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Editors: Handa, Victoria L.; Van Le, Linda Title: Te Linde's Operative Gynecology, 12th Edition Copyright ©2020 Lippincott Williams & Wilkins > Front of Book > Dedication Dedication As this 12th edition of Te Linde's Operative Gynecology was going to press, we were saddened to hear of the passing of Dr. Howard W. Jones, III on March 9, 2019 at the age of 76. Dr. Jones was editor of Te Linde's Operative Gynecology from 2003 to 2018. He was Division Director of Vanderbilt Gynecologic Oncology, then Chairman of the Department of Obstetrics and Gynecology at Vanderbilt University from 2009 to 2016, and Editor-in-Chief of the Obstetrical and Gynecological Survey from 1992 to 2009. He was active nationally, internationally, and locally and served as president of numerous societies. Academically, he shared his great wisdom and knowledge in 56 peerreviewed articles, 23 chapters, and 6 major medical text books. As a Gynecologic Oncologist, he took care of a broad range of cancers and had a special interest in precancers and cancers of the cervix. He was an educator and clinician with an equal love for both. His kindness, generosity, willingness to support junior faculty, and overall love of the specialty was well known. I (LVL) worked with Dr. Jones on the Survey when I was a junior faculty. He listened carefully, offered great advice, and was kind and patient. Dr. Jones was a great humanitarian, physician, leader, and mentor. He will be missed by all. 2 James J. Burke II, MD Associate Professor The Donald G. Gallup, MD, Scholar of Gynecologic Oncology Director Gynecologic Oncology Mercer University School of Medicine Savannah, Georgia Ronald T. Burkman, MD Professor Emeritus Department of Obstetrics and Gynecology Tufts University School of Medicine Baystate Medical Center Springfield, Massachusetts Erin T. Carey, MD Assistant Professor Division Director Division of Minimally Invasive Surgery Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North ; Carolina Paula M. Castaño, MD, MPH Associate Professor Department of Obstetrics and Gynecology Columbia University Irving Medical Center New York-Presbyterian Hospital New York, New York Chi Chiung Grace Chen, MD, MHS Associate Professor Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Mindy S. Christianson, MD Assistant Professor Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Leslie H. Clark, MD Assistant Professor Division of Gynecologic Oncology Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina 5 Editors: Handa, Victoria L.; Van Le, Linda Title: Te Linde's Operative Gynecology, 12th Edition Copyright ©2020 Lippincott Williams & Wilkins > Front of Book > Editors Editors Victoria L. Handa MD, MHS Professor, Gynecology and Obstetrics Director, Division of Female Pelvic Medicine and Reconstructive Surgery Chair, Department of Gynecology and Obstetrics, Johns Hopkins Bayview Medical Center Deputy Director, Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Linda Van Le MD Leonard Palumbo Distinguished Professor Division of Gynecologic Oncology Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina Contributors Melinda G. Abernethy, MD, MPH Associate Professor Department of Obstetrics and Gynecology Director, Division of Female Pelvic Medicine and Reconstructive Surgery Western Michigan University Homer Stryker MD School of Medicine Kalamazoo, Michigan Nadeem R. Abu-Rustum, MD Chief Attending Gynecology Service, Department of Surgery Memorial Sloan Kettering Cancer Center Professor Department of Surgery Weill Cornell Medical College New York, New York Marisa R. Adelman, MD Assistant Professor Division of General Gynecology Department of Obstetrics and Gynecology University of Utah School of Medicine Salt Lake City, Utah Arnold P. Advincula, MD, FACOG, FACS 3 Levine Family Professor of Women's Health Vice-Chair, Department of Obstetrics & Gynecology Chief of Gynecology, Sloane Hospital for Women Columbia University Medical Center New York-Presbyterian Hospital New York, New York Ted L. Anderson, MD, PhD Betty and Lonnie S. Burnett Professor Vice Chairman for Clinical Operations and Quality Director, Division of Gynecology Department of Obstetrics and Gynecology Vanderbilt University Medical Center Nashville, Tennessee Caroline C. Billingsley, MD Assistant Professor Division of Gynecology Oncology Department of Obstetrics and Gynecology University of Cincinnati College of Medicine Cincinnati, Ohio Linda D. Bradley, MD Professor of Surgery Vice Chair, OB/GYN & Women's Health Institute Director, Center of Menstrual Disorders Cleveland Clinic Cleveland, Ohio Vance A. Broach, MD Assistant Attending Gynecology Service, Department of Surgery Memorial Sloan Kettering Cancer Center Assistant Professor Department of Surgery Weill Cornell Medical College New York, New York Jubilee Brown, MD Professor and Associate Director Gynecologic Oncology Levine Cancer Institute, Atrium Health Charlotte, North Carolina Amy G. Bryant, MD, MSCR Associate Professor Division of Family Planning Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina 4 Sarah L. Cohen, MD, MPH Assistant Professor Harvard Medical School Director of Research and Fellowship Program Director, Division of Minimally Invasive Gynecology Brigham and Women's Hospital Boston, Massachusetts Marlene M. Corton, MD, MSCS Professor Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology Director, Anatomy Educator and Research University of Texas Southwestern Medical Center Dallas, Texas Geoffrey Cundiff, MD Dr. Victor Gomel Professor Head, Obstetrics & Gynaecology University of British Columbia Vancouver, British Columbia, Canada John O. L. DeLancey, MD Norman F. Miller Professor of Gynecology Department of Obstetrics and Gynecology Professor of Urology University of Michigan Ann Arbor, Michigan Jennifer E. Dietrich, MD, MSc Professor Department of Obstetrics and Gynecology and Pediatrics Chief of Pediatric and Adolescent Gynecology Texas Children's Hospital Division Director Pediatric and Adolescent Gynecology Baylor College of Medicine Houston, Texas Tommaso Falcone, MD Cleveland Clinic Lerner College of Medicine Case Western Reserve University Professor and Chief Academic Officer, Cleveland Clinic London Department of Obstetrics and Gynecology Cleveland Clinic Cleveland, Ohio Tola B. Fashokun, MD Assistant Professor Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland 6 Rajiv B. Gala, MD Associate Professor Department of Obstetrics and Gynecology University of Queensland/Ochsner Clinical School Vice-Chairman Ochsner Health System New Orleans, Louisiana Antonio R. Gargiulo, MD Associate Professor of Obstetrics, Gynecology and Reproductive Biology Harvard Medical School Center for Infertility and Reproductive Surgery Brigham and Women's Hospital Medical Director of Robotic Surgery Brigham Health Boston, Massachusetts Dana R. Gossett, MD, MSCI Professor Director, Obstetrics, Gynecology and Gynecologic Subspecialties Department of Obstetrics, Gynecology, and Reproductive Sciences University of California San Francisco San Francisco, California Cara Grimes, MD, MAS Associate Professor New York Medical College Chief of Advanced Urogynecology and Female Pelvic Medicine and Reconstructive Surgery Westchester Medical Center Valhalla, New York Robert E. Gutman, MD Associate Professor Department of Obstetrics and Gynecology and Urology Georgetown University Program Director, Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology Medstar Washington Hospital Center Washington, District of Columbia Victoria L. Handa, MD, MHS Professor, Gynecology and Obstetrics Director, Division of Female Pelvic Medicine and Reconstructive Surgery Chair, Department of Gynecology and Obstetrics, Johns Hopkins Bayview Medical Center Deputy Director, Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland 7 Geri Hewitt, MD Clinical Professor Department of Obstetrics and Gynecology Ohio State University College of Medicine Section chief, Pediatric and Adolescent Gynecology Nationwide Children's Hospital Columbus, Ohio Mitchel Hoffman, MD Professor Department of Oncologic Sciences Morsani College of Medicine University of South Florida Senior Member Department of Gynecologic Oncology Moffitt Cancer Center Tampa, Florida Howard W. Jones III, MD† Betty and Lonnis S Burnett Professor of Obstetrics and Gynecology Division of Gynecologic Oncology Director of Gynecologic Oncology Vanderbilt University School of Medicine Nashville, Tennessee †Deceased Chava Kahn, MD, MPH Instructor Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Kimberly Kenton, MD, MS Professor, Obstetrics & Gynecology and Urology Chief, Female Pelvic Medicine & Reconstructive Surgery Northwestern University Feinberg School of Medicine Chicago, Illinois Lindsay M. Kuroki, MD Assistant Professor Division of Gynecologic Oncology Department of Obstetrics and Gynecology Washington University School of Medicine St. Louis, Missouri David M. Kushner, MD John and Jeanne Flesch Professor of Gynecologic Oncology Department of Obstetrics and Gynecology University of Wisconsin School of Medicine and Public Health 8 Madison, Wisconsin Christina Lewicky-Gaupp, MD Associate Professor Medical Director, PEAPOD Perineal Clinic Director, Resident Surgical Education and Simulation Department of Obstetrics and Gynecology Division of Female Pelvic Medicine and Reconstructive Surgery Northwestern University Feinberg School of Medicine Chicago, Illinois Jaime Bashore Long, MD Assistant Professor Department of Obstetrics and Gynecology Division of Female Pelvic Medicine and Reconstructive Surgery Pennsylvania State College of Medicine Hershey, Pennsylvania Michelle Louie, MD, MSCR Assistant Professor Division of Minimally Invasive Gynecologic Surgery Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina Obianuju Sandra Madueke-Laveaux, MD, MPH Assistant Professor Department of Obstetrics and Gynecology The University of Chicago Medicine Chicago, Illinois David C. Mayer, MD Division Chief of Obstetric Anesthesia Professor Departments of Anesthesiology and OB/GYN University of North Carolina School of Medicine Chapel Hill, North Carolina Christine P. McKenzie, MD Assistant Professor Department of Anesthesiology University of North Carolina School of Medicine Chapel Hill, North Carolina Magdy Milad, MD, MS Professor Department of Obstetrics and Gynecology Northwestern University Chief, Gynecology and Gynecologic Surgery 9 Department of Obstetrics and Gynecology Northwestern Memorial Hospital Chicago, Illinois Jessica E. Morse, MD, PhD Assistant Professor Division of Family Planning Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina Margaret G. Mueller, MD Assistant Professor Division of Female Pelvic Medicine and Reconstructive Surgery Departments of Obstetrics and Gynecology and Urology Northwestern University Feinberg School of Medicine Chicago, Illinois David G. Mutch, MD Ira C. and Judith Gall Professor Vice-Chair of Obstetrics and Gynecology Division of Gynecologic Oncology Department of Obstetrics and Gynecology Washington University School of Medicine St. Louis, Missouri Kristin E. Patzkowsky, MD Assistant Professor Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Annette Perez-Delboy, MD, MBA Associate Professor Department of Obstetrics and Gynecology Columbia University College of Physicians and Surgeons New York, New York Anna Powell, MD, MS Assistant Professor Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland John A. Rock, MD, MHCM Senior Vice President, Health Affairs Founding Dean Emeritus, Herbert Wertheim College of Medicine Professor of Obstetrics and Gynecology Department of Obstetrics and Gynecology 10 Florida International University Miami, Florida Ritu Salani, MD, MBA Associate Professor Division of Gynecologic Oncology Department of Obstetrics and Gynecology The Ohio State University College of Medicine Columbus, Ohio Heather Z. Sankey, MD, CPE, MEd Professor and Chair Department of Obstetrics and Gynecology University of Massachusetts Medical School-Baystate Baystate Health Springfield, Massachusetts Howard T. Sharp, MD Professor Vice-Chair for Clinical Activities Department of Obstetrics and Gynecology University of Utah Health Sciences Salt Lake City, Utah Matthew T. Siedhoff, MD, MSCR Associate Professor Director, Center for Minimally Invasive Gynecologic Surgery Department of Obstetrics and Gynecology Cedars-Sinai-University of California, Los Angeles Los Angeles, California David E. Soper, MD Paul B. Underwood, Jr. Professor Department of Obstetrics and Gynecology Medical University of South Carolina Charleston, South Carolina John T. Soper, MD Catherine Sou-Mei Young Distinguished Professor of Gynecologic Oncology Division of Gynecologic Oncology Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina Ryan J. Spencer, MD, MS Assistant Professor Division of Gynecologic Oncology Department of Obstetrics and Gynecology University of Wisconsin School of Medicine and Public Health 11 Madison, Wisconsin Gretchen S. Stuart, MD, MPHTM Professor of Obstetrics and Gynecology Chief, Division of Family Planning Director, Fellowship in Family Planning University of North Carolina School of Medicine Chapel Hill, North Carolina Laurie S. Swaim, MD Professor of Obstetrics and Gynecology Director Division of Gynecologic and Obstetric Specialists Baylor College of Medicine Chief of Gynecologic Services Pavilion for Women at Texas Children's Hospital Houston, Texas Edward Tanner, MD Associate Professor Chief of Gynecologic Oncology Northwestern Medicine Northwestern University Feinberg School of Medicine Chicago, Illinois Arthur Jason Vaught, MD Assistant Professor Departments of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Karen C. Wang, MD Assistant Professor Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Renée M. Ward, MD Assistant Professor Department of Obstetrics and Gynecology Vanderbilt University Medical Center Nashville, Tennessee Katharine O'Connell White, MD, MPH Associate Professor Vice-Chair of Academics Department of Obstetrics and Gynecology Boston University School of Medicine Director, Fellowship in Family Planning Boston Medical Center 12 Boston, Massachusetts E. James Wright, MD Associate Professor Department of Urology Johns Hopkins University School of Medicine Baltimore, Maryland Jason D. Wright, MD Sol Goldman Associate Professor Chief, Division of Gynecologic Oncology Vice Chair of Academic Affairs Department of Obstetrics and Gynecology Columbia University College of Physicians and Surgeons New York, New York Emmanuel E. Zervos, MD Professor of Surgery Director of Cancer Services Division of Surgical Oncology East Carolina Brody School of Medicine Greenville, North Carolina 13 Editors: Handa, Victoria L.; Van Le, Linda Title: Te Linde's Operative Gynecology, 12th Edition Copyright ©2020 Lippincott Williams & Wilkins > Front of Book > Foreword Foreword Dr. Richard Te Linde personally wrote every page of Operative Gynecology, which was first published in 1946. He was an experienced and innovative surgeon and teacher who described not only the technique of the various gynecological surgical procedures but also the anatomy, physiology, and pathology associated with the diagnoses and indications for surgery. Gynecology was a relatively new specialty. "No longer is it simply a branch of general surgery. (The gynecologist) must be a surgeon, expert in his special field;… trained in the fundamentals of obstetrics;… have technical skills to investigate female urologic conditions;… have an understanding of endocrinology as it applies to gynecology;… be well grounded in gynecologic pathology; and, finally, must be able to recognize and deal successfully with the minor psychiatric problems which arise among gynecologic patients." In his textbook, Te Linde included all of these aspects of the specialty, which are so necessary to the complete and competent gynecologic surgeon. The text was written mainly for trainees, "when their minds are quick to grasp ideas and their fingers are nimble." But he was also quick to point out that things change and different points of view and different surgical approaches should be considered. "The housestaff should realize early in their careers that all is not forever settled in medicine." As new understanding of the pathophysiology of clinical conditions has emerged and new technologies have been developed, successive editions of Te Linde's Operative Gynecology have evolved. New surgical techniques have been introduced, while outdated procedures have been abandoned or modified. In his preface to the third edition, Te Linde emphasized the importance of this holistic surgical philosophy. "What does it profit a woman if the operation is technically perfect and the procedure unnecessary or even harmful?" Selection of the correct operation for the correct patient (or even avoiding an unnecessary surgical procedure altogether) is most likely when the surgeon understands all of the many factors that constitute a thorough evaluation of the patient and her symptoms, leading to a correct diagnosis. As the field of gynecology expanded, Te Linde invited experts on anesthetic management and pre- and postoperative care to contribute chapters. Eventually, with publication of the fourth edition in 1970, Dr. Richard Mattingly, one of Te Linde's former residents, was introduced as a coeditor. The text has continued to emphasize the importance of a thorough understanding of gynecologic conditions as well as indications and contraindications for the various procedures. The concept that "a sound surgical philosophy is perhaps more important than the technic" is still found in every chapter. Te Linde retired after the fourth edition. Laparoscopy replaced culdoscopy in the fifth edition, and another new chapter was devoted to the increasing problem of professional liability. With publication of the sixth edition in 1985, Dr. John Thompson, another former Te Linde resident from Johns Hopkins School of Medicine, joined Dr. Mattingly as coeditor. There were 22 contributors by this time, still mostly from Hopkins or Hopkins trained. Throughout the text, we continue to hear echoes of Te Linde or the Hopkins surgical philosophy. "The knowledge that is needed to formulate the proper indications for surgery include first and foremost a thorough understanding of the physiology and pathology of the female reproductive organs, as well as the clinical manifestations of the disease process and the normal and abnormal development of psycho-socialsexual behavior." A whole chapter on the psychological aspects of pelvic surgery was added. The increasing diversity within the specialty of gynecology was also recognized formally in the preface, which addresses "young men and women who are learning gynecologic surgery…" As the trend toward minimally invasive gynecologic surgery continued, Dr. John A. Rock, a Hopkins fellow, joined Dr. Thompson as coeditor with the seventh edition of the textbook. There was a new chapter on laser surgery in gynecology and another new chapter addressing chronic pelvic pain. Chemotherapy for ovarian cancer was also added, in recognition that Te Linde's Operative Gynecology was the sole textbook guiding surgical practice for many gynecologists. Several other words or phrases that are now so familiar were introduced with this edition. "Quality in service," "cost effective," and "competitive edge" indicate a recognition of the business aspect of medical practice. The increasing importance of the patient's role in her care and in society in general was recognized in this admonition—" the surgeon must respect the patient's autonomy in all phases of medical care, especially as the role of women in society changes." 14 By the ninth edition in 2003, there were 69 contributors and the book had grown from 725 to 1568 pages, reflecting the breath and complexity of gynecologic surgery in the 21st century. The beautiful black and white illustrations, which have been such an important part of the book since its inception, continued to be used liberally. Howard W. Jones III joined John A. Rock as coeditor, continuing the strong Hopkins roots. Reflecting the P.xii emphasis on surgical training and the concerns of many editors over the years that the surgical experience of residents was constantly being diminished, a chapter on The Training of the Gynecologic Surgeon was added. New concepts on the anatomy and surgical management of pelvic support were incorporated into an extensive revision of this section of the textbook. With the 10th and 11th editions, a chapter on the use of the robot in gynecologic surgery was added and electrosurgical instrumentation was updated to include vessel sealing techniques. The text continued to discuss not only common gynecologic surgical procedures, such as hysterectomy and pelvic prolapse surgery, but also less commonly encountered operations such as pelvic exenteration, intestinal operations, and surgical conditions of pregnancy. A whole new section on surgery for fertility was added, including a chapter on the Impact of Assisted Reproductive Technology on Gynecologic Surgery. The textbook was also "modernized" by adding color to the illustrations. Sections titled "best surgical practices" and "definitions" were added to most chapters. Over more than 70 years and now 12 editions of this textbook, various surgical procedures have come and gone, but the editors and the authors have remained true to the philosophy espoused by Te Linde in the first edition. More than a surgical atlas, Te Linde's Operative Gynecology clearly explains the pathophysiology behind the diagnoses so that the gynecologist can select the correct operation for the appropriate patient. Because the authors who have contributed to the various editions are experienced educators as well as talented surgeons, they have been able to transmit this holistic philosophy. This perspective has made Te Linde's textbook the most respected and widely read reference for gynecologic surgery in the world. We are confident that the experience, dedication, and enthusiasm of the editors and authors will carry on this great tradition and that Te Linde's Operative Gynecology will continue to be an irreplaceable reference for generations of gynecologic surgeons. Dr. Howard W. Jones III† Dr. John A. Rock †Deceased 15 Editors: Handa, Victoria L.; Van Le, Linda Title: Te Linde's Operative Gynecology, 12th Edition Copyright ©2020 Lippincott Williams & Wilkins > Front of Book > Preface from First Edition Preface from First Edition Gynecology has become a many-sided specialty. No longer is it simply a branch of general surgery. In order to practice this specialty in its broad sense, the gynecologist must be trained in a comprehensive field. He must be a surgeon, expert in his special field, he must be trained in the fundamentals of obstetrics, he must have the technical skill to investigate female urologic conditions, he must have an understanding of endocrinology as it applies to gynecology, he should be well grounded in gynecologic pathology, and finally, he must be able to recognize and deal successfully with minor psychiatric problems that arise so commonly among gynecologic patients. With this concept of the specialty in mind, this book has been written. It then becomes apparent, when one seeks training in gynecology beyond the simplest fundamentals such as are taught to undergraduates, that special works are necessary for training those who intend to practice it. The author is a firm believer in the system of long hospital residencies for training young men in the various surgical specialties when their minds are quick to grasp ideas and their fingers are nimble. This volume has been written particularly for this group of men. Unfortunately, there is a paucity of good gynecologic residencies in the United States in the sense that the author has in mind. Many positions bear the name of residency but fail to give the resident sufficient operative work to justify the name. Another excellent method of development of the young gynecologist is an active assistantship to a well-trained, mature gynecologist. If the assistant is permitted to stand at the operating table opposite his chief day after day, eventually he will acquire skill and judgment which he himself will be able to utilize as an operator. When such a preceptor system is practiced, it is important that the assistant be given some surgery of his own to do while he is still young. If a man is forced to think of himself only as a perennial assistant, this frame of mind will kill his ability to accept responsibility of his own. However, many must learn their operative gynecology under less favorable circumstances than those of the fortunate resident or assistant. This volume should be of value to those who, by selfinstruction, must acquire a certain degree of operative skill. Finally, it must be admitted that more gynecology is practiced today by general surgeons in this country than by gynecologists. Although this is not ideal, circumstances make it necessary, and much of this gynecologic surgery is well done. It is hoped that many general surgeons will use this volume as a reference book. In connection with general surgery, it is only fair to say that much has come to gynecology by way of general surgeons of the old school, who practiced general surgery in the broadest sense. Now that gynecology and/or obstetrics has become a specialty unto itself, it is well in our training of men not to swing too far from general abdominal surgery. In spite of the most careful preoperative investigation, mistakes in diagnosis will be made, and at times, the gynecologist will be called upon to take care of general surgical conditions in the region of lower abdomen and the rectum. With this in mind, the author has included in this volume a consideration of a few of the commoner general surgical conditions occasionally encountered incident. Dr. Richard Te Linde 1946 16 Editors: Handa, Victoria L.; Van Le, Linda Title: Te Linde's Operative Gynecology, 12th Edition Copyright ©2020 Lippincott Williams & Wilkins > Front of Book > Preface Preface This 12th edition of Te Linde's Operative Gynecology marks another evolution in the textbook's history. From 2003 until the 11th edition in 2015, the esteemed Drs. Rock and Jones have edited the text and brought the newest information to learners. With this 12th edition, they turned the responsibilities over to a new set of editors. Inasmuch as Te Linde's Operative Gynecology was conceived by Dr. Te Linde at Johns Hopkins in 1946, it is fitting that one of the editors is also on faculty at Johns Hopkins while the other is at University of North Carolina, Chapel Hill. The reader may appreciate a few changes to the 12th edition. First, recognizing that there are many resources that address the medical management of gynecologic disorders, this new edition is refocused on the operative aspects of gynecology. We retained discussion of the core gynecologic areas of urogynecology, pelvic pain, cancer surgery, and benign gynecology and invited new experts to contribute their surgical knowledge. For the first time ever, the textbook includes a primer on anesthesia that describes how our patients undergo anesthetic induction and different anesthetic options. This edition also offers a new chapter on safe positioning for gynecologic surgery, an issue that becomes increasingly important as we expand the scope of our surgical approaches. We have added a new chapter on surgical instruments to assist new learners on best surgical technique, dissection, and use of instruments. The robotic chapter has been updated to reflect the rapid evolution of robotic technology, techniques, and instrumentation. This edition includes a new chapter on management of müllerian abnormalities, as well as a completely new chapter on management of common pediatric gynecologic disorders. The illustrations have been updated and revised. When relevant, each chapter includes key steps for each of the procedures described. We are honored to serve as the new editors for this important textbook. As career surgeons, we have the utmost respect for excellent surgical technique. We appreciate the importance of surgical innovation, and aspire to offer the newest and best surgical care to our patients. The goal of Te Linde's Operative Gynecology has always been to present the latest and best of gynecologic surgery. As the editors of the 12th edition, it is our mission to educate and inform gynecologists so that surgeons can easily implement best surgical practices and new techniques. We hope you will find this textbook comprehensive, informative, and easy to use. Victoria L. Handa, MD, MHS Linda Van Le, MD 17 Editors: Handa, Victoria L.; Van Le, Linda Title: Te Linde's Operative Gynecology, 12th Edition Copyright ©2020 Lippincott Williams & Wilkins > Table of Contents > Section I - Preparing for Surgery > Chapter 1 - Surgical Anatomy of the Female Pelvis Chapter 1 Surgical Anatomy of the Female Pelvis Marlene M. Corton John O.L. DeLancey THE ABDOMINAL WALL The superior border of the abdominal wall is the lower edge of the rib cage (ribs 7 through 12). The inferior margin is formed by the iliac crests, inguinal ligaments, and pubic bones. It ends posterolaterally at the lumbar spine and its adjacent muscles. Knowledge of the layered structure of the abdominal wall allows the surgeon to enter the abdominal cavity with maximum efficiency and safety. A general summary of these layers is provided in TABLE 1.1 and discussed below. Skin and Subcutaneous Tissue The fibers in the dermal layer of the abdominal skin are oriented in a predominantly transverse direction following a gently curving upward line. This predominance of transversely oriented fibers results in more tension on the skin of a vertical incision and in a wider scar. Deep to the skin lies the subcutaneous tissue of the abdomen. This tissue is made of globules of fat held in place and supported by a series of branching fibrous septa. In the more superficial portion of the subcutaneous tissue, called the fatty layer (formerly Camper fascia), fat predominates, and fibrous tissue is less apparent. Closer to the rectus sheath, the fibrous tissue predominates relative to the fat, and this portion of the subcutaneous layer is called the membranous layer (formerly Scarpa fascia). The fatty and membranous layers are not discrete or well-defined layers but represent regions within the subcutaneous tissue. The membranous layer is best developed laterally and is not seen as a well-defined layer during midline vertical incisions. It is most evident at the lateral borders of low transverse incisions, just above the rectus sheath. Musculoaponeurotic Layer Deep to the subcutaneous tissue is a layer of muscle and fibrous tissue ("fascia") that holds the abdominal viscera in place and controls movement of the lower torso (FIGS. 1.1 and 1.2) The muscles of this layer can be considered in two groups: the vertical muscles in the midline (rectus abdominis and pyramidalis) and the more lateral flank muscles (the external oblique, internal oblique, and transversus abdominis). The fascia, properly called the rectus sheath, is created by the broad, sheetlike tendons of these muscles, which form aponeuroses that unite with their corresponding member of the other side. P.3 TABLE 1.1 Abdominal Wall Layers Skin Subcutaneous tissue Fatty layer (Camper fascia) 18 Membranous layer (Scarpa fascia) Musculoaponeurotic layer Rectus sheath—formed by aponeuroses of the external oblique, internal oblique, and transversus abdominis muscles (flank muscles). Invests rectus abdominis and pyramidalis muscles (vertical muscles). Fuse in the midline at the linea alba and laterally at the linea semilunaris. Anterior layer—formed by external oblique and internal oblique (split) aponeuroses Posterior layer—formed by internal oblique (split) and transversus abdominis aponeuroses Arcuate line—lower limit of the posterior layer, approximately one third of the distance from the umbilicus to the pubic crest. Below this line, posterior surface of rectus abdominis muscles in contact with transversalis fascia Transversalis fascia Preperitoneal fat Peritoneum Rectus Abdominis and Pyramidalis Muscles Each paired rectus abdominis muscle originates from the sternum and cartilages of ribs 5 through 7 and inserts into the anterior surface of the pubic bone. Each muscle has three to four tendinous intersections or inscriptions. These are fibrous interruptions within the muscle that firmly attach it to the rectus abdominis sheath. In general, they are confined to the region above the umbilicus, but they can be found below it. At these fibrous interruptions, the rectus sheath is attached to the rectus muscle and thus the two structures are difficult to separate (e.g., during a Pfannenstiel incision). The pyramidalis muscles arise from the pubic bones anterior to the rectus abdominis and insert into the midline linea alba several centimeters above the symphysis. Their development varies considerably among individuals. Their strong attachment to the midline makes separation here difficult by blunt dissection. Flank Muscles Lateral to the rectus abdominis muscles lie the broad, flat muscles of the flank. Their aponeurotic insertions join to form the rectus sheath, which covers the rectus abdominis muscles. Because of its importance, the rectus sheath is further discussed below. The most superficial of these muscles is the external oblique. Its fibers run obliquely anteriorly and inferiorly from their proximal origin on the lower eight (5 through 12) ribs to the broad distal insertions of their aponeuroses on the iliac crest, pubic tubercle, and linea alba. The inferior margin of the external oblique aponeurosis is thickened, and its free posterior edge forms the inguinal ligament. The fibers of the internal oblique muscle fan out superiorly and medially from their origin in the anterior two thirds of the iliac crest, the lateral part of the inguinal ligament, and the thoracolumbar fascia to their distal attachments on the inferior borders P.4 of ribs 10 through 12, the pecten pubis via the conjoint tendon, and the linea alba. In most areas, the fibers of the internal oblique are perpendicular to the fibers of the external oblique muscle; however, in the lower abdomen, the internal oblique 19 fibers arch somewhat more caudally and run in a direction similar to those of the external oblique muscle. FIGURE 1.1 External oblique, internal oblique, and pyramidalis muscles. (The original illustration is in the Max Brödel Archives in the Department of Art as Applied to Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. Used with permission.) 20 FIGURE 1.2 Abdominal wall muscles and rectus sheath. (The original illustration is in the Max Brödel Archives in the Department of Art as Applied to Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. Used with permission.) As the name transversus abdominis implies, the fibers of the deepest of the three flat muscles have a primarily transverse orientation. They arise from the costal cartilages of the lower six (7 through 12) ribs, the thoracolumbar fascia, the iliac crest, and the lateral third of the inguinal ligament. Their distal attachments are to the pubic crest, the pecten pubis via the conjoint tendon, and the linea alba. The caudal portion of the transversus abdominis muscle is fused with the internal oblique muscle to form the inguinal falx, also called the conjoint tendon. This fusion explains why, during transverse incisions of the lower abdomen, only two layers are discernible at the lateral portion of the incision. The aponeurotic fibers of the conjoint tendon attach to the pubic crest and pecten pubis. This tendon lies immediately behind the superficial inguinal ring, and along with the transversalis fascia, forms the posterior wall of the inguinal canal. A weakening of the conjoint tendon can lead to a direct inguinal hernia. The inferior free edge of the transversus abdominis and internal oblique muscle fibers form the superior boundary (roof) of the inguinal canal. Although the fibers of the flank muscles are not strictly parallel to one another, their primarily transverse orientation and the transverse pull of their attached muscular fibers place vertical suture lines in the rectus sheath under more tension than transverse ones. For this reason, vertical incisions are more prone to dehiscence. Rectus Sheath The muscle fibers of the external oblique become aponeurotic approximately at the midclavicular line. In the lower abdomen, 21 this demarcation gradually develops more laterally (FIG. 1.3). At its inferior margin, the muscle fibers of the internal oblique extend farther toward the midline than do the muscle fibers of the external oblique. Because of this, fibers of the internal oblique muscle are found underneath the aponeurotic portion of the external oblique muscle during a low transverse incision (FIG. 1.4). In addition, between the internal oblique and transversus abdominis muscles lies a neurovascular plane, which corresponds to a similar plane in the intercostal spaces. This plane contains the nerves and arteries that supply the anterolateral abdominal wall. In the anterior part of the abdominal wall, these nerves and vessels exit the neurovascular plane and lie mostly in the subcutaneous tissue. Although not often possible, the nerves should be identified and spared, and strategies used to avoid injury within the neurovascular plane should be P.5 P.6 used. For example, low transverse fascial incisions often used for gynecologic surgery should not extend beyond lateral margins of rectus muscles to avoid nerve and inferior epigastric vessel injury. In addition, suture purchases that extend lateral to the edges of incision should be avoided as they may entrap the iliohypogastric and/or ilioinguinal nerve, which may lead to denervation injury or pain as described later (under ilioinguinal and iliohypogastric sections below). FIGURE 1.3 Nerve supply to the abdominal wall. Right: Deep innervation to the transverse abdominis, internal oblique, and rectus muscles. Left: Superficial distribution, including cutaneous nerves, after penetration and innervation of the external oblique muscle and fascia. Innervation of the groin and thigh also is shown. 22 FIGURE 1.4 Cross sections of lower abdominal wall above and below the arcuate line. 1, external oblique; 2, internal oblique; and 3, transversus abdominis muscle. A: Above the arcuate line (linea semicircularis): the anterior fascial sheath of the rectus muscle (in gray) is derived from the external oblique and split aponeurosis of internal oblique muscles. The posterior sheath is formed by aponeurosis of the transversus abdominis muscle and split aponeurosis of the internal oblique muscle. B: Lower portion of the abdominal wall, below the arcuate line: The rectus muscle does not have a posterior fascial sheath, while all of the fascial aponeuroses form the anterior rectus muscle sheath. The rectus muscle is in direct contact with the transversalis fascia. Many specialized aspects of the rectus sheath are important to the surgeon (FIG. 1.4). In its lower one fourth, the sheath lies entirely anterior to the rectus muscle. Above that point, it splits to lie both anterior and posterior to the rectus muscle, thus forming the anterior and posterior layers of the rectus sheath. The transition between these two arrangements occurs at the arcuate line, approximately one third of the distance from the umbilicus to the pubic crest, which lies medial to the pubic tubercle. Superior to this line, the midline ridge of the rectus sheath, the linea alba, unites the anterior and posterior layers of the sheath. Sharp dissection is usually required to separate these layers in the midline during a Pfannenstiel incision. Below the arcuate line, the rectus abdominis muscles are in contact with the transversalis fascia. A vertical incision that extends to or above the umbilicus therefore requires incision of the posterior sheath. The lateral border of the rectus muscle is marked by the linea semilunaris, a curved tendinous line that extends from the cartilage of the ninth rib to the pubic tubercle. It is formed by the internal oblique aponeurosis at its line of division to enclose the rectus muscle and is reinforced anteriorly by the external oblique and transversus abdominis aponeurosis. The linea semilunaris is not always where the three layers of flank muscles fuse: above the arcuate line, the internal oblique muscle aponeurosis splits to contribute to the anterior and posterior layers of the rectus sheath, while below the arcuate line, the transversalis fascia lies immediately posterior to the rectus muscles. During a transverse lower abdominal incision, the external and internal oblique aponeuroses are often separable near the midline. A hernia through the linea semilunaris is called a Spigelian hernia or lateral-ventral hernia. 23 The inguinal canal lies at the lower edge of the musculofascial layer of the abdominal wall. It is superior and parallel to the inguinal ligament. The midinguinal point is halfway between the pubic symphysis and the anterosuperior iliac spine. The femoral pulse can be palpated here. The inguinal canal has two openings, the superficial and deep inguinal rings. In the embryological stage, the canal is lined by an outpocketing of the peritoneum (processus vaginalis) and the abdominal musculature. Failure of the processus vaginalis to regress can lead to an indirect inguinal hernia, where the peritoneal sac or potentially loops of bowel enter the inguinal canal through the deep inguinal ring, lateral to the inferior epigastric vessels. Through the inguinal canal, in the woman, the round ligament extends to its termination in the labium majus. In addition, the ilioinguinal nerve and the genital branch of the genitofemoral nerve pass through the canal. Transversalis Fascia, Peritoneum, and Bladder Reflection Deep to the muscular layers and superficial to the peritoneum lies the transversalis fascia, a layer of fibrous tissue that lines the abdominopelvic cavity. It is visible during abdominal incisions as the layer just underneath the rectus abdominis muscles suprapubically (FIG. 1.2). It is separated from the peritoneum by a variable layer of extraperitoneal adipose tissue, sometimes called the preperitoneal fat. The transversalis fascia is frequently incised or bluntly dissected off the bladder to take the tissues in this region "down by layers." This is the layer of tissue that is last penetrated to gain extraperitoneal entry into the retropubic space. The peritoneum is a single layer of epithelial cells and supporting connective tissue called the serosa that lines the abdominal cavity and covers the abdominopelvic organs. The infraumbilical part of the anterolateral abdominal wall is characterized by five peritoneal folds (FIG. 1.5) that converge toward the umbilicus. The single median umbilical fold extends from the apex of the bladder to the umbilicus and covers the median umbilical ligament, a fibrous remnant of the urachus. Lateral to this are paired medial umbilical folds, which cover the medial umbilical ligaments, formed by the occluded part of the umbilical arteries. The lateral umbilical folds cover the inferior epigastric arteries and veins and, if transected, can lead to significant bleeding. The reflection of the bladder onto the abdominal wall is triangular in shape, with its apex blending into the median umbilical ligament. Because the apex is highest in the midline, incision in the peritoneum lateral to the midline is less likely to result in bladder injury. Umbilical Area The umbilicus is an important surgical landmark and the most common point of entry during endoscopic surgery. All layers of the anterolateral abdominal wall fuse at the umbilicus (see FIG. 1.5). The umbilicus usually lies at a vertical level corresponding to the junction between the third and fourth lumbar vertebrae. This is also the level at which the iliac veins join to form the vena cava and at which the abdominal aorta bifurcates. The skin around the umbilicus is innervated by the 10th thoracic spinal nerve (T10 dermatome). The umbilicus contains the umbilical ring, a defect in the linea alba through which the fetal umbilical vessels passed to and from the umbilical cord and placenta. The umbilical ring provides a window through which umbilical hernias may develop. The round ligament of the liver and median umbilical and medial umbilical ligaments variably attach to the ring with inconsistent arrangements. P.7 The umbilical fascia is formed by a thickening in the transversalis fascia behind the umbilicus, with possible contributions from the upward extension of the bladder visceral fascia (umbilicovesical fascia). 24 FIGURE 1.5 Intraperitoneal view of anterior abdominal wall, demonstrating five peritoneal folds: the median umbilical fold (covering the median umbilical ligament), paired medial umbilical folds (covering the medial umbilical ligaments), and the lateral umbilical folds (covering the inferior epigastric arteries and veins). Note all umbilical peritoneal folds (ligaments) merge at the umbilicus. Neurovascular Supply of the Abdominal Wall Vessels of the Abdominal Wall Knowledge of the course of the abdominal wall blood vessels helps the surgeon anticipate their location during abdominal incisions or insertion of laparoscopic trocars (FIG. 1.6). The blood vessels that supply the abdominal wall can be separated into those that supply the skin and subcutaneous tissues and those that supply the musculofascial layer. Three groups of vessels provide blood supply to the skin and subcutaneous tissues. The superficial epigastric vessels run a diagonal course in the subcutaneous tissue from the femoral vessels toward the umbilicus, beginning as a single artery that branches extensively as it nears the umbilicus. Its position can be anticipated midway between the skin and musculofascial layer, in a line between the palpable femoral pulse and the umbilicus. The external pudendal artery runs a diagonal course medially from the femoral artery to supply the region of the mons pubis. It has many midline branches, and bleeding in its territory of distribution is heavier than that from the abdominal subcutaneous tissues. The superficial circumflex iliac vessels course laterally from the femoral vessels toward the flank. 25 The blood supply to the lower abdominal wall's deeper musculofascial layer parallels the subcutaneous vessels. The inferior epigastric and the deep circumflex iliac arteries branch from the external iliac, and their course parallels that of their superficial counterparts (see FIG. 1.6). The deep circumflex iliac artery lies between the internal oblique and transversus abdominis muscle. The inferior epigastric artery and its two veins originate lateral to the rectus muscle. They run diagonally toward the umbilicus and intersect the muscle's lateral border P.8 midway between the pubis and umbilicus. Below the point at which the vessels pass under the rectus, they are found lateral to the muscle and deep to the transversalis fascia. After crossing the lateral border of the rectus muscle, they lie on the muscle's dorsal surface, between it and the posterior rectus sheath. As the vessels enter the rectus sheath, they branch extensively, so that they no longer represent a single trunk. The angle between the inferior epigastric vessels and the lateral border of the rectus muscle forms the apex of the inguinal triangle (Hesselbach triangle), the base of which is the inguinal ligament. This triangle represents the area through which direct inguinal hernias protrude medial to the inferior epigastric vessels. Around the umbilical area, the inferior epigastric artery anastomoses with the superior epigastric, a branch of the internal thoracic artery. FIGURE 1.6 Normal variation in epigastric vessels. A, B, and C designate safe spots for laparoscopic trocar insertion. Dotted lines indicate lateral border of the rectus muscle. (Reprinted from Hurd WW, Bude RO, DeLancey JOL, et al. The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at laparoscopy. Am J Obstet Gynecol 1994;171(3):642-646, with permission. Copyright © 1994, Elsevier.) 26 Lateral laparoscopic trocars are placed in a region of the lower abdomen where injury to the inferior epigastric and superficial epigastric vessels can easily occur. The inferior epigastric arteries and the superficial epigastric arteries run similar courses toward the umbilicus. Knowing the typical location of these blood vessels helps in choosing insertion sites that will minimize their injury, reducing the potential for hemorrhage and hematomas. Just above the pubic symphysis, the vessels lie approximately 5.5 cm from the midline, whereas at the level of the umbilicus, they are 4.5 cm from the midline (see FIG. 1.6). Therefore, placement either lateral or medial to the line connecting these points minimizes potential vascular injury. In addition, the location of the inferior epigastric vessels can often be directly seen through the peritoneal layer laparoscopically (see FIG. 1.5), and during laparoscopic procedures, the superficial epigastric vessels can often be identified in thin patients by transillumination. The round ligament is traced to its point of entry into the deep inguinal ring, recognizing that the vessels lie just medial to this point (FIG. 1.7). FIGURE 1.7 Sagittal view of female pelvis, showing inguinal anatomy. Note that the inferior epigastric artery and vein lie just medial to the round ligament as it enters the deep inguinal ring. (The original illustration is in the Max Brödel Archives in the Department of Art as Applied to Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. Used with permission.) 27 Nerves of the Abdominal Wall The innervation of the abdominal wall (see FIG. 1.3) arises from the abdominal extension of intercostal nerves 7 through 11, subcostal nerve (T12), and iliohypogastric and ilioinguinal nerves (both L1). Dermatome T10 lies at the umbilicus. P.9 FIGURE 1.8 Nerve and vessel locations on anterior abdominal wall relative to surgically important landmarks. (Redrawn from Rahn DD, Phelan JN, Roshanravan SM, et al. Anterior abdominal wall nerve and vessel anatomy: clinical implications for gynecologic surgery. Am J Obstet Gynecol 2010;202(3):234. e1-234.e5. Copyright © 2010 Elsevier. With permission.) The cutaneous sensory innervation of the abdominal wall is derived from the intercostal nerves and the iliohypogastric and ilioinguinal nerves. After giving off a lateral abdominal cutaneous branch, each intercostal nerve pierces the lateral border of the rectus sheath. There it provides a lateral branch that ends in the rectus muscle. This branch then passes through the muscle and perforates the rectus sheath to supply the subcutaneous tissues and skin as anterior abdominal cutaneous branches. Incisions along the lateral border of the rectus lead to denervation of the muscle, which can render it atrophic and weaken the abdominal wall. Elevation of the rectus sheath off the muscle during the Pfannenstiel incision stretches the perforating nerve, which is sometimes ligated or cauterized to provide hemostasis from the accompanying artery. This may leave an area of cutaneous anesthesia. The iliohypogastric and ilioinguinal nerves (FIG. 1.8) pass medial to the anterosuperior iliac spine in the abdominal wall. The former supplies the skin of the suprapubic area. The latter supplies the lower abdominal wall, and by sending a branch through the inguinal canal, it supplies the upper portions of the labia majora (anterior labial nerves) and medial portions of the thigh. The ilioinguinal and iliohypogastric nerves can be entrapped or cut during closure of a transverse incision or insertion of 28 accessory trocars in the lower abdomen. This may lead to chronic pain syndromes that may manifest months to years after surgery. The risk of iliohypogastric and ilioinguinal nerve injury can be minimized if lateral trocars are placed superior to the anterosuperior iliac spines and if low transverse fascial incisions are not extended beyond the lateral borders of the rectus muscles. Other Lumbar Plexus Branches The genitofemoral nerve (L1 and L2) and lateral cutaneous nerve of the thigh (L2 and L3) can be injured during gynecologic surgery. The genitofemoral nerve lies on the anterior surface of the psoas muscle (FIG. 1.9), where pressure from a retractor can damage it and lead to anesthesia in the medial thigh and lateral labia. This nerve can also be injured during pelvic lymphadenectomy and ureteral reimplantation with psoas hitch. The lateral cutaneous nerve courses over the iliacus muscle and passes under the inguinal ligament just medial to the anterosuperior iliac spine. It can be compressed either by a retractor blade lateral to the psoas or by excessive flexion of the hip in the lithotomy position, causing anesthesia over the anterior and lateral thigh. Meralgia paresthetica is a term often used when pain is also present. The largest branch of the lumbar plexus, the femoral nerve (L2-L4) can also be injured during gynecologic surgery. In the greater (false) pelvis, it emerges from the inferolateral surface of the psoas muscles (see FIG. 1.9). It then passes under the inguinal ligament to provide innervation to the anterior thigh compartment muscles and sensation to the anterior thigh and medial leg (FIG. 1.10). Femoral nerve injury during abdominal procedures can result from nerve compression by the P.10 lateral blades of retractors. During vaginal surgery, femoral nerve injury is most often attributed to lithotomy positioning. The nerve can be compressed against the inguinal ligament with thigh hyperflexion (>90 degrees) or with excessive hip abduction and/or lateral rotation. Clinical manifestations of femoral nerve injury may include difficulty or inability to flex the thigh and extend the knee, absent patellar reflexes, and sensory loss over the anterior thigh and medial aspect of the leg. 29 FIGURE 1.9 Nerves of the lumbar plexus: 1, sciatic nerve; 2, femoral nerve; 3, lateral cutaneous nerve of the thigh; 4, ilioinguinal nerve; 5, iliohypogastric nerve; 6, subcostal nerve; 7, sympathetic trunk and ganglion; 8, genitofemoral nerve; 9, femoral branch of genitofemoral nerve; and 10, genital branch of genitofemoral nerve. (Reprinted with permission from Bigeleisen PE, Gofeld M, Orebaugh SL. Ultrasound-guided regional anesthesia and pain medicine, 2nd ed. Philadelphia, PA: Wolters Kluwer, 2015. Figure 35.9.) 30 FIGURE 1.10 Nerves of the lumbosacral plexus: Note that several branches (femoral nerve, lateral cutaneous nerve of the thigh, and femoral branch of genitofemoral nerve) pass under inguinal ligament and can be compressed in lithotomy. (Reprinted with permission from Agur AM, Dalley AF. Grant's atlas of anatomy, 14th ed. Baltimore, MD: Wolters Kluwer, 2016. Figure 4.78.) The obturator nerve (L2-L4) is the only branch of the lumbar plexus that courses through the lesser (true) pelvis (FIG. 1.11). It exits through the obturator canal and enters the thigh to supply the adductor muscles and skin over the medial thigh. The obturator nerve may be injured during pelvic lymphadenectomies or incontinence or pelvic support procedures where the retropubic space or the thigh compartment is entered. Clinical manifestations of obturator nerve injury include difficulty or inability adducting the thigh and sensory loss over the inner thigh. If obturator nerve transection is recognized intraoperatively, appropriate surgical consultation is warranted as microsurgical reapproximation can result in almost complete recovery of motor function. P.11 31 FIGURE 1.11 Arteries and veins of the pelvis. VULVA AND ERECTILE STRUCTURES The pudendum or vulva is part of the female external genitalia and is found on the superficial pouch of the anterior perineal triangle (FIGS. 1.12, 1.13 and 1.14). The perineum can be divided into anterior and posterior triangles, which share a common base along a line between the ischial tuberosities (see FIG. 1.13). The outer boundaries of these triangles are those of the bony pelvic outlet: the pubic arch and ischiopubic rami anterolaterally and the sacrotuberous ligament and coccyx posterolaterally. The tissues filling the anterior triangle (TABLE 1.2) have a layered structure similar to that of the abdominal wall. More specifically, there is a skin and subcutaneous tissue overlying a fascial layer (perineal membrane). The superior boundary of both anterior and posterior perineal triangles is the inferior fascia of the levator ani muscles. Subcutaneous Tissues of the Vulva The structures of the vulva lie on the pubic bones and extend posteriorly under the pubic arch (FIG. 1.12). They consist of the mons, labia, vestibule, clitoris, and associated erectile structures and their muscles. The mons consists of hair-bearing skin over a cushion of adipose tissue that lies on the pubic bones. Extending posteriorly from the mons, the labia majora are composed of similar hair-bearing skin and adipose tissue, which contain the termination of the round ligaments of the uterus and the obliterated vaginal process (canal of Nuck). The round ligament can give rise to leiomyomas in this region, and the obliterated vaginal process can be a dilated embryonic remnant in the adult. Incomplete obliteration of the canal can result in an indirect inguinal hernia or a hydrocele, which are rare conditions in women. Anterior to the pudendal cleft and below the mons, each labium majus joins to form the anterior commissure of the labia majora. The posterior commissure represents the anterior or upper part of the perineal body skin. The labia minora, vestibule, and glans of the clitoris can be seen between the two labia majora. The labia minora are hairless 32 skin folds, each of which splits anteriorly to run over, and under, the glans of the clitoris. The more anterior folds unite to form the distal end of the prepuce of the clitoris, which partially or completely covers the glans of the clitoris and is often called the hood of the clitoris; the posterior folds insert into the underside of the glans as the frenulum of the clitoris. Posteriorly, the labia minora join in the midline to form the frenulum of labia minora or fourchette. FIGURE 1.12 External genitalia. P.12 33 FIGURE 1.13 Anterior and posterior perineal triangles. Structures within the superficial compartment of the anterior triangle and their relationship to perineal membrane are shown. Unlike the skin of the labia majora, the cutaneous structures of the labia minora and vestibule do not lie on an adipose layer but on a connective tissue stratum that is loosely organized and permits mobility of the skin during intercourse. This loose attachment of the skin to underlying tissues allows the skin to be easily dissected off the underlying tissue during skinning vulvectomy in the area of the labia minora and vestibule. The labia minora are highly sensitive structures that lie in close proximity to the clitoris and vestibular bulbs. Clinically, great variation exists in shape and size of the labia minora. In some women, one or both labia may markedly extend beyond the labia majora and can be drawn into the vagina during coitus or other activities. If P.13 associated with dyspareunia or pain in these settings, the labia minora can be surgically reduced. Among others, complications such as hypoesthesia and paresthesias may develop following labial reduction procedures, given the vast sensory innervation to these structures. Moreover, chronic dermatologic diseases such as lichen sclerosus may lead to significant atrophy or disappearance of the labia minora. Surgical procedures that involve removal of the prepuce or adjacent skin and underlying connective tissue may lead to injury of the dorsal nerve of the clitoris. The path of this nerve will be discussed later with other terminal pudendal nerve branches. 34 FIGURE 1.14 Pudendal nerve and vessels. TABLE 1.2 Layers and Pouches of the Anterior Triangle of the Perineum Skin Subcutaneous perineal pouch (compartment, space) Fatty layer (Camper fascia) Membranous layer (Colles fascia) Superficial pouch (compartment, space) 35 Superficial layer of investing fascia of perineal muscles (inferior boundary) Clitoris and its crura Bulb of the vestibule Greater vestibular (Bartholin) gland ischiocavernosus muscle Bulbospongiosus muscle Superficial transverse perineal muscle Deep perineal pouch (compartment, space) Perineal membrane (inferior boundary) External urethral sphincter (sphincter urethrae) Compressor urethrae Sphincter urethrovaginalis In the posterolateral aspect of the vestibule, the duct of the greater vestibular (Bartholin) gland can be seen 3 to 4 mm outside the hymen or hymenal caruncles at the hymenal ring. The lesser vestibular gland openings are found along a line extending anteriorly from this point, parallel to the hymenal ring and extending toward the external urethral orifice. More anteriorly, the urethra protrudes slightly beyond the surrounding vestibular skin, anterior to the vagina and posterior to the clitoris. Its orifice is flanked on either side by two small folds. The openings of the most distal of the paraurethral glands, often called Skene ducts, open into the inner aspect of these folds and can be seen as small, punctate openings when the external urethral orifice is exposed. Within the skin of the vulva are specialized glands that can become enlarged and thereby require surgical removal. The holocrine sebaceous glands are associated with hair shafts in the labia majora; in the labia minora, they are freestanding. They lie close to the surface, which explains their easy recognition with minimal enlargement. In addition, lateral to the introitus and anus, there are numerous apocrine sweat glands, along with the normal eccrine sweat glands. The former structures undergo change with the menstrual cycle, having increased secretory activity in the premenstrual period. They can become chronically infected, as in hidradenitis suppurativa, or neoplastically enlarged, as in hidradenomas, both of which may require surgical therapy. The eccrine sweat glands in the vulvar skin rarely present abnormalities, but on occasion form palpable masses as syringomas. The subcutaneous tissue of the labia majora is similar in composition to that of the abdominal wall. It consists of lobules of fat interlaced with connective tissue septa. Although there are no well-defined layers in the subcutaneous tissue, regional variations in the relative quantity of fat and fibrous tissue exist. The superficial region of this tissue, where fat predominates, 36 is the fatty layer, as it is on the abdomen. In this region, there is a continuation of fat from the anterior abdominal wall that contains smooth muscle and the termination of the round ligament of the uterus; this tissue is called a finger-shaped process of fat. In the deeper layers of the vulva, there is less fat, and the interlacing fibrous connective tissue septa are much more evident than those in the fatty layer. As it is in the abdomen, this more fibrous layer is called the membranous layer (previously Colles fascia) and is similar to the membranous layer (Scarpa fascia) on the abdomen. The membranous layer attachments or the attachments of the membranous layer to other structures have clinical significance. The interlacing fibrous septa of the subcutaneous tissue attach laterally to the ischiopubic rami and fuse posteriorly with the posterior edge of the perineal membrane (previously urogenital diaphragm). Anteriorly, however, there is no connection to the pubic rami, and this permits communication between the area deep to this layer and the abdominal wall. These fibrous attachments to the ischiopubic rami and the posterior aspect of the perineal membrane limit the spread of hematomas or infection deep to the membranous layer posterolaterally but allow spread into the abdomen. This clinical observation has led to the consideration of the membranous layer as a separate entity from the superficial fatty layer, which lacks these connections. Spread of hematomas or infection from the subcutaneous layer of the abdomen to the corresponding layer of the perineum is also possible. Extravasation of carbon dioxide into the subcutaneous layer, as can occur during laparoscopy (either with accidental trocar displacement or with lengthy procedures), can lead to subcutaneous emphysema that extends from the subcutaneous tissue of the abdominal wall to the subcutaneous layer of the perineum. Superficial Compartment The space between the superficial layer of investing fascia of perineal muscles and perineal membrane, which contains the clitoris, crura, vestibular bulbs, P.14 and ischiocavernosus and bulbospongiosus muscles, is called the superficial perineal pouch or compartment (see FIG. 1.13). The deep compartment is the region just deep to the perineal membrane; it is discussed later. The erectile bodies (body and crura of the clitoris and bulb of the vestibule) and their associated muscles within the superficial compartment lie on the caudal surface of the perineal membrane. The clitoris is a complex erectile and highly sensitive organ, which is homologous to the penis. It is embryologically derived from the genital tubercle. In contrast to the penis, the clitoris is not functionally related to the urethra, and thus, its primary function is in sexual arousal and orgasm. It is composed of a midline body, topped with the glans, and paired crura. The body lies on, and is suspended from, the pubic bones by the subcutaneous suspensory and fundiform ligaments of the clitoris. The fundiform ligament of the clitoris is fibrous condensation of the subcutaneous tissue descending from the linea alba above the pubic symphysis, which splits and surrounds the body of the clitoris, before fusing with the fascia of the clitoris. Along with the suspensory ligament, it contributes to the support and positioning of the clitoral body. The paired crura of the clitoris bend downward from the body and are firmly attached to the pubic bones, continuing dorsally to lie on the inferior aspects of the ischiopubic rami. They join in midline to form the body of the clitoris. The body of the clitoris consists of paired corpora cavernosa separated in midline by a fibrous septum, appropriately called the septum of corpora cavernosa. Both the corpora cavernosa and the paired crura are invested by a layer of fibroconnective tissue called the tunica albuginea. The dorsal nerve and vessels of the clitoris, discussed later, lie outside the tunica albuginea but within the clitoral fascia, which is continuous with the deep portion of the suspensory ligament of the clitoris. The ischiocavernosus muscles originate at the ischial tuberosities and the free surfaces of the crura to insert on the upper crura and often on the body of the clitoris. A few muscle fibers, called the superficial transverse perineal muscles, originate in common with the ischiocavernosus muscle from the ischial tuberosity and course transversely toward the lateral margins of the perineal body. The paired vestibular bulbs are elongated 3- to 4-cm masses of richly vascular spongy erectile tissue that lie immediately under the vestibular skin. They overlie the greater vestibular (Bartholin) glands posteriorly, and the bulb from each side join anteriorly at the commissure of the bulbs, where the spongy tissue attaches to the undersurface of the glans and body of the clitoris. The bulbs are partially covered by the bulbospongiosus muscles, which originate in the perineal body. These muscles, along with the ischiocavernosus muscles, insert into the body of the clitoris and act to pull it downward. All muscles in the superficial perineal triangle, bulbospongiosus, ischiocavernosus, and superficial transverse perineal are covered by a layer of fascia called the perineal fascia, which is continuous with the clitoral fascia. The greater vestibular (Bartholin) gland is found at the tail end of the bulb of the vestibule and is connected to the vestibular mucosa by a duct lined with squamous epithelium. The gland lies on the perineal membrane and beneath the bulbospongiosus 37 muscle (previously referred to as bulbocavernosus). The intimate relation between the enormously vascular tissue of the vestibular bulb and the Bartholin gland is responsible for the risk of hemorrhage associated with removal of this latter structure. The perineal membrane and perineal body are important to the support of the pelvic organs. They are discussed in the section on the pelvic floor. Pudendal Nerve and Vessels The pudendal nerve is the main sensory and motor nerve of the perineum. Its course and distribution in the perineum parallel the internal pudendal artery and veins that connect with the internal iliac vessels (see FIG. 1.14). The course and division of the nerve are described with the understanding that the vascular channels parallel them. The pudendal nerve arises from the sacral plexus (S2-S4), and the associated arteries originate from the anterior division of the internal iliac artery. They leave the pelvis through the greater sciatic foramen by passing behind the sacrospinous ligament, just medial to the ischial spine (FIG. 1.15). They then enter the pudendal (Alcock) canal through the lesser sciatic foramen. The pudendal canal is formed by a splitting of the obturator fascia covering the medial surface of the obturator internus muscle. It roughly expands from the ischial spine proximally to the ischial tuberosity distally. The nerve and vessels have three branches: the clitoral, perineal, and inferior rectal. The course and distribution of each nerve branch is described below with the understanding that vessels follow a similar path. Terminal Branches of Pudendal Nerve The three terminal branches of the pudendal nerve are the dorsal nerve of clitoris, perineal nerve, and inferior anal (rectal) nerves. These nerves provide sensation to the external female genitalia and motor innervation to the superficial perineal muscles, parts of the striated urethral sphincter muscles, and external anal sphincter muscle. Dorsal nerve of clitoris. This nerve is the primarily sensory nerve to the clitoris (FIG. 1.16). After exiting the pudendal canal, this nerve remains within the deep pouch of the anterior perineal triangle firmly adherent to the inner surface of the ischiopubic ramus. It perforates the perineal membrane adjacent to the medial surface of the ramus to reach the superficial perineal pouch. Here, it courses on the deep surface of the ischiocavernosus muscle and clitoral crus. In this region, the nerve is surrounded by a dense fibrous capsule adherent to the P.15 P.16 periosteum of the ischiopubic ramus. Approximately 2 to 3 cm lateral to the mid pubic symphysis, it emerges from the deep and lateral surface of the crus and then courses toward the dorsal surface of the clitoral body tightly embedded in layers of fibroconnective tissue, including that of the suspensory and fundiform ligaments of the clitoris. In this region, the nerve is consistently 2 to 4 mm in diameter. The nerve from each side then courses along the dorsal surface of the clitoral body, at approximately the 11 o'clock and 1 o'clock positions. It remains deep to the clitoral fascia but superficial to the tunica albuginea layer that surrounds the corpora cavernosa. In this area, it gives off small branches to the skin of the prepuce and to the corpora cavernosa. It ends by perforating the glans of the clitoris to which it provides sensory innervation. The section of this nerve that courses deep within the suspensory ligament is covered by vulvar and prepuce skin as well as by their underlying layer of connective tissue. Thus, excisional procedures that extend deep to the subcutaneous tissue in this region, pelvic fractures, and some anti-incontinence procedures risk injury to this nerve and can affect clitoral sensation and sexual function. 38 FIGURE 1.15 Course of pudendal nerve (n) and vessels in the pelvis and in the pudendal canal. LSF, lesser sciatic foramen; SSL, sacrospinous ligament; STL, sacrotuberous ligament. 39 FIGURE 1.16 Clitoral anatomy, including the dorsal nerve of the clitoris. (Illustration by Elizabeth Han.) Perineal nerve (see FIG. 1.14). The perineal nerve is the largest branch of the pudendal nerve. Branches of this nerve include the posterior labial nerves, which supply the labia minora and all but the anterior part of the labia majora; muscular branches, which provide motor innervation to the muscles of the superficial perineal pouch (ischiocavernosus, bulbospongiosus, and superficial transverse perineal) and sensory branches to the vestibular bulbs, vestibule, and lower part of the vagina. Although data are limited, branches of perineal nerve may provide innervation to the distal part or the striated urogenital sphincter muscles (compressor urethrae and urethrovaginalis), which are found in the deep perineal pouch, superior to the perineal membrane. The dorsal nerve of the clitoris may also contribute branches to these structures. Inferior anal (rectal) nerve (see FIG. 1.14). The inferior anal nerve innervates the external anal sphincter and perianal skin. Thus, injury to this nerve may lead to fecal incontinence and pain syndromes. The path of the inferior rectal nerve differs from that of the other pudendal nerve branches in that this nerve does not enter the pudendal canal in approximately 50% of specimens examined in cadaver studies. This finding may have clinical implications in certain surgical procedures where the ischioanal fossa is entered and during radiographic-guided injections used to manage pain. Autonomic Innervation to Erectile Structures The erectile tissues of the perineum are innervated by the cavernous nerves of the clitoris. These are the distal extensions of the uterovaginal plexus, a component of the inferior hypogastric plexus. These fibers course within the paravaginal and paraurethral connective tissue and reach the perineum by passing under the pubic bones. Fibers join the dorsal nerve of the clitoris and provide innervation to the corpora cavernosa. In contrast to the dorsal nerve of the clitoris, the cavernous nerve fibers are of very small caliber and their presence can only be confirmed by microscopy. These nerves consist of sympathetic and parasympathetic components and are critical to sexual function. Injury to the inferior hypogastric plexus during radical hysterectomy or other extensive pelvic or perineal surgeries can lead to varying degrees of voiding, sexual, and defecatory dysfunction. Anti-incontinence procedures where sutures or trocars are passed through the paraurethral tissue may also disrupt these fibers within the retropubic space. 40 Lymphatic Drainage Injection studies and clinical observation have established the pattern of the vulvar lymphatic vessels and drainage into the superficial inguinal group of lymph nodes. This anatomy is important to the treatment of vulvar malignancies; an overview of this system is provided here. This area is described and illustrated in more detail in Chapter 23. Tissues external to the hymenal ring are supplied by an anastomotic series of vessels and lymphatics in the superficial tissues that coalesce to a few trunks lateral to the clitoris and proceed laterally to the superficial inguinal nodes (FIG. 1.17). The vessels draining the labia majora also run in an anterior direction, lateral to those of the labia minora and vestibule. These lymphatic channels lie medial to the labiocrural fold, establishing it as the lateral border of surgical resection for vulvar malignancies. Injection studies of the urethral lymphatics have shown that lymphatic drainage of this region terminates in either the right or left inguinal nodes. The clitoris has been said to have some direct drainage to deep pelvic lymph nodes, bypassing the usual superficial nodes, but the clinical significance of this appears to be minimal. The inguinal lymph nodes are divided into two groups—the superficial and the deep nodes. There are 12 to 20 superficial nodes, and they lie in a T-shaped distribution parallel to and 1 cm below the inguinal ligament, with the stem extending down along the saphenous vein. The nodes are often divided into four quadrants, with the center of the division at the saphenous opening (fossa ovalis). The vulvar drainage goes primarily to the medial nodes of the upper quadrant. These nodes lie deep in the adipose layer of the subcutaneous tissues, in the membranous layer, just superficial to the fascia lata. The large saphenous vein joins the femoral vein through the saphenous opening. Within 2 cm of the inguinal ligament, several superficial blood vessels branch from the saphenous vein and femoral artery. They include the superficial epigastric vessels that supply the subcutaneous tissues of the lower abdomen, the superficial circumflex iliac vessels that course laterally to the region of the iliac crest, and the P.17 superficial external pudendal vessels that supply the mons, labia majora, and prepuce of clitoris. FIGURE 1.17 Lymphatic drainage of the vulva and femoral triangle. Superficial inguinal nodes are shown in the right thigh, and deep inguinal nodes are shown in the left thigh. Fascia lata has been removed on the left. 41 Lymphatics from the superficial nodes enter the saphenous opening and drain into one to three deep inguinal nodes, which lie in the femoral canal of the femoral triangle. They pass through the saphenous opening in the fascia lata, which lies approximately 3 cm below the inguinal ligament, lateral to the pubic tubercle, along with the saphenous vein on its way to the femoral vein. The membranous layer of the subcutaneous tissues spans this opening as a trabeculate layer called the cribriform fascia, pierced by lymphatics. The deep nodes are found under this fascia in the femoral triangle. Medial Thigh Compartment The medial thigh compartment is one of three anatomic divisions of the thigh. The muscles of the medial thigh primarily function to adduct the thigh at the hip joint. The most anterior and lateral adductor muscle is the pectineus, which originates on the pectineal line of the pubis and inserts onto the femur. This muscle contributes to the floor of the femoral triangle in the anterior thigh, and its primary function is hip flexion. As this muscle has a dual innervation as discussed below, it is considered a transitional muscle between the anterior thigh and medial thigh compartments. Medial to the pectineus muscle is the adductor longus muscle, which originates on the superior ramus of the pubis and inserts onto the femur. It forms the medial border of the femoral triangle. Its main action is to adduct and flex the thigh. The gracilis muscle forms the medial border of this region and is the most superficial muscle in the medial thigh. It originates on the body of the pubis and the upper half of the inferior pubic ramus and inserts onto the proximal and medial surface of the tibia. This muscle crosses both the hip and knee joints, and its main function is adduction of the thigh at the hip and flexion of the leg at the knee. Between the adductor longus and gracilis lie the adductors magnus and brevis muscles. The adductor brevis lies underneath the adductor longus and between the anterior and posterior branches of the obturator nerve. It originates on the body of the pubis and the inferior pubic ramus. Its function is to adduct the thigh. The adductor magnus is the largest muscle in the medial compartment and lies posterior to the other muscles. It has an adductor part, which originates from the ischiopubic ramus and inserts along the posterior shaft of the femur, and a hamstring head, which originates from the ischial tuberosity and inserts on the medial epicondyle of the femur. The primary action of the adductor part is adduction, and the primary action of the hamstring part is hip extension. Beneath these three adductor muscles lies the obturator externus, which originates from the distal surface of the obturator membrane and adjacent bone and inserts onto the femur. The primary action of the obturator externus is the same as that of the obturator internus muscle, which is lateral rotation of the hip. The muscles of the medial thigh compartment receive blood supply from the femoral and obturator arteries. Although significant variability exists, presented here is a frequent pattern of blood supply. The profunda femoris is a branch of the femoral artery that supplies the pectineus and adductors longus, brevis, and magnus. A smaller branch of this vessel, the medial circumflex femoral artery, perforates the adductor brevis, obturator externus, and gracilis muscles. The obturator artery passes through the obturator canal and then separates into anterior and posterior branches, which encircle the obturator membrane. Its branches supply the pectineus and obturator externus muscles. Deep veins of the thigh correspond with the major arteries described. The major source of innervation to the medial thigh is from the obturator nerve. It enters the thigh through the obturator canal and promptly separates into anterior and posterior branches, which travel on the anterior P.18 and posterior aspects of the adductor brevis muscle. The anterior branch supplies the adductors longus and brevis muscles. The posterior branch supplies the gracilis, adductors brevis and magnus, and obturator externus muscles. The hamstring head of the adductor magnus receives innervation from the tibial branch of the sciatic nerve. Notably, though the pectineus muscle is anatomically part of the medial thigh and may receive some innervation from the anterior branch of the obturator nerve, it receives primary innervation from the femoral nerve. The obturator nerve was described earlier under lumbar plexus branches. Symptoms of obturator nerve injury may include medial thigh or groin pain, weakness with thigh adduction, and sensory loss in the medial thigh of the affected side. THE PELVIC FLOOR When humans assumed the upright posture, the opening in the bony pelvis came to lie at the bottom of the abdominopelvic cavity. This required the evolution of a supportive system to prevent the pelvic organs from being pushed downward through this opening. In the woman, this system must withstand these downward forces but allow for the passage of the large and cranially dominant human fetus. The supportive system that has evolved to meet these needs consists of a fibromuscular floor that forms a shelf spanning the pelvic outlet and that contains a cleft for the birth canal and excretory drainage. A series of visceral ligaments and fasciae tethers the organs and maintains their position over the closed portions of the pelvic diaphragm 42 muscles (levators) and covering fasciae. The openings in the pelvic diaphragm and in the perineal membrane for parturition and elimination have required the development of ancillary fibrous elements that are concentrated over open areas in the muscular floor to support the viscera in these weak areas. This section discusses the structures of the perineal portion of the pelvic floor; the fibrous supportive system is described in the section on the pelvic viscera and cleavage planes and fascia. FIGURE 1.18 Structures visible within deep perineal pouch/compartment after removal of the superficial perineal muscles and perineal membrane. Perineal Membrane The perineal membrane forms the inferior portion of the anterior pelvic floor below the levator muscles and covering fasciae. It is a triangular sheet of dense, fibromuscular tissue that spans the anterior half of the pelvic outlet, separating the superficial from the deep perineal pouch (see FIG. 1.13). It was previously called the urogenital diaphragm, and this change in name reflects the appreciation that it is not a two-layered structure with muscle in between, as was previously thought. It lies just caudal to the skeletal muscle of the striated urogenital sphincter (formerly the deep transverse perineal muscle). Because of the presence of the vagina, the perineal membrane cannot form a continuous sheet to close off the anterior pelvis in the woman, as it does in the man. It does provide support for the posterior vaginal wall by attaching the vagina and perineal body to the ischiopubic rami, thereby limiting their downward descent. This layer of the floor arises from the inner aspect of the inferior ischiopubic rami superior to the ischiocavernosus muscles and the crura of the clitoris. The medial attachments of the perineal membrane are to the urethra, walls of the vagina (approximately at the level of hymenal ring), and perineal body. Just cephalad to the perineal membrane, in the deep pouch of anterior perineal triangle lie two arch-shaped striated muscles that begin posteriorly and pass anteriorly to arch over the urethra (FIG. 1.18) These are the compressor urethrae and the sphincter urethrovaginalis muscles. They are a part of the striated urogenital sphincter P.19 43 muscle in the woman and are continuous with the external urethral sphincter muscle. They act to compress the distal urethra. Posteriorly, intermingled within the membrane are skeletal muscle fibers of the transverse vaginal muscle and some smooth muscle fibers. Parts of the dorsal and deep nerve and vessels of the clitoris are also found within this membrane and were described previously. The primary function of the perineal membrane is related to its attachment to the vagina and perineal body. By attaching these structures to the bony pelvic outlet, the perineal membrane supports the perineal part of the pelvic floor against gravity and the effects of increases in intra-abdominal pressure. The anterior part of pubococcygeus and puborectalis portions of the levator ani muscles lie just at the upper margin of the perineal membrane contacting its cranial surface. Contraction of these muscles elevates the medial margin of the perineal membrane (along with the vagina), while relaxation allows for its caudal movement. The amount of downward descent that is permitted by the connections of the perineal membrane to the midline structures can be assessed during an examination under anesthesia by placing a finger in the rectum, hooking it forward, and gently pulling the perineal body downward. If the perineal membrane has been torn during parturition, then an abnormal amount of descent is detectable, and the pelvic floor sags and the introitus gapes. Perineal Body Within the area bounded by the lower vagina, perineal skin, and anus is a mass of fibromuscular tissue called the perineal body (see FIG. 1.14). The term central point (tendon) of the perineum has been applied to this structure and is descriptive, suggesting its role as a central point into which many muscles insert. FIGURE 1.19 Schematic view of anorectal region. The external sphincter muscle is cut in the anterior midsagittal plane and reflected posteriorly. Note the relationship of anterior muscle bundle to perineal body and interdigitations with the transverse perineal muscle. Note origin and position of internal anal sphincter relative to external anal sphincter muscle. The origin of the anterior muscle bundle is clarified, and the remaining anterolateral portions of the external sphincters are interdigitated into the transverse perinei. 44 The perineal body is attached to the inferior pubic rami and ischial tuberosities through the perineal membrane and superficial transverse perineal muscles. Anterolaterally, it receives the insertion of the bulbospongiosus muscles. On its lateral margins, the upper portions of the perineal body are connected with some fibers of the pelvic diaphragm, the puboperinealis portion of the pubococcygeus muscle. Posteriorly, the perineal body is indirectly attached to the coccyx by the external anal sphincter. These connections anchor the perineal body and its surrounding structures to the bony pelvis and help to keep it in place. Posterior Triangle: Ischioanal Fossa In the posterior triangle of the pelvis, the ischioanal fossa lies between the obturator muscle and medial layer of fascia at the perineal walls and the levator ani muscles and its inferior layer of fascia (see FIG. 1.14). It has an anterior recess that lies above the perineal membrane. It is bounded superomedially by the levator ani muscles and laterally by the obturator internus muscle. The main portion of the fossa is lateral to the levator ani and external anal sphincter, and it has a posterior portion that extends above the gluteus maximus. Traversing this fossa is the pudendal neurovascular trunk. The pudendal canal with neurovascular bundle lies on its lateral wall. Anal Sphincters The external sphincter lies in the posterior triangle of the perineum (FIG. 1.19). It is a single mass of muscle that has traditionally been divided into a subcutaneous, superficial, and deep portion. The subcutaneous part lies attached to the perianal skin and forms an P.20 encircling ring around the anal canal. It is responsible for the characteristic radially oriented folds in the perianal skin. The superficial part attaches to the coccyx posteriorly, contributing to the anococcygeal body, and sends a few fibers into the perineal body anteriorly. The superficial part of the external anal sphincter forms the bulk of the anal sphincter when seen separated in third-degree midline obstetric tears. The fibers of the deep part generally encircle the rectum and blend indistinguishably with the puborectalis, which forms a loop under the dorsal surface of the anorectum and which is attached anteriorly to the pubic bone (see FIG. 1.19). The internal anal sphincter is a thickening in the circular smooth muscle of the anal wall. It lies just inside the external anal sphincter and is separated from it by a visible intersphincteric groove. It extends downward inside the external anal sphincter to within a few millimeters of the external sphincter's caudal extent. The internal sphincter can be identified just outside the anal submucosa in repair of a chronic fourth-degree laceration as a rubbery white layer that is often erroneously been referred to as fascia during obstetrical repair of fourth-degree laceration. The longitudinal smooth muscle layer of the bowel, along with some fibers of the levator ani, separates the external and internal sphincters as they descend in the intersphincteric groove. Levator Ani Muscles The typical depiction of the levator ani muscles in anatomy textbooks is unfortunately distorted by the extreme abdominal pressures generated during embalming that forces them downward. Many of these illustrations therefore fail to give a true picture of the horizontal nature of this strong supportive shelf of muscle. Examination of the normal standing patient is the best way to appreciate the nature of this closure mechanism, because the lithotomy position causes some relaxation of the musculature. During routine pelvic examination of the nullipara, the effectiveness of this closure can be appreciated, because it is often difficult to insert a speculum if the muscles are contracted. 45 FIGURE 1.20 Anatomy of the pelvic floor, perineal view. The bony pelvis is spanned by the levator muscles of the pelvic diaphragm. This diaphragm consists of two components: (a) a thin horizontal shelflike layer formed by the iliococcygeus muscle and (b) a thicker "U"-shaped sling of muscles that surround the levator hiatus that include the pubococcygeus and puborectalis muscles (FIG. 1.20). The open area within the U (through which the urethra, vagina, and rectum pass) is called the levator hiatus, and the portion of the hiatus anterior to the perineal body is called the urogenital hiatus. The pubococcygeus muscle arises from a thin aponeurotic attachment to the inner surface of the pubic bone and inserts to the distal lateral vagina, perineal body, and anus. Some fibers also attach to the superior surface of the coccyx, hence the name pubococcygeus. Because the majority of the attachments, however, are to the vagina and anus, the term pubovisceral muscle is replacing this older term. The puborectalis muscle is distinct from the pubococcygeus muscle and lies lateral to it (see FIG. 1.20). P.21 Its fibers originate from the lower pubis and some from the top of the perineal membrane. The muscle fibers pass beside the rectum forming a sling behind the anorectal junction. The iliococcygeus muscle arises from a fibrous band overlying the obturator internus called the tendinous arch of levator ani. From these broad origins, the fibers of the iliococcygeus pass behind the rectum and insert into the midline anococcygeal body, which includes the iliococcygeal raphe, and the coccyx. The ischiococcygeus (coccygeus) muscle arises from the ischial spine and sacrospinous ligament to insert into the borders of the coccyx and the lowest segment of the sacrum. These muscles are covered on their superior and inferior surfaces by fasciae. When the levator ani and ischiococcygeus muscles 46 and their fasciae are considered together, they are called the pelvic diaphragm, not to be confused with the perineal membrane (formerly called the urogenital diaphragm). The normal tone of the muscles of the pelvic diaphragm keep the base of the U in the levator hiatus close to the backs of the pubic bones, keeping the vagina and rectum closed. The region of the levator ani between the anus and coccyx formed by the anococcygeal body and iliococcygeal raphe is clinically called the levator plate. It forms a supportive shelf on which the rectum, upper vagina, and uterus can rest. The relatively horizontal position of this shelf is determined by the anterior traction on the fibromuscular levator plate by the pubococcygeus and puborectalis muscles and is important to vaginal and uterine support. FIGURE 1.21 The pelvic viscera. The levator ani muscles receive their innervation from an anterior branch of the anterior ramus of the third, fourth, and fifth sacral nerves called, appropriately, the nerve to the levator ani, which perforates the muscle from its pelvic surface. Some parts of the puborectalis muscle may also receive a small contribution from the inferior anal (rectal) branch of the pudendal nerve. PELVIC VISCERA This section on the pelvic viscera discusses the structure of the individual pelvic organs and considers specific aspects of their 47 interrelations (FIG. 1.21). Those aspects of blood supply, innervation, and lymphatic drainage that are unique to the specific pelvic viscera are covered here. However, the section on the retroperitoneum, where the overall description of these systems is given, provides the general consideration of the pelvic vasculature, innervation, and lymphatic drainage. Genital Structures Vagina The vagina is a pliable hollow viscus with a shape that is determined by the structures surrounding it and by its attachments to the pelvic wall. These attachments are to the lateral margins of the vagina, so that its lumen is a transverse slit, with the anterior and posterior walls in contact with one another. The lower portion of the vagina is constricted as it passes through the urogenital P.22 hiatus. The upper part is much more capacious. The vagina is bent at an angle of 120 degrees by the anterior traction of the levator ani muscles at the junction of the lower one third and upper two thirds of the vagina (FIG. 1.22). The cervix typically lies within the anterior vaginal wall, making the anterior vaginal wall shorter than the posterior wall by 2 to 3 cm. The anterior wall is about 7 to 9 cm in length, although there is great variability in this dimension. FIGURE 1.22 Bead-chain cystourethrogram (with barium in the vagina) showing the normal vaginal axis in a patient in the standing position. 48 When the lumen of the vagina is inspected through the introitus, many landmarks can be seen. The anterior and posterior walls have a midline ridge, called the anterior and posterior columns, respectively. These are caused by the impression of the urethra and bladder and the rectum on the vaginal lumen. The caudal portion of the anterior column is distinct and is called the urethral carina of the vagina. The recesses in front of, behind, and lateral to the cervix are called the anterior, posterior, and lateral fornices of the vagina, respectively. The creases along the side of the vagina, where the anterior and posterior walls meet, are called the lateral vaginal sulci. The vagina's relations to other parts of the body can be understood by dividing it into thirds. In the lower third, the vagina is fused anteriorly with the urethra, posteriorly with the perineal body, and laterally to each levator ani by the "fibers of Luschka." The portion of the pubococcygeus muscle that attaches to the vagina is called the pubovaginalis. In the middle third are the vesical neck and trigone anteriorly, the rectum posteriorly, and the levators laterally. In the upper third, the anterior vagina is adjacent to the bladder, posterior to the cul-de-sac, and lateral to the cardinal ligaments. The vaginal wall contains the same layers as all hollow viscera (i.e., mucosa, submucosa, muscularis, and adventitia). The adventitial layer represents the visceral fascia surrounding a pelvic organ as discussed below. Except for the area covered by the cul-de-sac, the vagina has no serosal covering. The mucosa consists of the epithelium and lamina propria layers. It is of the nonkeratinized stratified squamous type and lies on a dense, dermis-like submucosa. The vaginal muscularis is fused with the submucosa, and the pattern of the muscularis is a bihelical arrangement. Outside the muscularis, the adventitial layer or visceral pelvic fascia has varying degrees of development in different areas of the vagina. Visceral pelvic fascia is a component of the endopelvic fascia and has been given a separate name because of its unusual development. When it is dissected in the operating room, the muscularis is usually adherent to it, and this combination of specialized adventitia and muscularis is the surgeon's "fascia," which might better be called the fibromuscular layer of the vagina, as Nichols and Randall suggested in Vaginal Surgery. Uterus The uterus is a fibromuscular organ with shape, weight, and dimensions that vary considerably, depending on both estrogenic stimulation and previous parturition. It has two portions: an upper muscular body and a lower fibrous cervix. In a woman of reproductive age, the body is considerably larger than the cervix, but before menarche, and after the menopause, their sizes are similar. Within the body, there is a triangularly shaped endometrial cavity surrounded by a thick muscular wall. That portion of the uterus that extends above the top of the endometrial cavity (i.e., above the insertions of the uterine tubes) is called the fundus. The muscle fibers that make up most of the uterine body are not arranged in a simple layered manner, as is true in the gastrointestinal tract, but are arranged in a more complex pattern. This pattern reflects the origin of the uterus from paired paramesonephric primordia, with the fibers from each half crisscrossing diagonally with those of the opposite side. The uterus is lined by a unique mucosa, the endometrium. It has both a columnar epithelium that forms glands and a specialized stroma. The superficial portion of this layer undergoes cyclic change with the menstrual cycle. Spasm of hormonally sensitive spiral arterioles that lie within the endometrium causes shedding of this layer after each cycle, but a deeper basal layer of the endometrium remains to regenerate a new lining. Separate arteries supply the basal endometrium, explaining its preservation at the time of menses. The cervix is divided into two portions: the vaginal part, which is that part protruding into the vagina, and the supravaginal part, which lies above the vagina and below the body. The cervical wall, especially its distal segment, is primarily composed of dense, fibrous connective tissue P.23 with only a small amount (approximately 10%) of smooth muscle. This smooth muscle is located peripherally within the cervix, connecting the myometrium with the muscle of the vaginal wall. This smooth muscle and accompanying fibrous tissue are easily dissected off the underlying, denser fibrous cervix core and for