the visceral connective tissue of the
cardinal ligament. On the floor of the space of Retzius,
the pubocervical fascia is attached to the fascia of pelvic
sidewall muscles via the arcus tendineus fasciae pelvis
and ends at the ischial spine, which can be palpated in
the space.
The dissection to the retropubic space with the laparo-
scope begins by filling the bladder with 250 mL sterile Dissection Over the Psoas Muscle to Harvest Lymph
water and incising the peritoneum 2 to 3 cm above the Nodes
filled bladder. The incision must be extended transversely The pelvic brim is important for the surgical oncologist for
between the obliterated umbilical arteries under the ante- harvesting pelvic lymph nodes from around the external iliac
rior abdominal wall, and the bladder must be allowed to artery and vein. This area is entered by tenting and opening the
drain. The laparoscopic grasper gently sweeps the fatty peritoneum between the round ligament and the infundibulo-
areolar tissue from anterior to posterior toward the pelvic ligament and then extending the incision superiorly in a
bladder to expose the back of the pubic symphysis, the ‘‘millimeter by millimeter’’ progression. The external iliac ar-
bladder, and the floor of the space. Care must be taken tery and vein can be visualized on the medial aspect of the
laterally because of the course of the obturator artery,
vein, and nerve on the anterior aspect of the obturator in-
ternus fascia (just under the superior pubic ramus); these Fig. 8
structures exit the body into the inner thigh through the The obturator foramen on the patient’s right side. A 5 obliterated um-
obturator canal (obturator notch). In the supine patient, bilical artery; B 5 obturator nerve; C 5 corona mortis (small branch
the obturator notch is approximately 4 cm back/lateral from the external iliac vein coursing medially and anastomosing with
from the pubic symphysis and approximately 6 cm a vein in the obturator canal); D 5 Cooper ligament; E 5 external iliac
vein; F 5 external iliac artery.
directly above/anterior to the ischial spine. Laterally, the
surgeon also uncovers the superior pubic rami, on top of
which are the external iliac vein and artery on each
side, and which are usually not seen because they are en-
veloped in fatty visceral connective tissue. The Cooper’s
ligament is the thickened parietal fascia covering the su-
perior pubic rami (Fig. 7). The retropubic space of Re-
tzius is where the surgeon performs a Burch retropubic
colposuspension and a paravaginal defect repair. When
performing a Burch procedure and anchoring sutures in
the Cooper’s ligament, the surgeon must be aware of the
possibility of small branches from the external iliac artery
and vein passing over the superior pubic rami to anasto-
mose with the obturator vessels traveling to the obturator
canal. These vessels are potential causes of hemorrhage
when inadvertently lacerated during suturing and are
appropriately called the ‘‘corona mortis’’ (Fig. 8).

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Rogers and Pasic. The Art of Surgical Dissection 551

Fig. 9 psoas muscle and are surrounded by the lymphatic chain of

nodes enveloped in the yellow, fatty areolar connective tissue.
The dissected area of the external iliac artery and vein. The patient’s
The external iliac artery and vein most commonly do not have
right side external iliac artery, vein, and genitofemoral nerve.
branches in this area, which is important to know when per-
A 5 external iliac vein; B 5 external iliac artery; C 5 Psoas muscle;
D 5 genitofemoral nerve.
forming a pelvic lymphadenectomy procedure. The first
branch is the deep circumflex iliac vein, which represents
the lower border (near the inguinal ligament) of the external
iliac node dissection. Parallel and lateral to the external iliac
artery and vein on the surface of the psoas muscle is the gen-
itofemoral nerve. Care should be taken not to injure this sen-
sory nerve when removing nodes in the area (Fig. 9).

References
1. American Congress of Obstetricians and Gynecologists for Women’s
Health Care Physicians. Available at: http://cfweb.acog.org/scog/
scog014/. Accessed January 31, 2017.
2. Rogers RM Jr, Taylor RH. The core of a competent surgeon: a working
knowledge of surgical anatomy and safe dissection techniques. Obstet
Gynecol Clin North Am. 2011;38:777–788.
3. Rogers RM. Pelvic anatomy seen through the laparoscope. In: Pasic R,
Levine RL, editors. A Practical Manual of Laparoscopy: A Clinical
Cookbook. 2nd ed. London: Informa; 2007. p. 7–17.

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