Basic clinical retroperitoneal anatomy for pelvic surgeons

Abstract

Basic anatomical knowledge should be improved during residency period with clinical practice. Especially pelvic surgeons; obstetricians, gynecologists, gynecological oncologists, urologists and general surgeons must have an advanced level practise of retroperitoneal anatomy to gain surgical skills. Retroperitoneal topographic anatomy, retroperitoneal vasculature, ureteric dissection and pelvic avascular spaces are the precise points during pelvic surgery.

Keywords: Surgery; anatomy; gynecology; hypogastric; ureter.

Figure 1

Transverse section of the anterior abdominal wall; the extraperitoneal fascia with fatty tissue under the parietal peritoneum lies on the posterior abdominal wall called the retroperitoneum (Gray’s Anatomy for Students, 3^rd Edition, Churchill Livingstone/Elsevier, 2015)⁽¹⁾

Figure 2

Pelvic viscera and retroperitoneum (Atlas of Human Anatomy, 6^th Edition, Saunders/Elsevier, 2014)⁽²⁾

Figure 3

Demonstration to enter the retroperitoneum between the round ligament and infundibulopelvic ligament (lateral parietal peritoneum), right pelvic side wall (cadaveric dissection)

Figure 4

Demonstration of opening retroperitoneum, right pelvic side wall (cadaveric dissection)

Figure 5

Paraaortic region, aorta and inferior vena cava after paraaortic lymphadenectomy (surgical archieve)

Figure 6

Polar renal artery arising from the right common iliac artery and also abdominal aorta (surgical archive) VCI: Vena cava inferior, CIA: Common iliac artery

Figure 7

Uterine artery, right pelvic side wall (surgical archive)

Figure 8

Pubic vein, left pelvic side wall (surgical archive)

Figure 9

Left and right common iliac veins and arteries (surgical archive) IVC: Inferior vena cava

Figure 10

Right ureter below the right ovarian vein medial to the ascending colon and lateral to inferior vena cava, and left ureter underneath the mesentery of descending colon, medial/ parallel to the inferior mesenteric vein and lateral to aorta/ superior hypogastric plexus (surgical archive) RCIV: Right common iliac vein, RCIA: Right common iliac artery, LCIV: Left common iliac vein

Figure 11

Vascularization of ureter from the kidney to the bladder (left side), while dissecting the ureter traction should be applied towards the side of blood vessels (Moore Clinically Oriented Anatomy, 7^th Edition, Wolters Kluwer/Lippincott Williams & Wilkins, 2013)⁽⁶⁾

Figure 12

Vascular branch to ureter from internal iliac artery, right pelvic side wall, in the pelvis the most important vascular supply of the ureter is the branch from the internal iliac artery (surgical archive) IIA: Internal iliac artery

Figure 13

Sites of ureter injury, left pelvic side wall: Zone I, during infundibulopelvic ligament ligation just below the level of pelvic inlet; zone II, during uterine artery ligation (ureter crosses the cardinal ligament-uterine artery complex); zone III, during vaginal excision (ureter is anterolateral to the anterior vagina before entering the bladder-trigone) (cadaveric dissection) EIA: External iliac artery

Figure 14

Avascular spaces and supporting ligaments in the pelvis (Sobotta Atlas of Human Anatomy, 15^th Edition, Elsevier, Urban&Fischer. Copyright 2013/Gray’s Anatomy, The Anatomical Basis of Clinical Practice, 41^th edition, Elsevier, 2016)⁽⁷⁾

Figure 15

Prevesical space and contents (cadaveric dissection)

Figure 16

Paravesical space, right pelvic side wall (cadaveric dissection)

Figure 17

Presacral space (cadaveric dissection)

Figure 18

Presacral space and superior hypogastric plexus (surgical archive)

Figure 19

Pararectal space, right pelvic side wall (cadaveric dissection)

Figure 20

Right pelvic side wall; the paravesical space, anterior to the cardinal ligament is divided into two parts by the obliterated umbilical artery and the pararectal space, posterior to the cardinal ligament is divided into two parts by the ureter, the lateral part is called Latzko’s space and the medial part is called Okabayashi’s space (cadaveric dissection)

Figure 21

Vesicovaginal space (cadaveric dissection)

Figure 22

Rectovaginal space (cadaveric dissection)