Anatomical considerations during

G- laparoscopic surgery

Presented by
Professor Dr. Fatema Ashraf
Head, Dept. of Obs and Gynae
What should be considered?

A through knowledge not

only of pelvic anatomy
including vascular, nervous,
muscular, ligamental, fascial,
virtual and physical
spaces(foramina) and bony
structures but also of the
mechanical forces and
physiological process should
be familiar with
Compartments of Pelvis
Pelvis of female is divided into three
functional entities-
• Anterior compartment
• Mid compartment
• Posterior compartment
Different land marks
• Umbilicus, an important landmark – at L3-L4 vertebra
• Aortic bifurcation is located at the level of L4- L5 in
80% cases
• Most dangerous situation is observed in thin pts when
umbilicus is perpendicular to the aortic bifurcation or
in 50% cases perpendicular to lt common iliac vein
which crosses the sacral promontory near the midline
Contd..
• Lateral Umbilical fold :Further lateral runs lateral umbilical
folds of peritoneum overlying inferior epigastric artery. So its
is the key landmark. During insertion of port you must be
careful to avoid the injury. It is at 10 o clock position
Clinical importance
• Before ancillary Trocar placement it is necessary to
locate inferior epigastric vessels to avoid injury
• Approaximately 5 cm above the symphysis pubis the
distance between the inferior Epigastric and the midline
is 5-6 cm.
• Mean distance between medial Umbilical ligament and
inferior epigastric vessel is 2 cm
• Lateral trocar should be 8cm lateral to midline
Posterior Compartment

Several Important anatomical structures can be

identified through the parietal peritoneum are –
• Ureter can be found entering the pelvis over or
just below the bifurcation of Common Illiac artery
• Internal Iliac artery runs parallel and just posterior
to the ureter
Contd..
• External artery is seen little lateral and anterior to IIA on to
the medial edge of Psoas muscle
• External Illiac vein seen posterior and medial to EIA.
• Tracing ILA and EIA superiorly leads to point of bifurcation
of CIA at the pelvic brim overlying the sacroiliac joint
• Tracing the Rt. CIA upwards leads to bifurcation of the aorta,
overlying the L4
• Left Common Iliac may be difficult to identify because of
overlying sigmoid mesentry
• Left C l is located posterior and medial to artery
Structures at the pelvic brim
Superficially from lateral to medial-
• Infundibulopelvic (IP) with ovarian vessels, Ureter,
bifurcation of CIA and Common Iliac vein
• Deeper dissection exposes medial edge of Psoas
muscle, obturator nerve and fascia overlying
capsule of Sacroilliac joint
Pelvic Sidewalls
• Pelvic side wall is entered by opening a triangular peritoneal
reflection bounded anteriorly by round ligament, posteriorly by IP
ligament, laterally by External Iliac vessels
• From Superficial to deep three surgical layers can be dissected -
i)First layer of parietal peritoneum with ureter in its facial sheath
ii) Second layer, vascular layer composed of Internal Illiac vessels
With its visceral anterior branches like uterine, superior vesical
and inferior vesical, vaginal and middle rectal arteries
Contd…
iii) Third layer, from anterior to posterior consists
of Psoas muscle with external Iliac artery along
its medial border
External iliac vein medial and posterior to artery
and obturator internus muscle with obturator
nerve and vessels coursing towards obturator canal
Ligaments : Broad ligament, Round ligaments, ovarian ligaments

• Broad ligament : consists of a double layer fold of

peritoneum extending from uterus to lateral wall of
pelvis.
• Fallopian tube is attached in its upper free margin
• ovarian mesentry (Mesovarium) is attached to the
upper part of posterior leaf. Ovarian vessels and
nerves enter into mesoovarium through IP
Pelvic anatomy in a female
Contd..
• Ip is a part of Broad ligament, lies between lateral
end of Fallopian tube and pelvic wall. It crosses
the external iliac vessels approaximately 2 cm in
front of ureter.
• Meso salpinx lies between Falopian tube and level
of attachment of ovary to the broad ligament. It
contains infra tubal, infra ovarian and tubal
branches of ovarian vessels and infra tubal nerve
plexus
Contd..
• Ovarian Fossa is between meso ovarium anteriorly, peritoneal fold of
ureter posteriorly and Illiac vessls on lateral side.
• Anterio posteriorly base of broad ligament is broader than its upper
part
• Anterior leaf runs towards uterovesical pouch, posterior leaf
continues downwards to a lower level upto uterosacral ligament.
• It contains loose areolar tissue, and fat, cardinal ligaments, terminal
part of ureter and paracervical nerve and the lymphatic plexuses.
Contd..
• Upper portion of cardinal ligament is penetrated by
ureter as it traverse into tunnel of Wertheim’s just
beneath the uterine artery, 1-2 cm lateral to
isthmus of uterus, just lateral to the uterosacral
ligament
• Base of broad ligament delineates two important
spaces : anteriorly the paravesical space and
posteriorly the pararectal spsce
Ligaments
• Round ligament is a fibromuscular cord extending from the uterine
cornu to the deep inguinal ring through which it enters into the
inguinal canal
• Cardinal ligament: extends from lateral aspect of supravaginal cervix
and upper vagina to the side walls of pelvis. It has a vascular and a
nervous part. From above to downwards – Superficial uterine vein,
uterine artery, deep uterine veins and the middle rectal artery
constitute vascular part of parametrium.
Contd…
• Uterosacral ligament : paired fibromuscular firm bands extends from
posteriolateral aspect of cervix and vaginal fornix to the lateral edge
of 2nd, 3rd and 4th sacral vertebra
• Vesico uterine/ Vesico cervical ligament : extends from posterio
lateral aspect of bladder to the isthmus and cervix where it fuses with
anterior cervicovaginal fascia.
Spaces surrounding pelvic organ
Eight different avascular spaces :separated by three pairs of different
ligaments –
i) Retropubic space
ii) Paired paravesical space
iii) Paired para rectal space
iv) Vesicovaginal space
v) Rectovaginal space
vi) Presacral space
Contd..
• Retropubic space : Potential avascular space located between back of
pubic bone and anterior to bladder
• Paravesical space : located anterior to base of broad ligament on both
sides
Contd…
• Contiguos medially with retropubic space, point of
separation being the obliterated umbilical ligament
• Obliterated umbilical artery is retracted medially to expose
the virtual space whose lateral limit is by External Iliac vessel
• Dissection is continued deep through the loose areolar tissue
of the paravesical space until obturator internal muscle is
reached.
• The space bounded medially by the bladder, laterally by
obturator Internus muscle and pelvic diaphragm. Postrerior
border is represented by endopelvic facial sheath around
internal iliac vessels
Checklist before surgery
• Whether plan is organ conservation or removal
• Routine and Type of surgery
• Complications and possibility of conversion to laparotomy should be
discussed and documented via an informed consent
• Those pt who have severe adhesions or malignancy might be detected,
should have preoperative bowel preparation
• All patients should receive prophylactic antibiotics and wear antithrombotic
stocking
• Surgery Routinely done under GA
• Foley Catheter should beplaced to empty bladder
Contd..
• Abdominal skin should be prepared from xiphoid process to Mons
pubis like an abdominal laparotomy
• In the case of previous hysterectomy a vaginal placed sponge –on-
stick is helpful
Steps
• In a standered lap. Technique after induction of GA,
peneumoperitonium is attained using a veress needle
• A 10 mm laparoscope is introduced through 1 cm umbilical incision
• On direct view 2 to 3 accessory 5-12 mm trocars placed
• Rotate the scope around within pelvis and abdomen to evaluate them
properly
Thank you