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LaparoscopicSurgeon
StuartHart,MD,FACOG,FACS
AssistantProfessor
DivisionofFemalePelvicMedicineand ReconstructiveSurgery
DepartmentofObstetricsandGynecology
Director,USFCenterfortheAdvancementof MinimallyInvasivePelvicSurgery(CAMPS)
MedicalDirector,TampaBayResearchand InnovationCenter(TBRIC)
USFHealthCenterforAdvancedMedicalLearningandSimulation(CAMLS)
UniversityofSouthFlorida Morsani CollegeofMedicine
LaparoscopicAnatomy
Asoundknowledgeofanatomyiscrucialfor
performingsafe,efficientandeffectivesurgery
Thegynecologiclaparoscopistmustdevelopa
thoroughunderstandingoftheanatomyofthe:
Anteriorabdominalwall
Structuralanatomyoftheabdomenandpelvis
Retroperitoneallandmarksandunderlying
structures
Endopelvicfascialsupportivestructures
LaparoscopicAnatomy
Anterior Abdominal Wall
Structurallandmarksoftheanteriorabdominalwall
Umbilicus
Anteriorsuperioriliacspines
Pubicsymphysis
Vesselsoftheanteriorabdominalwall
Inferiorepigastricvessels
Superficialepigastricvessels
Superficialcircumflexiliacvessels
Layersoftheanteriorabdominalwall
Rectusabdominismuscle
Anteriorandposteriorrectussheath
Arcuateline
AnteriorAbdominalWallVessels
Inferiorepigastricvessels
Originatefromtheexternaliliacvesselsbeforeentry
beneaththeinguinalligament
Coursesmedialtotheroundligament
Travelsunderneaththelateralthirdoftherectus
abdominismuscles
Typicallynotvisualizedbytransillumination
Superficialepigastricvessels
Courseswithinthesubcutaneoustissueoftheanterior
abdominalwall
Maybevisualizedbytransillumination
Followsasimilarcoursetotheinferiorepigastricvessels
Superficialpelvicandperitonealstructures
Anteriorabdominalwall
Medianumbilicalfold
Peritonealcoveringofthemedianumbilicalligament/urachus
Medialumbilicalfolds
Peritonealcoveringoftheobliteratedumbilicalarteries
Allowlaparoscopicsurgeontoidentifyuterinearterybecauseof
originfrominternaliliacartery
Lateralumbilicalfolds
Peritonealcoveringoftheinferiorepigastricvessels
Directherniasoccursmedialtothelateralumbilicalfold
Indirectherniasoriginateslateraltotheumbilicalfold
Hasselbach'sTriangle: Laterally:InferiorEpigastricsarteryandvein
Medially:RectusSheath
Inferiorly:InguinalLigament
Posteriorly:TransversalisFascia
AnteriorAbdominalWallAnatomy
Urachus
Coursesfromthebladdertotheumbilicusinthemidline
beneaththeanteriorabdominalwallandmedianumbilical
fold
LiesinthespaceofRetzius,betweenthetransversalis
fasciaanteriorlyandtheperitoneumposteriorly
Lumennormallybecomesobliteratedduringembryonic
development,thusbecomingafunctionlessremnant
Patenturachusisrare
AnteriorAbdominalWallAnatomy
AnteriorAbdominalWallAnatomy
Anatomic Landmark Lateral to Midline
3 cm above
symphysis 5.6 +/- 1.0 cm 5.5 +/- 2.0 cm 8.5 +/- 1.0 cm
5 cm above
symphysis 5.2 +/- 1.2 cm 5.2 +/- 1.8 cm 9.5 +/- 1.6 cm
16 cm above
symphysis 4.6 cm 4.6 +/- 1.4 cm 10.7 +/- 1.7 cm 7.6 +/- 1.5cm
Hurd WW. Bude RO. DeLancey JO. Newman JS. The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at
laparoscopy. American Journal of Obstetrics & Gynecology. 171(3):642-6, 1994 Sep.
Ideal Port Placement
A: 5 cm above symphsis / 8 cm from midline
B: 3 cm above symphsis / 4 cm from midline
C: 16 cm above symphsis / 8cm from midline
Hurd WW. Bude RO. DeLancey JO. Newman JS. The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at
laparoscopy. American Journal of Obstetrics & Gynecology. 171(3):642-6, 1994 Sep.
VariationsinAnatomy
TypesofUmbilicalLigamentinsertioninto
UmbilicalRing
(oval or round)
AnteriorAbdominalWallAnatomy
Effect of obesity on location of great
vessels
Isaacson Keith., ed. Complications of Gynecologic Endoscopic Surgery. Philadelphia: Saunders, 2006.
UmbilicalPortPlacement
UmbilicalPortPlacement
Abdominal/PelvicCavity
Anatomy
Landmarks
Sacralpromontory
Uterus
Ovaries
Ureters
Rectosigmoid
Bladder
Ureters
BonyPelvis
Ilium
Ischium
Pubis
Pelvic inlet
Anteriorly: Pubic symphysis
Pubic tubercle
Laterally: Iliopectineal line
Linea terminalis
Posteriorly: First sacral vertebra
PelvicFloor
Muscles:
Puborectalis
Pubococcygeus
Iliococcygeus
Coccygeus
Piriformis
BonyLandmarks:
Pubicsymphysis
Ischialspine
Coccyx
Ligaments
Sacrospinousligaments
Sacrotuberous
Pelvic support
Uterosacral ligaments
Cardinal ligaments
Rectovaginal fascia
Pubocervial fascia
Endopelvic fascia
Collagen fibers
Elastin
Smooth muscle
UterosacralLigamentAnatomy
Ureter:
Enters pelvic cavity at the
pelvic brim
Courses superficial to the
common iliac artery and
deep to the
infundibulopelvic ligament
Travels in the medial leaf
of the broad ligament
Pelvic vasculature:
Internal iliac
External iliac
Ovarian vessels
Ureter:
Passes lateral to the uterosacral ligament and beneath the uterine artery lateral to
the cervix
Travels in an endopelvic fascia tunnel medially and anteriorly along the upper part
of the vagina, and enters into the bladder wall and then opens into the trigone
CourseofUreter
Protectingtheureterduringpelvicsurgery
AbnormalCourseofUreter
Pelvicvasculature
Hypogastricartery
Anteriorbranch
Obturatorartery
Inferiorglutealartery
Umbilicalartery
Uterineartery
Vaginalartery
Superiorvesicalartery
Inferiorvesicalartery
Middlerectalartery
Internalpudendalartery
Obliteratedumbilical
Posteriorbranch
Iliolumbarartery
Lateralsacralarteries
Superiorglutealartery
SidewallAnatomy
RetroperitonealAnatomy
SacralAnatomy
Hypogastricartery
Anteriorbranch
Obturatorartery
Inferiorglutealartery
Umbilicalartery
Uterineartery
Vaginalartery
Inferiorvesicalartery
Middlerectalartery
Internalpudendalartery
Internalpudendalbranches
Inferiorrectalartery
Perinealartery
Posteriorlabialarteries
Dorsalarteryofclitoris
Deeparteryofclitoris
Arteryofbulbofvestibule
LaparoscopicAnatomy
Asoundknowledgeofanatomyiscrucialfor
performingsafe,efficientandeffectivesurgery
ThisunderstandingwillkeeptheGynecologic
surgeryoperatinginasafemannerandreduce
complications
References
NetterAtlasofHumanAnatomy
BaggishM,KarramM.AtlasofPelvicAnatomy
andGynecologicSurgery.2nd edition.
Philadelphia:Saunders,2006
IsaacsonK.ComplicationsofGynecologic
EndoscopicSurgery.Philadelphia:Saunders,
2006.