Topography of the pelvis. Topographic anatomy of the pelvic organs
The small pelvis is a collection of bones and soft tissues located below the border line.
The walls of the pelvis, represented by the pelvic bones below the borderline, the sacrum, coccyx and muscles that cover the large sciatic (piriformis) and obturator (internal obturator muscle) openings, front, back and sides limit the pelvic cavity. From below, the pelvic cavity is limited by the soft tissues of the perineum. Its muscular basis is formed by the levator ani muscle and the deep transverse perineal muscle, which take part in the formation of the pelvic diaphragm and the urogenital diaphragm, respectively.
The pelvic cavity is usually divided into three sections, or floors:
Peritoneal cavity of the pelvis- the upper part of the pelvic cavity, enclosed between the parietal peritoneum of the small pelvis (is the lower part of the abdominal cavity). It contains parts of the pelvic organs covered by the peritoneum - the rectum, bladder, in women - the uterus, wide uterine ligaments, fallopian tubes, ovaries and the upper part of the posterior wall of the vagina. After emptying the pelvic organs, loops of the small intestine, the greater omentum, and sometimes the transverse or sigmoid colon, and the appendix can descend into the peritoneal cavity of the pelvis.
Subperitoneal cavity of the pelvis- part of the pelvic cavity
enclosed between the parietal peritoneum and the sheet of the pelvic fascia, which covers the top of the muscle that lifts the anus. Contains blood and lymphatic vessels, lymph nodes, nerves, extraperitoneal parts of the pelvic organs - the bladder, rectum, pelvic part of the ureter. In addition, in the subperitoneal cavity of the pelvis in women there is a vagina (except for the upper part of the back wall) and the cervix, in men - the prostate gland, pelvic parts of the vas deferens, seminal
bubbles. The listed organs are surrounded by fatty tissue, divided by the spurs of the pelvic fascia into several cellular spaces.
Subcutaneous pelvic cavity- the space related to the perineum and lying between the skin and the diaphragm of the pelvis. It contains the sciatic-rectal fossa filled with fatty tissue with internal genital vessels and the pudendal nerve passing through it, as well as their branches, parts of the organs of the genitourinary system, and the distal part of the rectum. The exit from the small pelvis is closed by the pelvic and urogenital diaphragms formed by muscles and fascia.
Course of the peritoneum
In the cavity of the male pelvis, the peritoneum passes from the anterolateral wall of the abdomen to the anterior wall of the bladder, covers its upper, posterior and part of the side walls and passes to the anterior wall of the rectum, forming a recto-vesical cavity. From the sides, it is limited by the rectovesical folds of the peritoneum. This recess can accommodate part of the loops of the small intestine and the sigmoid colon.
In women, the peritoneum passes from the bladder to the uterus (covers mesoperitoneally), then to the posterior fornix of the vagina, and then to the anterior wall of the rectum. Thus, two depressions are formed in the cavity of the female pelvis: vesico-uterine and rectal-uterine. When moving from the uterus to the rectum, the peritoneum forms two folds that stretch in the anteroposterior direction, reaching the sacrum. The greater omentum may be located in the vesicouterine cavity; in the rectum-uterine - loops of the small intestine. Blood, pus, urine can also accumulate here in case of injuries and inflammation.
Fascia of the pelvis
The pelvic fascia is a continuation of the intra-abdominal fascia, and consists of parietal and visceral sheets.
The parietal sheet of the pelvic fascia covers the parietal muscles of the pelvic cavity and is divided into the superior fascia of the urogenital and pelvic diaphragm and the inferior fascia of the urogenital
howling and pelvic diaphragm, which contain the muscles that form the bottom of the small pelvis (deep transverse perineal muscle and the muscle that raises the anus).
The visceral sheet of the pelvic fascia covers the organs located in the middle floor of the small pelvis. This sheet forms fascial capsules for the pelvic organs (Pirogov-Retzia for the prostate gland and Amyuss for the rectum), separated from the organs by a layer of loose fiber, in which the blood and lymphatic vessels, nerves of the pelvic organs are located. The capsules are separated by a septum located in the frontal plane (Denonville-Salishchev aponeurosis; rectovesical septum in men and rectovaginal septum in women), which is a duplication of the primary peritoneum. Anterior to the septum are the bladder, prostate gland, seminal vesicles and parts of the vas deferens in men, the bladder and uterus in women. Behind the septum is the rectum.
Pelvic cellular spaces Classification:
1. Parietal: retropubic (preperitoneal, prevesical), retrovesical, retrorectal, parametric, lateral.
2. Visceral: paravesical, pararectal, oculocervical.
Lateral cellular space-paired (right-, and
left-sided), laterally limited by the parietal fascia of the pelvis, medially by the sagittal spurs of the visceral fascia of the pelvis.
Content: internal iliac vessels and their branches, pelvic parts of the ureters, vas deferens, branches of the sacral plexus.
Ways of spread of pus:
l into the retrovesical space (along the ureter);
l into the retroperitoneal space (along the ureter);
l in the gluteal region (along the upper and lower gluteal vessels and nerves);
l into the inguinal canal (along the vas deferens).
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Retropubic space
1. prevesical space –limited in front of the forehead
kovy symphysis and branches of the pubic bones, behind - prevesical fascia.
2. preperitoneal space -between the prevesical fascia and the anterior leaf of the visceral fascia of the bladder.
Ways of spread of pus:
l into the subcutaneous fatty tissue of the thigh (through the femoral ring);
l into the tissue surrounding the medial thigh muscle group (through the obturator canal);
l in the preperitoneal tissue of the anterior wall of the abdomen;
l into the lateral cellular space of the pelvis (through defects in the sagittal spurs of the visceral fascia of the pelvis).
Paravesical space-located between walls
which is the bladder and the visceral fascia that covers it.
Content: vesical venous plexus.
Posterior bladder space– limited front to rear
with a leaf of the visceral fascia of the bladder, behind
- the peritoneal-perineal fascia, which forms the recto-intestinal-vesical septum in men or the recto-intestinal-vaginal septum in women.
Content: in men, the prostate gland, seminal vesicles, vas deferens and ureters; in women, the vagina and ureters.
Ways of spread of pus:
l in the inguinal region and scrotum (along the vas deferens through the inguinal canal);
l into the retroperitoneal cellular space (along the ureters).
Posterior rectal space– limited special
among the rectum, covered with the visceral fascia of the pelvis; behind - the sacrum, lined with parietal fascia of the pelvis.
Content: sacral parts of the sympathetic trunks, sacral lymph nodes, lateral and median sacral arteries, veins of the same name that form the sacral
venous plexus, superior rectal artery and vein.
Ways of spread of pus(along the vessels) :
l into the retroperitoneal space;
l into the lateral cellular space of the pelvis.
Perirectal space-between visceral-
noah fascia of the pelvis, covering the rectum, and its wall.
Periouterine (parametrical) space - steam-
noe ( right-, and left-sided), between the leaves of the wide uterine ligaments .
Ways of spread of pus:
l laterally and down - into the lateral space of the pelvis;
l medially and down - into the pericervical tissue;
l into the retrovesical space.
Peri-cervical space - located around the cervix.
Pelvic vessels
The walls and organs of the pelvis are supplied with blood by the internal iliac arteries, which enter the lateral cellular spaces and are divided into anterior and posterior branches. Branches depart from the anterior branches of the internal iliac arteries, supplying blood mainly to the pelvic organs:
the umbilical artery, which gives off the superior vesical artery;
inferior vesical artery; uterine artery - among women, in men- seminal artery
efferent duct; middle rectal artery;
internal genital artery.
From the posterior branches of the internal iliac arteries
branches that supply blood to the walls of the pelvis:
iliac-lumbar artery; lateral sacral artery; obturator artery; superior gluteal artery;
inferior gluteal artery.
The parietal branches of the internal iliac arteries are accompanied by two veins of the same name. Visceral veins form well-defined venous plexuses around the organs. There are venous plexus of the bladder, prostate, uterus, vagina and rectum. The veins of the rectum, in particular, the superior rectal vein, through the inferior mesenteric vein, flow into the portal vein, the middle and inferior rectal veins into the system of the inferior vena cava. They are connected to each other, forming porto-caval anastomoses. From other venous plexuses, blood flows into the system of the inferior vena cava.
Innervation of the pelvis sacral plexus(somatic, paired) formed
anterior branches of IV, V lumbar and I, II, III sacral spinal nerves.
Branches:
muscle branches; superior gluteal nerve;
inferior gluteal nerve; posterior cutaneous nerve of the thigh; sciatic nerve; sexual nerve.
Pelvis and perineum.
COMMON DATA
The name "pelvis" in topographic anatomy is understood to mean that part of the body that is externally limited by the bone pelvis and tissues that form the so-called pelvic diaphragm. The soft tissues and skin covering the pelvic bones are other areas.
The exit from the pelvis is closed by soft tissues that make up a special area - the perineum, which will be discussed in the same chapter. Have with the anterior perineum is usually described and the area of the external genital organs - the pudendal region (regio pudendalis).
Part of the organs enclosed in the pelvis belongs to the abdominal cavity, in particular, the sections of the large intestine located in the iliac fossae. The latter make up what is commonly called the large pelvis. Below the boundary line (linea terminalis, s. innominata), the small pelvis begins, the topography of which is the content of this chapter.
Since access to the pelvic cavity and the organs enclosed in it is carried out either from the side of the anterior abdominal wall, or from the side of the sacrum, coccyx and gluteal region, or from the side of the perineum and, finally, from the side of the thigh, it seems necessary to note the main landmarks (bone, muscle and etc.), which surgeons and doctors of other specialties (for example, gynecologists) use both for diagnostic purposes and for surgical treatment.
Of the bone landmarks, here it is necessary to name first of all the symphysis (its upper edge) and the parts of the horizontal branches of the pubic bones adjacent to it, with the pubic tubercles located on them outward from the symphysis. Feeling them is not difficult. Further, the always well-palpable anterior superior iliac spines are important landmarks. Outside and behind them, the iliac crests are palpated. Behind, parts of the sacrum and coccyx are well defined, and within the gluteal regions - ischial tubercles. Outside and slightly above the latter, large skewers of the femur are palpable. The lower edge of the symphysis and the pubic arch in men can be palpated behind the scrotal root. In women, the lower edge of the pubic fusion, as well as the pelvic cape (promontorium), is determined during vaginal examinations. Other landmarks include the inguinal ligament, which can be felt deep in the inguinal fold.
The determination of certain changes in the configuration and consistency of the pelvic organs is often made from the side of the rectum with a finger inserted into the anus, and in women - also from the side of the vagina (often simultaneously from the side of the vagina and the anterior abdominal wall - the so-called bimanual study). In men, for example, by examining the rectum (per rectum), pathological changes in the prostate gland and seminal vesicles are determined.
THREE STORIES OF THE PELVIC CAVITY
The pelvic cavity is divided into three sections, or floors: cavum pelvis peritonaeale, cavum pelvis subperitonaeale and cavum pelvis subcutaneum (Fig. 350 and 351).
The first floor - cavum pelvis peritonaeale - is the lower part of the peritoneal cavity and is limited (conditionally) from above by a plane passing through the pelvic inlet. It contains those organs or parts of the pelvic organs that are covered by the peritoneum. In men, in the peritoneal cavity of the pelvis, the part of the rectum covered with the peritoneum is located, and then the upper, partially postero-lateral and, to a small extent, the anterior walls of the bladder.
Rice. 350. The relationship of muscles and fascia on the frontal cut of the female pelvis (diagram; according to A.P. Gubarev).
1 - vagina; 2 – m. levator ani; 3 - arcus tendineus fasciae pelvis; 4 - m. obturator interims; 5 - spatium ischiorectale; 6 - m. transversus perinei profundus; 7 - m. transversus perinei superficialis; 8 - m. constrictor cunni (s. bulbocavernosus); 9 - bulbus vestibuli; 10 - labium pudendi minus; 11 - labium pudendi majus; 12 - fascia perinei superficialis; 13 - tuber ischii dextrum; 14 - fascia perinei media; 15 - acetabulum dextrum; 16 - fascia perinei superior (s. profunda).
Passing from the anterior abdominal wall to the anterior and upper walls of the bladder, the peritoneum forms a transverse cystic fold, more clearly visible when the bladder is empty. Further, in men, the peritoneum covers part of the lateral and posterior walls of the bladder. the inner edges of the ampullae of the vas deferens and the tops of the seminal vesicles (the peritoneum is about 1 cm away from the prostate gland). Then the peritoneum passes to the rectum, forming the rectovesical space, or notch, - excavatio rectovesicalis. From the sides, this notch is limited by rectovesical folds (plicae rectovesicales), stretched in the anterior-posterior direction between the bladder and the rectum. They contain ligaments of the same name, consisting of fibrous and smooth muscle fibers, partly reaching the sacrum.
In the space between the bladder and the rectum, part of the loops of the small intestine, sometimes the transverse colon or sigmoid colon, can be placed; in very rare cases, a caecum with a appendix is placed here. It should, however, be noted that the deepest part of the rectovesical space is a narrow gap, bounded above and on the sides by the indicated folds of the peritoneum; intestinal loops usually do not penetrate into this gap, but effusions and streaks can accumulate in it. Similar conditions occur in the recto-uterine space of the female pelvis.
The sharply stretched rectum occupies most of the first floor of the pelvic cavity; then, as the cuts made by N.I. Pirogov show, intestinal loops do not penetrate into the rectovesical space (Fig. 352).
The position of the anterior and posterior folds of the peritoneum (as N.I. Pirogov called the folds of the peritoneum, which are formed during its transition from the anterior abdominal wall to the bladder and from the bladder to the rectum) is largely related to the degree of filling of the bladder. N. I. Pirogov found that with a high degree of bladder filling, the anterior fold of the peritoneum extends 4–6 cm upwards from the symphysis, while the posterior (bottom of the rectovesical space) is 9 cm away from the anus. in the collapsed bladder, the anterior fold of the peritoneum adjoins the upper edge of the symphysis, while the posterior fold is 4–5 cm away from the anus (Fig. 353). These data were confirmed in the work of V. N. Shevkunenko on anterior extraperitoneal incisions.
With an average degree of bladder filling, the bottom of the rectovesical space in men is located at the level of the sacrococcygeal joint and is 6–7 cm away from the anus.
Rice. 351. The cavity of the male pelvis on the frontal cut (according to E. G. Salishchev).
1 - bladder; 2 - cystic opening of the ureter; 3 - seminal vesicle and vas deferens; 4 - aponeurosis peritonaeoperinealis; 5 - rectum; 6 - visceral sheet of the pelvic fascia; 7 - m. levator ani; 8 - fascia of the perineum (spur of the parietal leaf of the fascia of the pelvis); 9, 15 - cavum pelvis subperitonaeale; 10 - m. sphincter ani externus; 11 - cavum pelvis subcutaneum (fossa ischiorectalis); 12 - vasa pudenda interna and n. pudendus; 13 - m. obturator interims; 14 - parietal sheet of the pelvic fascia; 16 - peritoneum; 17 - cavum pelvis peritoneale.
In women, in the first floor of the pelvic cavity, the same parts of the bladder and rectum are placed as in men, most of the uterus and its appendages (ovaries and fallopian tubes), wide uterine ligaments, as well as the uppermost part of the vagina (throughout 1–2 cm).
Rice. 352. Cross section of the male pelvis at the level of the upper edge of the symphysis (according to N. I. Pirogov). The cut was made through the pubic tubercles, hip joints, large skewers. The figure depicts the bottom surface of the cut.
1 - the bladder and the internal opening of the urethra; 2 - m. pectineus; 3-n. obturatorius and vasa obturatoria; 4 - inguinal lymph nodes; 5 - mucous bag located between the tendon m. iliopsoas and hip joint capsule; 6 - m. sartorius; 7 - m. iliopsoas; 8 - m. rectus femoris; 9 - m. tensor fasciae latae; 10 - m. glutaeus medius; 11 - capsule of the hip joint; 12 - common tendon m. obturator interims and stumps. gemelli; 13 - mucous bag, located motnu tendon m. glutaeus medius and greater skewer; 14 - trochanter major; 15-lig. teres femoris; 10 - m. obturator internus; 17 - extrapelvic part m. obturator internus with bundles mm. gemelli; 18 - incisura ischiadica minor, dissected near the ischial spine, and a mucous bag located between the tendon in. obturator interims and ischium; 19 - in. levator ani; 20 - the cavity of the rectum (stretched) and the semilunar fold of its mucous membrane; 21 - coccyx (dissected at a distance of 1.5 cm from the connection with the sacrum); 22 - vas deferens; 23 - seminal vesicle; 24 - vasa pudenda interna and n. pudendus; 25-n. ischi adieus and vasa glutaea inferiora; 26-m. glutaeus maximus; 27 - head of the femur, dissected almost in the middle; 28 - n. femoralis; 29 - Femoral vessels and a septum between them; 30 - anterior leaf of the wide fascia of the thigh; 31 - aponeurosis of the external oblique muscle of the abdomen; 32 - horizontal branch of the pubic bone; 33 - spermatic cord; 34 - symphysis.
In women, when the peritoneum passes from the bladder to the uterus, and then to the rectum, two peritoneal spaces (recesses) are formed: the anterior - excavatio vesicouterina (vesico-uterine space) and the posterior - excavatio rectouterina (rectal-uterine space).
Rice. 353. The position of the transitional folds of the peritoneum in the pelvis with varying degrees of filling of the bladder on the sagittal cut (according to N. I. Pirogov). Both figures depict the left segment of the section:
A - with an empty bladder; B - with a filled bubble. 1 - I sacral vertebra; 2 - small intestines; 3 - rectus abdominis; 4 - anterior transitional fold of the peritoneum; 5 - bladder; 6 - symphysis; 7 - prostate gland; 8 - seed tubercle; 9 -urethra; 10 - bulbus urethrae; 11 - rectum; 12 - posterior transitional fold of the peritoneum; 13 - excavatio rectovesicalis.
When moving from the uterus to the rectum, the peritoneum forms two lateral folds that stretch in the anterior-posterior direction and reach the sacrum. They are called sacro-uterine folds (plicae sacrouterinae) and contain ligaments consisting of muscular-fibrous bundles (ligamenta sacrouterina).
In the recto-uterine space, intestinal loops can be placed, in the vesico-uterine space - a greater omentum (Fig. 354).
Rice. 354. Transverse cut / horse pelvis, carried out 2 cm above the upper edge of the symphysis (according to N. I. Pirogov). The figure depicts the bottom surface of the cut.
l - rectus abdominis; 2 - Greater omentum (performs excavatio vesicouterina); 3 - ilium (near its connection with the pubis); 4 - m. obturator interims; 5 - m. glutaeus minimus; 6-n. ischiadicus and vasa glutaea inferiora; 7 - m. piriformis; 8 - m. glutaeus maximus; 9 – excavatio rectouterina (end of excavation); 10 - fallopian tube; 11 - sacrum (near the junction with the coccyx); 12 - rectum; 13 - the uterus, dissected between its body and the bottom (located in the left part of the pelvic cavity); 14 - bladder.
The second floor - cavum pelvis subperitonaeale - is enclosed between the peritoneum and the sheet of the pelvic fascia covering m. levator ani on top. Here, in men, there are the extraperitoneal sections of the bladder and rectum, the prostate gland, seminal vesicles, the pelvic sections of the vas deferens with their ampullae, and the pelvic sections of the ureters. In women, in this floor of the pelvic cavity there are the same sections of the ureters, bladder and rectum as in men, the cervix, the initial section of the vagina (with the exception of a small area covered by the peritoneum and belonging to the first floor of the pelvic cavity). The organs located in the cavum pelvis subperitonaeale are surrounded by connective tissue cases formed by the pelvic fascia (see below about these fascial formations). In addition to these organs, in the fiber layer between the peritoneum and the pelvic fascia there are blood vessels, nerves, lymphatic vessels and nodes (for convenience, their topography is described in the next section).
The third floor - cavum pelvis subcutaneum - is enclosed between the lower surface of the pelvic diaphragm and integuments. This section belongs to the perineum and contains parts of the organs of the genitourinary system and the final section of the intestinal tube. This, therefore, also includes the fat-filled fossa ischiorectalis, located on the side of the perineal rectum.
VESSELS, NERVES AND LYMPH NODES OF THE PELVIS
The hypogastric artery - a. hypogastrica - arises from the common iliac at the level of the sacroiliac joint and goes downward, outward and backward, located on the posterolateral wall of the pelvic cavity. The accompanying hypogastric vein runs posterior to the artery. The trunk of the artery is usually short (3–4 cm) and splits into parietal and visceral branches. The first go to the walls of the pelvis and the external genital organs, the second - to the pelvic viscera (Fig. 355).
From parietal branches a. obturatoria goes into the canal of the same name, accompanied by n. obturatorius. Approximately in 1/3 cases a. obturatoria starts from a. epigastrica inferior (V.P. Vorobyov). In 10% of cases, the obturator artery originates not from the hypogastric artery, but from the superior gluteal artery, and in half of these cases it arises from two sources (“two-rooted” obturator artery): the branch that departs from the superior gluteal artery merges with the obturator artery from the external iliac (T. I. Anikina).
Ah. glutaea superior and inferior through foramen supra- and infrapiriforme, accompanied by the nerves of the same name, go to the gluteal region. A. pudenda interna through the foramen infrapiriforme, accompanied by p. pudendus, goes to the lower floor of the pelvic cavity, giving the final branches to the external genital organs. A. iliolumbalis goes backwards, upwards and outwards under m. psoas and splits into two branches, one of which anastomoses with branches a. circumflexa ilium profunda, the other with the lumbar arteries. A. sacralis lateralis goes inwards and downwards and sends branches to the spinal nerves and to the muscles of the pelvis.
Visceral branches are aa. vesicalis superior and inferior, haemorrhoidalis media and uterina.
The parietal veins accompany the arteries in the form of paired vessels, the visceral veins form massive venous plexuses.
Blood flows into the hypogastric vein (partially into the portal vein system).
A number of works from the school of V. N. Shevkunenko are devoted to the study of the venous plexuses of the pelvic organs. Differences in the structure of this section of the venous system are associated with varying degrees of reduction of the primary venous cloacal network, since the distal intestine and pelvic sections of the genitourinary system arose from the cloaca that once existed, which had a single venous network. The differentiation of these organs and their functions was naturally accompanied by the differentiation of their venous systems. Thus, in cases of extreme reduction of the primary venous cloacal network, the maximum dissociation of these systems is observed, and quite the opposite occurs with delayed reduction.
It has been established that in some cases the veins pl. urogenitalis have a network structure, and there are a large number of connections with the parietal veins and veins of neighboring organs, especially with the veins of the rectum (delayed reduction of the primary venous network); in other cases, the veins of the urogenital plexus look like isolated trunks with a very small number of anastomoses between them and connections with the veins of neighboring organs (an extreme degree of reduction of the primary venous network).
Rice. 355. The position of the hypogastric artery and its branches, the ureter and the vas deferens on the parasagittal section of the pelvis (according to N. I. Pirogov).
1 - left common iliac artery and vein; 2 - right hypogastric artery; 3 - rami sacrales dorsales (often extending from a. sacralis lateralis) 4 - a. glutaea superior; 5 - part of the rectum; 6 - part of the bladder 7 - a. umbilicalis; 8-a. obturatoria; 9 - entrance to canalis obturatorius; 10 - pelvic fascia; 11 - vas deferens; 12 - transverse fascia; 13 - n. obturatorius; 14 - vasa spermatica interna; 15 - iliac fascia; 16 - right external iliac vein; 17 - common trunk a. glutaea inferior and a. pudenda interna; 18 - ureter 19 - right external iliac artery; 20 - right common iliac artery and vein; 21 - inferior vena cava; 22 - inferior mesenteric artery; 23 - abdominal aorta.
Similar differences are observed in the venous system pl. uterovaginalis in women. With an extreme degree of reduction of the primary network in this system, the venous outflow from the internal genital organs is carried out mainly through the veins of the ovaries, while with a delayed reduction there are many ways of outflow.
The sacral plexus lies directly on the piriformis muscle. It is formed by the anterior branches of the IV and V lumbar nerves and the I, II, III sacral nerves, exiting through the anterior sacral foramen (Fig. 356). The nerves arising from the plexus, with the exception of short muscular branches, are sent to the gluteal region through the foramen suprapiriforme (n. glutaeus superior with the vessels of the same name) and foramen infrapiriforme (n. glutaeus inferior with the vessels of the same name, as well as n. cutaneus femoris posterior, n. ischiadicus). Together with the last nerves, n comes out of the pelvic cavity. pudendus accompanied by vessels (vasa pudenda interna). This nerve arises from pl. pudendus, lying at the lower edge of the piriformis muscle under the sacral plexus and formed by II, III and IV sacral nerves.
Along the side wall of the pelvis, below the innominate line, somewhat obliquely behind and from top to front and down, passes n. obturatorius (from the lumbar plexus), which crosses the sacroiliac joint on its way, and in the small pelvis is located first posteriorly, then outwards from the hypogastric vessels; on the border of the anterior and middle third of the lateral wall of the small pelvis, the entertaining nerve, together with the vessels of the same name, penetrates into the canalis obturatorius and through it into the region of the adductor muscles of the thigh (Fig. 355).
Along the inner edge of the anterior sacral foramina lie nodes (3-4) of the sympathetic nerve, interconnected by interganglionic branches, and through rami communicantes - with the anterior branches of the sacral nerves that form the sacral plexus. On fig. 356 shows the topography of the sacral sympathetic nerve, as well as differences in its structure.
The main sources of nerve supply to the pelvic organs are the right and left hypogastric plexuses, branches of the right and left border trunk of the sympathetic nerve (the so-called nn. hypogastrici) and branches III and IV of the sacral nerves, which provide parasympathetic innervation (the so-called nn. splanchnici sacrales, also known under the name nn. erigentes, or nn. pelvici) (Fig. 357). The branches of the border trunks and the branches of the sacral nerves are not directly involved in the innervation of the pelvic organs, but are part of the hypogastric plexuses, from which secondary plexuses arise that innervate the pelvic organs. In addition, along the course of the superior rectal artery, branches from the inferior mesenteric plexus extend to the rectum, forming here the superior rectal plexus (plexus haemorrhoidalis superior). The latter connects to the middle rectal plexus, arising from the right and left hypogastric plexuses.
The details of the formation and branching of the hypogastric plexuses have recently been developed by R. D. Sinelnikov, who used methods of macromicroscopic radiation of innervation (according to V. P. Vorobyov) with staining of preparations. According to him, each of the hypogastric plexuses (plexus hypogastricus dexter and sinister) is, as it were, a branch of the unpaired so-called prelumbosacral plexus (plexus praelumbosacralis) (see p. 567), which is a continuation of the preaortic plexus, which in turn arises from the solar plexus (Fig. 358).
Plexus hypogastricus dexter and sinister arise below the promontory and lie on either side of the rectum, between it and the hypogastric vessels. In each of these plexuses, two parts should be topographically distinguished - the back (pars dorsalis plexus hypogastrici), which has the shape of an elongated cord and usually does not contain nodes, and the front (pars ventralis plexus hypogastrici), which has the shape of a powerful plate and contains, in addition to trunks, a large number of nodes.
The dorsal parts of the hypogastric plexuses are located medially from the vasa hypogastrica, at a distance of several centimeters from the ureter, blind - closer to the ureter (2-3 cm), to the right - farther from it (3-5 cm). Landmarks in finding the posterior part of the hypogastric plexus are the vasa hypogastrica and the ureter, near which, by dissecting the parietal peritoneum, one can find the dorsal part of the hypogastric plexus enclosed in the retroperitoneal tissue.
Rice. 356. Differences in the structure of the sacral part of the border trunk of the sympathetic nerve (own preparations).
On fig. A: 6 nodes of the sympathetic trunk are noted on the right, 4 on the left; nodes have different shapes and sizes. 1,2,3,4 - sacral nodes of the left border trunk; 5 - coccygeal node; 6,7,8,9,10,11 - sacral nodes of the right border trunk.
On fig. B: 3 nodes of the sympathetic trunk are noted on the right, 2 on the left; nodes are spindle-shaped; the coccygeal node is barely grown. 1,2 - sacral nodes of the left border trunk; 3 - coccygeal node; 4,5,6 - sacral nodes of the right border trunk.
The ventral parts of the hypogastric plexuses are projected from the side of the pelvic cavity in the deep sections of the plicae rectovesicales in men and plicae rectouterinae in women. These areas are therefore the most sensitive during surgical interventions on the organs of the upper floor of the pelvic cavity. To expose the ventral part of the hypogastric plexus, the bladder should be displaced anteriorly (in women - the uterus), posteriorly - the rectum, and then, having identified the stretched plica rectovesicalis in men and plica rectouterina in women, incise the parietal peritoneum at the outer periphery of this fold, behind which v fiber and the central part of the hypogastric plexus is located.
The dorsal part of the hypogastric plexus, which usually does not have nodes, sends branches mainly to the rectum and ureter. The ventral part, which forms three clusters of nodes (upper, anterior and posterior), gives rise to several plexuses that innervate the pelvic organs: plexus haemorrhoidalis medius et inferior, plexus vesicalis, plexus deferentialis, plexus prostaticus, plexus cavernosus (Fig. 358); in women, in addition to the plexus of the rectum and bladder, there are plexus uterovaginalis (utero-vaginal nerve plexus of Rhine-Yastrebov), plexus cavernosus clitoridis.
The elements of the sympathetic nervous system in the pelvic cavity are subject to significant variations in terms of the shape, size and number of nodes and their connections. In particular, differences in the structure of the sacral part of the border trunk of the sympathetic nerve can be seen from Fig. 356 showing the topography of this nerve and its rami communicantes.
There are three groups of lymph nodes in the pelvis: one group is located along the external and common iliac arteries, the other along the hypogastric artery, and the third on the anterior concave surface of the sacrum (see Fig. 344). The first group of nodes receives lymph from the lower limb, superficial vessels of the gluteal region, the walls of the abdomen (their lower half), the superficial layers of the perineum, from the external genitalia. The hypogastric nodes collect lymph from most of the pelvic organs and formations that make up the pelvic wall. The sacral nodes receive lymph from the posterior wall of the pelvis and from the rectum.
The nodes of the iliac lymphatic plexus are combined into two groups (D. A. Zhdanov): the lower iliac nodes (lymphonodi iliaci inferiores) adjacent to the external iliac artery, and the upper iliac nodes (lymphonodi iliaci superiores) adjacent to the common iliac artery.
Rice. 357. Plexus hypogastricus dexter and nn. splanchnici sacrales dextri (nn. erigentes) (scheme; according to R. D. Sinelnikov).
1 - plexus praelumbosacralis; 2 - plexus hypogastricus sinister (pars dorsalis); 3 - plexus hypogastricus dexter (pars dorsalis); 4 - branches extending from the upper nodal thickening to the bladder; 5 - plexus hypogastricus (pars ventralis); 6 - branches extending from the anterior nodular thickening to the prostate gland and seminal vesicle; 7 - branches extending from the posterior nodular thickening to the rectum; 8 - ramus anterior n. sacralis IV; 9 - plexus sacralis; 10 - ramus anterior n. sacralis III; 11 - nn. splanchnici sacrales (nn. erigentes); 12 - ramus anterior n. sacralis II; 13 - n. hypogastrici; 14 - ramus anterior n. sacralis I; 15 - ramus anterior n. lumbalis V; 16 - ganglion lumbosacrale; 17 - truncus sympathicus.
Rice. 358. Plexus praeaorticus abdominalis, praelumbosacralis, haemorrhoidalis and hypogastricus sinister (according to R. D. Sinelnikov).
1 - left ureter; 2 - plexus mesentericus inferior; 3 - m. psoas major; 4-a. iliaca communis sinistra; 6-v. iliaca communis sinistra; 6 - plexus praelumbosacralis; 7 - truncus sympathicus; 8 - stem descending along the ureter from the plexus praelumbosacralis; 9 - promontorium; 10 - rami communicantes; 11 - ramus anterior n. lumbalis V; 12 - pars dorsalis plexus hypogastrici sinistri; 13 - ganglion lumbosacrale; 14 - branch descending along the ureter from pars dorsalis plexus hypogastrici; 15 - ramus anterior n. sacralis I; 16 - branch from ganglion lumbosacrale to pars dorsalis plexus hypogastrici; 17 - rami communicantes; 18 - truncus sympathicus; 19 - branches from the border trunk to pars dorsalis plexus hypogastrici; 20 - ramus anterior n. sacralis II; 21 - ganglion sacrale II trunci sympathici; 22 - rami communicantes; 23 -pars ventralis plexus hypogastrici; 24 - ganglion sacrale III trunci sympathici; 25 - ramus anterior n. sacralis III; 26 - rami communicantes; 27–nn. splanchnici sacrales from S III; 28 - plexus sacralis; 29-nn. splanchnici sacrales from S IV; 30-nn. splanchnici sacrales formed by links between S III and S IV; 31 - ramus anterior n. sacralis IV; 32 - branch from truncus sympathicus to pars ventralis plexus hypogastrici; 33-nn. splanchnici sacrales from S IV; 34 - branches to m. levator ani; 35 - m. levator ani; 36-nn. haemorrhoidales medii; 37-m. sphincter ani externus; 38 - prostata and plexus prostaticus; 39 - seminal vesicle and nerves lying on it; 40 - nerves suitable for the bladder below the confluence of the ureter; 41 - symphysis; 42 - nerves suitable for the bladder above the confluence of the ureter; 43 - vas deferens and nerves accompanying it; 44 - bladder; 45 - branches descending along the ureter and entering partly into the plexus deferentialis, partly into the plexus paravesicalis; 46-a. vesicalis superior; 47 - branch from pars dorsalis plexus hypogastrici to plexus paravesicalis; 48 - excavatio rectovesicalis; 49 - branch lost in the wall of the ureter; 50 - plexus haemorrhoidalis superior; 51 - peritonaeum parietale; 52 - branches from pars dorsalis plexus hypogastrici to plexus haemorrhoidalis superior; 53 - pars dorsalis plexus hypogastrici dextri; 54 - rectum and its peritoneal cover; 55-a. sacralis media; 56-a. haemorrhoidalis superior and accompanying nerves; 57-a. iliaca communis dextra; 58-v. iliaca communis dextra; 59 - vasa spermatica interna and their accompanying nerves; 60 - plexus praeaorticus abdominalis; 61-v. cava inferior; 62 - aorta abdominalis.
The lower iliac nodes form three chains: external, middle (prevenous) and internal. The lowest of the lower iliac nodes receive a special name "- lymphonodi suprafemorales; they are located immediately above the inguinal ligament and are usually represented by two large nodes - external and internal, of which the external lies next to the artery or in front of the artery.
The superior iliac nodes form two chains: external and posterior, and the node lying at the bifurcation of the common iliac artery is designated as lymphonodus interiliacus. The latter is important because it is the end node of the chain of iliac nodes and two lymph currents meet in it - from the pelvic organs and from the lower limb. In the chains of the iliac nodes, retrograde movement of the lymph is possible.
The afferent vessels of the iliac nodes are sent to the nodes lying at the inferior vena cava (right) and the aorta (left). Some of these vessels are interrupted in the so-called subaortic nodes, which lie at the level of the aortic bifurcation near the right and left common iliac arteries. From the hypogastric nodes, the vessels end partly in the iliac nodes (on the external and common iliac arteries), and partly in the lower lumbar nodes. From the sacral nodes, the referring vessels terminate in the iliac nodes.
R. A. Kurbskaya (in the laboratory of D. A. Zhdanov) established the existence of direct and indirect connections between the draining lymphatic vessels of the organs of the male and female pelvis. In the male pelvis, in the paravesical tissue, a direct connection was found between the efferent lymphatic vessels of the posterior wall of the body and the top of the bladder and the base of the prostate gland. In addition, the draining lymphatic vessels of both organs were noted to flow into the same regional lymph node, either into the hypogastric or the lower node of the medial chain of iliac nodes located between the external iliac vein and the obturator nerve.
In the lymph nodes located along the course of the superior rectal artery, there are efferent lymphatic vessels of the prostate and rectum.
Connections between the efferent lymphatic vessels of both testicles exist in the form of a common lymphatic plexus located around the ampullae of the vas deferens; in addition, lymphatic flows from both testicles are found in the subaortic nodes and in the nodes located in the circumference of the abdominal aorta. Separate lymphatic vessels of the testis are connected in the pelvis with the lymphatic vessels of the bottom of the bladder and prostate gland.
In the female pelvis, direct connections were noted between the efferent lymphatic vessels of the bladder and vagina, vagina and rectum (in the latter case, the lymphatic vessels of both organs merge in the thickness of the rectovaginal septum or flow into the regional hypogastric lymph node common to both organs). There is also a fusion of the efferent lymphatic vessels of the body or the bottom of the bladder with the efferent lymphatic vessels of the body and cervix at the base of the wide uterine ligament or the confluence of these vessels into one common regional node (the lower node of the middle chain of the iliac nodes located in front of the external iliac vein).
Under the peritoneum in the region of the recto-uterine space, a network of lymphatic vessels was found, in which the draining lymphatic vessels of the uterus and rectum merge. There is also a meeting of these vessels in the nodes located along the superior rectal artery.
The efferent lymphatic vessels of the fundus of the uterus, fallopian tube and ovary form a plexus (plexus subovaricus) located in the thickness of the mesentery of the tube and ovary. Part of the lymphatic vessels of the uterine fundus is directed along the round ligament to the inguinal nodes.
In addition to direct connections between the efferent lymphatic vessels of the pelvic organs, there are indirect connections. These are observed in the system of efferent lymphatic vessels of the vagina. These vessels, on the one hand, are associated with the efferent lymphatic vessels of the bottom of the bladder and the beginning of the urethra, and on the other hand, with the lymphatic vessels of the rectum.
The given data on the connections between the efferent lymphatic vessels of the pelvic organs are important for studying the processes of the spread of malignant neoplasms and infection in the pelvis.
FASCIA AND CELLULAR SPACES OF THE PELVIS
The walls and insides of the small pelvis are covered with pelvic fascia (fascia pelvis). It is, as it were, a continuation of the visceral fascia of the abdomen and, by analogy with it, is called the visceral fascia of the pelvis (fascia endopelvina).
Fascia endopelvina in the definitive state appears to be one. The concept of the fascia of the pelvis as a single fascia with numerous spurs converging in the circumference of the prostate gland was first put forward by N. I. Pirogov back in the 40s of the last century. In the explanations to the atlas of cuts, N. I. Pirogov points out that in academic lectures and demonstrations of anatomical preparations, he recommended adhering to such a view of the pelvic fascia. He then already believed that capsula pelvioprostatica is the place of confluence (locus confluxus) of all fibrous plates of the pelvis and perineum.
The location of the sheets of the pelvic fascia is notable for its considerable complexity, which was also noted by N.I. Pirogov. This complexity can be explained by the difference in the origin of the different sections of the pelvic fascia. In the early stage of embryonic development, the pelvic cavity is filled with a homogeneous loose connective tissue, in which the pelvic organs are located. With further development, differentiation of this fiber occurs, fascial plates are organized from it on the surface of organs (visceral sheet) and on the muscles of the walls and pelvic floor (parietal sheet).
Part of the parietal fascia, lining mainly the bottom of the pelvis, is the remnant of the reduced muscle (m. pubococcygeus). The fascial septum, located frontally between the prostate gland and the rectum and known as the peritoneal-perineal aponeurosis (aponeurosis peritonacoperinealis), represents a duplication of the primary peritoneum, dividing the cloaca into two sections (urogenital sinus and rectum).
As noted above, it is customary to distinguish between two sheets of the pelvic fascia - parietal and visceral. The first lines the walls and bottom of the pelvic cavity, the second covers the organs of the pelvis. On the side wall of the pelvis, the parietal sheet covers m. obturator interims, and along the length from the lower part of the pubic fusion to the ischial spine, the parietal leaf of the pelvic fascia thickens, forming a tendon arc, arcus tendineus fasciae pelvis.
Inwardly, the parietal sheet covers the upper surface of the muscle that lifts the anus (m. levator ani) and starts from the tendon arch; in the posterior part of the pelvic floor, the parietal sheet covers m. piriformis.
Stretching between the symphysis and the prostate gland in men or the bladder in women, the fascia forms two thick longitudinal folds or ligaments: ligamenta puboprostatica (in men) or ligamenta pubovesicalia (in women). Between them there is a deep hole, at the bottom of which there are several holes in the fascia, through which the veins pass, connecting pl. vesicalis with pl. pudendalis.
In the region of the vessels and nerves, the pelvic fascia not only forms openings that allow individual branches to pass through, but fuses with them, continuing along their sheaths, which is of great importance in the spread of pelvic abscesses through the vessels and nerves.
The visceral sheet of the pelvic fascia is not a direct continuation of the parietal sheet, but represents a plate that. as mentioned above, it occurs by compacting the loose fiber surrounding the rectum and bladder, and then grows together with the parietal sheet. The line along which the parietal sheet on the lateral surfaces of the organs fuses with the visceral sheet is indicated by a not always pronounced tendon arch (the so-called median arch of the pelvic fascia) (A. V. Starkov). In the area of the urogenital diaphragm, the fascial cover of the prostate gland is fused with the upper fascial layer of this diaphragm.
In the middle section of the pelvic cavity, the visceral fascia forms a chamber closed on all sides. This chamber is divided into two sections, anterior and posterior, by a special septum extending in the frontal direction from the bottom of the peritoneal sac to the perineum. This is the peritoneal-perineal aponeurosis (aponeurosis peritonaeoperinealis), representing the duplication of the primary peritoneum (Fig. 359). The peritoneal-perineal aponeurosis is located between the rectum and the prostate gland, so that the anterior chamber contains the bladder, prostate gland, seminal vesicles and ampullae of the vas deferens in men, the bladder and vagina in women; the posterior section contains the rectum (Fig. 360, 361 and 382).
In the formation of the fascial cover of one or another pelvic organ, as recently shown by L.P. Kraizelburd, the fascial sheaths of neighboring organs can take part. So, the fascial cover of the bladder is made up of two elements: the prevesical fascia and the sheath of the umbilical artery. The prevesical fascia is located in front of the wall of the bladder, extending from the lower semicircle of the navel to the bottom of the pelvis. It does not reach the side walls of the pelvis, but ends on the side walls of the urinary bladder.
The sheath of the umbilical artery is a fascial plate, which is divided into two sheets: lateral and medial. The lateral leaf of the sheath of the umbilical artery on the lateral wall of the bladder adheres to the prevesical fascia and gives off the lateral process to the wall of the small pelvis, forming a lateral valve. The latter separates the prevesical cellular space from the lateral cellular space of the pelvis. The medial sheath of the umbilical artery covers the posterior wall of the bladder.
With regard to the peritoneal-perineal aponeurosis, it has been established that it does not pass into the lateral sections of the pelvis, but is attached to the posterior wall of the rectum, bending around its side walls.
Both between individual organs and between the organs and walls of the pelvis there are cellular spaces
In the female pelvis, the blood supply, innervation and covering of the peritoneum of the rectum is the same as in the male. Anterior to the rectum are the uterus and vagina. Behind the rectum lies the sacrum. The lymphatic vessels of the rectum are connected with the lymphatic system of the uterus and vagina (in the hypogastric and sacral lymph nodes) (Fig. 16.4).
Bladder in women, as in men, lies behind the pubic symphysis. Behind the bladder are the uterus and vagina. Loops of the small intestine are adjacent to the upper, covered with peritoneum, part of the bladder. On the sides of the bladder are the muscles that lift the anus. The bottom of the bladder lies on the urogenital diaphragm. The blood supply and innervation of the bladder in women occurs in the same way as in men. The lymphatic vessels of the bladder in women, like the lymphatic vessels of the rectum, form connections with the lymphatic vessels of the uterus and vagina in the lymph nodes of the broad ligament of the uterus and iliac lymph nodes.
As in the male pelvis, the right and left ureters at the level of the borderline cross the external iliac and common iliac arteries, respectively. They are adjacent to the side walls of the pelvis. At the point of departure from the internal iliac arteries of the uterine arteries, the ureters intersect with the latter. Below in the cervical region, they once again intersect with the uterine arteries, and then adjoin the wall of the vagina, after which they flow into the bladder.
Rice. 16.4. Topography of the organs of the female pelvis (from: Kovanov V.V., ed., 1987): I - fallopian tube; 2 - ovary; 3 - uterus; 4 - rectum; 5 - posterior fornix of the vagina; 6 - anterior fornix of the vagina; 7 - entrance to the vagina; 8 - urethra; 9 - clitoris; 10 - pubic articulation; II - bladder
Uterus in the small pelvis of women, it occupies a position between the bladder and the rectum and is tilted forward (anteversio), while the body and cervix, separated by the isthmus, form an angle open anteriorly (anteflexio). Loops of the small intestine are adjacent to the bottom of the uterus. The uterus has two sections: the body and the cervix. The part of the body located above the confluence of the fallopian tubes into the uterus is called the fundus. The peritoneum, covering the uterus in front and behind, converges on the sides of the uterus, forming broad ligaments of the uterus. At the base of the broad ligament of the uterus are the uterine arteries. Next to them lie the main ligaments of the uterus. In the free edge of the broad ligaments of the uterus lie the fallopian tubes. Also, the ovaries are fixed to the wide ligaments of the uterus. On the sides, the broad ligaments pass into the peritoneum, covering the walls of the pelvis. There are also round ligaments of the uterus running from the angle of the uterus to the internal opening of the inguinal canal. The uterus is supplied with blood by two uterine arteries from the system of internal iliac arteries, as well as by the ovarian arteries - branches of the abdominal aorta. Venous outflow is carried out through the uterine veins into the internal iliac veins. The uterus is innervated from the hypogastric plexus. The outflow of lymph is carried out from the cervix to the lymph nodes that lie along the iliac arteries and the sacral lymph nodes, from the body of the uterus to the peri-aortic lymph nodes.
The uterine appendages include the ovaries and fallopian tubes.
The fallopian tubes lie between the leaves of the broad ligaments of the uterus along their upper edge. In the fallopian tube, an interstitial part is distinguished, located in the thickness of the uterine wall, an isthmus (narrowed part of the tube), which passes into an expanded section - an ampulla. At the free end, the fallopian tube has a funnel with fimbriae, which is adjacent to the ovary.
ovaries with the help of the mesentery, they are connected with the posterior sheets of the broad ligament of the uterus. The ovaries have uterine and tubal ends. The uterine end is connected to the uterus by its own ligament of the ovary. The tubular end is attached to the lateral wall of the pelvis by means of the suspensory ligament of the ovary. At the same time, the ovaries themselves are located in the ovarian fossae - depressions in the side wall of the pelvis. These recesses are located in the area of dividing the common iliac arteries into internal and external. Nearby are the uterine arteries and ureters, which should be taken into account during operations on the uterine appendages.
Vagina located in the female pelvis between the bladder and rectum. At the top, the vagina passes into the cervix, and at the bottom
opens with an opening between the labia minora. The anterior wall of the vagina is closely connected with the posterior wall of the bladder and urethra. Therefore, with ruptures of the vagina, vesicovaginal fistulas can form. The back wall of the vagina is in contact with the rectum. The vagina is isolated vaults - recesses between the cervix and the walls of the vagina. In this case, the posterior fornix borders on the Douglas space, which allows access to the recto-uterine cavity through the posterior fornix of the vagina.
Completed:Sudents L-407b group,
Prokhorova T. D.
Nuritdinova A.F.
Nidvoryagin R.V.
Kurbonov S.
The pelvis is a part of the human body, which is limited by the pelvic bones: ilium, pubic and ischial, sacrum, coccyx,
bundles.The pubic bones are connected to each other by means of a pubic fusion.
The ilium with the sacrum form inactive semi-joints.
The sacrum is connected to the coccyx through the sacrococcygeal fusion.
Two ligaments start from the sacrum on each side:
- sacrospinous (lig. Sacrospinale; attached to the ischial spine) and
- sacrotuberous (lig. sacrotuberale; attached to the ischial tuberosity).
They transform the greater and lesser sciatic notches into the greater and lesser sciatic foramen.
BORDERS AND FLOORS OF THE SMALL PELVIS By the boundary line (linea terminalis), the pelvis is divided into large and small
bigMade up of the spine and
wings of the iliac bones.
Contains: abdominal organs
- caecum with worm-like
process, sigmoid colon,
loops of the small intestine.
small
Limited:
Upper pelvic aperture - borderline
line.
The inferior pelvic inlet formed by
coccyx behind,
on the sides - ischial tubercles,
in front - pubic fusion and
inferior branches of the pubic bones.
BORDERS AND FLOOR PELVIS
The bottom of the small pelvis is formed by the muscles of the perineum.They make up the pelvic diaphragm
pelvis) and urogenital diaphragm (diaphragma
urogenital).
The pelvic diaphragm is represented by:
The superficial layer of the muscles of the pelvic diaphragm -
m. sphincter ani externus
Deep layer of muscles
levator posterior muscle
pass
coccygeal muscle
covering their top and bottom
fasciae of the pelvic diaphragm
The urogenital diaphragm is located between the lower
branches of the pubic and ischial bones and is formed by:
deep transverse perineal muscle
sphincter of the urethra with the upper and
lower layers of the fascia of the urogenital diaphragm
The pelvic cavity is divided into three floors: - peritoneal - subperitoneal - subcutaneous
The peritoneal floor of the pelvis (cavum pelvisperitoneale) - between the parietal peritoneum of the small pelvis;
is the lower abdomen.
Content:
In men, in the abdominal floor of the pelvis there is a part
rectum and part of the bladder.
In women, the same parts are placed in this floor of the pelvis
bladder and rectum, as in men,
most of the uterus, fallopian tubes, ovaries, wide
ligaments of the uterus, upper part of the vagina.
Behind the bladder in men is the peritoneum
covers the inner edges of the ampoules of the vas deferens
ducts, tops of the seminal vesicles and passes
into the rectum, forming the rectovesical
deepening (excavatio rectovesicalis), limited
on the sides with rectovesical folds
peritoneum (plicae rectovesicales).
In women, during the transition from the bladder to the uterus and
from the uterus to the rectum, the peritoneum forms
anterior - vesicouterine cavity (excavatio
vesicouterina) and posterior - recto-uterine
deepening
In the recesses of the pelvis can accumulate
inflammatory exudates, blood (with
abdominal injuries and
pelvis, tubal ruptures with ectopic
pregnancy), gastric contents
(perforation of gastric ulcer), urine (injuries
Bladder). accumulated
content
Subperitoneal floor of the pelvis (cavum pelvis subperitoneale) - a section of the pelvic cavity enclosed between the parietal peritoneum of the pelvis
and a sheet of pelvic fascia,covering the top of the muscle that lifts the anus.
Fascia and cellular spaces
pelvis:
1 - perirectal cellular
space,
2 - periuterine cellular
space,
3 - prevesical cellular
space,
4 - lateral cellular space,
5 - parietal leaf intrapelvic
fascia,
6 - visceral leaf intrapelvic
fascia,
7 - abdominal perineal aponeurosis
Contents: extraperitoneal bladder and
rectum,
prostate,
seminal vesicles,
pelvic sections of the vas deferens with their ampullae,
pelvic ureters,
and in women - the same sections of the ureters, bladder
and rectum, as well as the cervix and the initial section
vagina.
Major cellular spaces of the pelvis
The main cellular spaces of the pelvis, located in its middlefloor, are prevesical, paravesical, periuterine (in women),
pararectal, retrorectal, right and left lateral
space.
Prevesical cellular space (spatium prevesicale; space
Retcia) - cellular space, limited
in front of the pubic symphysis and branches of the pubic bones,
behind - a visceral sheet of the pelvic fascia covering the bladder.
In the prevesical space with fractures of the pelvic bones, hematomas develop,
and with damage to the bladder - urinary infiltration.
From the sides, the prevesical space passes into
paravesical space (spatium paravesicale) - cellular
pelvic space around the bladder, limited
in front of the prevesical, and
behind the retrovesical fascia.
Periouterine space (parametrium) - cellular space
small pelvis, located around the cervix and between the sheets of its wide
ligaments. The uterine arteries pass through the peritoneal space and
ureters crossing them, ovarian vessels, uterine venous and
nerve plexus.
Subcutaneous floor of the pelvis (cavum pelvis subcutaneum) - the lower part of the pelvis between the diaphragm of the pelvis and the integument related to the area
perineum.Content:
- parts of the organs of the genitourinary system and the final section of the intestinal tube.
- ischiorectal fossa (fossa ischiorectalis) - a paired depression in
perineum, filled with fatty tissue, limited
medially by the pelvic diaphragm, laterally by the obturator internus muscle with
covering it with fascia. Fiber of the ischiorectal fossa
communicate with the tissue of the middle floor of the pelvis.
TOPOGRAPHY OF THE MALE PELVIC ORGANS
Rectum (rectum). The beginning of the rectum corresponds to the upperedge of the CIII sacral vertebra.
2 main sections of the rectum: pelvic (lensitis above the pelvic diaphragm and contains
supramolecular part and ampulla), perineal (below the pelvic diaphragm)
supracular part covered with peritoneum on all sides;
Syntopia: anterior to rectum: prostate, bladder, aticles
vas deferens, seminal vesicles, ureters; back - sacrum,
coccyx; on the sides - ischiorectal fossa.
Veins - refer to systems v. cava interior et v. portae; form the plexus venosus
rectalis, which is located in 3 floors: subcutaneous, submucosal and subfascial plexus
veins
Innervation: sympathetic fibers - from the inferior mesenteric and aortic plexus:
parasympathetic fibers - from II-IV sacral nerves.
Lymph drainage: into the inguinal (from the upper zone), behind - rectal, internal
iliac, lateral sacral (from the middle zone), to nodes located along a. rectalis
superios and a. mesenterica inferior (from the upper zone). Bladder
Structure: top, body, bottom, bladder neck.
The mucosa of the bladder forms folds, with the exception of
bladder triangle - a smooth area of mucosa
triangular, devoid of submucosa. Vertex
triangle - the internal opening of the urethra,
base - plica interurerica, connecting the mouths of the ureters.
Involuntary sphincter of the bladder - m. sphincter
vesicae 0 - located at the beginning of the urethra.
Arbitrary - m. sphincter urethrae - in a circle
membranous part of the urethra. Between the pubic bones and urinary
the bubble is a layer of fiber, peritoneum, passing from
anterior abdominal wall on the bladder, when it is filled
shifts upward (which makes it possible to quickly
intervention on the bladder without damaging the peritoneum).
Syntopy: from above and sides - loops of the small intestine, sigmoid,
caecum (separated by the peritoneum); to the bottom - the body is adjacent
prostayae, ampullae of the vas deferens, seminal vesicles.
Blood supply: from the system a. iltacaiuferna.
Veins flow into v. iliaca inferna.
Lymphatic drainage - to the nodes lying along the ailiace exterma et interna and
on the anterior surface of the sacrum.
Innervation: branches of the hypogastric plexus. Prostate
Has a capsule (ujfascia pelvis); consists of glands that open into the urethra
channel. There are 2 lobes and an isthmus.
Borders: in front - the lower branches of the false and ischial bones, on the sides - ischial
tubercles behind and sacrotuberous ligaments; behind - coccyx and sacrum. Subdivided into 2
department: anterior (urogenital) - anterior to linea biischtadica; rear -
(anus) - posterior to linea btischiadica. These departments despair of the number and
interposition of fascial sheets. The pram area in men (regio
pudendalis) includes the penis, scrotum and its contents.
I. Penis (penis) - consists of 3 cavernous bodies - 2 upper and 1 lower.
The posterior end of the esophageal body of the urethra forms the bulb of the urethra, the anterior ends of all 3 bodies form the head of the penis. Each cavernous body has its own protein shell,
all together they are covered with fascita penis. The skin of the penis is very mobile, at the anterior end
forms a diplicature - red flesh, aa pass under the skin. vn. protondae penis.
Urethra. 3 parts (prostatic, membranous and cavernous)
3 constrictions: the beginning of the canal, the membranous part of the urethra and the external opening.
3 extensions: navicular fossa at the end of the canal, in the bulbous part, in the prostate
parts.
2 curvature: subpubic (transition of the membranous part to the cavernous) and prepubic
(transition of the fixed part of the urethra to the mobile).
II. Scrotum (scrotum) - a leather bag, divided into 2 parts, each of which
contains the testis and scrotum of the spermatic cord.
Layers of the scrotum (they are also testicular membranes): 1) skin; 2) fleshy membrane (tunica dartos); 3)
fasca sperma tica externa; 4) m. cremaster and fascta cremasterica; 5) fascita spermatica; 6) tunica
vaginalis testis (parietal and visceral sheets).
The egg has a white coat. Along the posterior edge is an appendage - epidiymis. Organ topography
male pelvis (from:
Kovanov V.V., ed.,
1987):
1 - lower hollow
vein;
2 - abdominal aorta;
3 - left common
iliac
artery;
4 - cape;
5 - rectum;
6 - left
ureter;
7 - rectovesical fold;
8 - rectovesical
deepening;
9 - seed
vial;
10 - prostatic
gland;
11 - muscle,
elevating
anus;
12 - outer
anal sphincter
holes;
13 - testicle;
14 - scrotum;
15 - vaginal
testicle shell;
16 - epididymis;
17 - foreskin;
18 - head
penis;
19 - vas deferens
duct;
20 - internal
seminal fascia;
21 - cavernous bodies
penis;
22 - spongy
sexual substance
member;
23 - seed
cord;
24 - bulb
penis;
25 - sciatic-cavernous muscle;
26 urethra
th channel;
27 - supporting
ligament of genital
member;
28 - pubic bone;
29 - urinary
bubble;
30 - left common
iliac vein;
31 - right common
iliac
artery
TOPOGRAPHY OF THE FEMALE PELVIC ORGANS
Rectum lateral to rectum peritoneumforms plicae rectouterinae.
part of the ampulla of the rectum in the lower struc
adjacent to the posterior wall of the cervix and
posterior fornix of the vagina. IN
subperitoneal rectum adjoins
to the posterior wall of the vagina.
Bladder and urethra.
Behind the bladder is the body
cervix and vagina. With the last
the bladder is tightly bound.
Urethra short, straight, easy
extensible. Opens on the threshold
vagina. Below the genitourinary
diaphragm in front of the urethra
clitoris. The posterior wall of the urethra is tight
fused with the anterior wall of the vagina.
The ureter crosses twice a. uterine:
near the side wall of the pelvis (near the place
discharge a. uteruna from a. iliaca inferno)
- lies on the surface of the artery; near
the lateral wall of the uterus is deeper than the artery. Uterus
The uterus (uterus) consists of the bottom, body, isthmus, neck. At the cervix, the vaginal and
supravaginal parts. The sheets of the peritoneum, covering the anterior and posterior walls of the uterus, along
sides converge, forming a wide ligament of the uterus, between the sheets of which is located
cellulose. At the base of the broad ligament of the uterus lie the ureter, a. uterina, uterovaginal venous and nerve plexus, the main ligament of the uterus (aa. cardinale uferi).
Together with the transition of the broad ligament into the peritoneum, the supporting ligament of the ovary is formed, in
which pass a. and v. ovarica. The ovary is fixed to the back by means of the mesentery
leaf of the broad ligament. In the free edge of the broad ligament lies the ligament of the ovary, downward and
posterior to it is the own ligament of the ovary, and downward and anteriorly is the round uterine ligament.
Syntopia: in front - the bladder; behind - the rectum; loops adjoin to the bottom of the uterus
large intestine.
Blood supply: aa. uterinae vv. uterina.
Innervation - branches of the uterovaginal plexus.
Lymph outflow: from the cervix - to the nodes lying along a. iliaca interna in the sacral nodes;
from the body of the uterus - to the nodes in the circumference of the aorta and v. cava tuferior. The urethra and vagina pass through the urogenital diaphragm.
From the side of the perineum, the urogenital diaphragm is covered
formations related to the genital area, fascia, muscles.
In the lateral parts of the region are the cavernous bodies of the clitoris,
covered m. ischiocavernosus. On the sides of the vestibule of the vagina lie
vestibule bulbs covered with m. bullocaverhones that cover
clitoris, urethra and vaginal opening. At the rear end of the bulbs
Bartholin's glands are located.
The pudendal region - contains the external genitalia - large and
labia minora, clitoris.
OPERATIONS ON THE URINARY BLADDER
suprapubic puncture(syn.: bladder puncture, bladder puncture) - percutaneous
puncture of the bladder in the midline of the abdomen. Perform
intervention, either in the form of suprapubic capillary puncture, or in the form of
trocar epicystostomy.
Suprapubic capillary puncture
Indications: evacuation of urine from the bladder if it is impossible or
the presence of contraindications to catheterization, with trauma to the urethra, burns
external genitalia.
Contraindications: small bladder capacity, acute cystitis or
paracystitis, tamponade of the bladder with blood clots, the presence of
bladder neoplasms, large scars and inguinal hernias that change
topography of the anterior abdominal wall.
Anesthesia: local infiltration anesthesia with a 0.25-0.5% solution
novocaine. Position of the patient: on the back with a raised pelvis.
puncture technique. A needle with a length of 15-20 cm and a diameter of about 1 mm is used.
The bladder is punctured with a needle at a distance of 2-3 cm above the pubic
adhesions. After removing urine, the puncture site is treated and applied
sterile label.
Suprapubic capillary puncture of the bladder (from: Lopatkin N.A., Shvetsov I.P., ed., 1986): a - puncture technique; b - scheme
puncture Trocar epicystostomyIndications: acute and chronic urinary retention.
Contraindications, position of the patient,
anesthesia is the same as for capillary
bladder puncture.
Operation technique. Skin at the site of surgery
dissect for 1-1.5 cm, then puncture
tissue is carried out using a trocar, removed
stylet mandrel, into the bladder through the lumen
trocar tube insert the drainage tube, the tube
removed, the tube is fixed with a silk suture to the skin.
Scheme of the stages of trocar epicystostomy (from: Lopatkin N.A., Shvetsov I.P., ed., 1986): a - the position of the trocar after injection; b -
Scheme of stages of trocar epicystostomy (from: Lopatkin N.A., Shvetsov I.P., ed.,1986):
a - the position of the trocar after injection; b - extracting the mandrin; c - introduction
drainage tube and removal of the trocar tube; d - the tube is installed and
fixed to the skin
Cystotomy is an operation to open the cavity of the bladder (Fig. 16.7). High cystotomy (syn.: epicystotomy, high section
Cystotomy is an operation to open the cavity of the bladder (Fig. 16.7).High cystotomy (syn.: epicystotomy, high section of the bladder, section alta)
performed at the apex of the bladder extraperitoneally through an incision in the anterior
abdominal wall.
Anesthesia: local infiltration anesthesia with 0.25-0.5% novocaine solution or epidural anesthesia.
Access - lower middle, transverse or arcuate
extraperitoneal. In the first case, after dissection of the skin, subcutaneous
fatty tissue, the white line of the abdomen is bred to the sides straight and
pyramidal muscles, the transverse fascia is dissected in the transverse
direction, and the prevesical tissue is exfoliated along with
transitional fold of the peritoneum upward, exposing the anterior wall
Bladder. When performing a transverse or arcuate
access after incision of the skin and subcutaneous fat anterior
the walls of the sheaths of the rectus abdominis muscles are dissected in the transverse
direction, and the muscles are bred to the sides (or cross). Opening
bladder must be produced as high as possible between the two
ligatures-holders, after emptying the bladder
through a catheter. The bladder wounds are sutured with a two-row suture: the first row through all layers of the wall with absorbable suture material, the second
a row - without flashing the mucous membrane. anterior abdominal wall
are sutured in layers, and the prevesical space is drained.
Stages of cystostomy. (from: Matyushin I.F., 1979): a - skin incision line; b - fatty tissue together with a transitional fold
Stages of cystostomy. (from: Matyushin I.F., 1979): d - a training apparatus was introduced into the bladdera - the line of the skin incision;
tube, bladder wound sutured around drain;
b - adipose tissue together with transition e - the final stage of the operation
the fold of the peritoneum is exfoliated upward;
c - opening of the bladder;
OPERATIONS ON THE UTERUS AND ADDITIONS
OPERATIONS ON THE UTERUS AND ADDITIONSOperative access to the female genital organs
in the pelvic cavity:
abdominal wall
vaginal
lower
middle
laparotomy
anterior
colpotomy
suprapubic
transverse
laparotomy (by
Pfannenstiel)
rear
colpotomy
Colpotomy - operative access to the organs of the female
pelvis by dissection of the anterior or posterior wall
vagina. Types of operations on the uterus
with removal of the uterus;
with preservation of the uterus.
Removal of the uterus is performed in case of malignant tumors, as well as extensive and
multiple fibromatous nodes, severe bleeding that cannot be stopped
conservatively. Removal can be complete - hysterectomy (extirpation) with the neck and
appendages, and partial - supravaginal amputation with preservation of the neck, high
amputation of the uterus with preservation of the lower section.
According to the technology of performing operations on the uterus, they are also divided into 2 groups:
1) traditional; 2) laparoscopic; 3) endoscopic.
Traditional surgical procedures are performed through a skin incision in the abdomen, in
mainly in particularly difficult cases, when a large volume of surgery is to be performed (for
advanced cancer, uterine and bladder prolapse).
Laparoscopic surgery today dominates gynecological practice. They
performed through a special fiberoptic video probe, with small incisions, not
leaving scars on the skin.
Endoscopic operations are performed inside the uterine cavity through a special apparatus.
hysteroscope with a camera, which is inserted into the uterine cavity, and under the control of the image on
various manipulations are performed on the screen. This is the removal of internal nodes, polyps,
stop bleeding, curettage of the mucous membrane, diagnostic
biopsy. Puncture of the posterior fornix of the vagina diagnostic puncture of the abdominal
cavity performed by a needle on a syringe
by its introduction through a puncture in the wall
posterior fornix of the vagina
recto-uterine cavity
pelvic peritoneum. Position
patient: on the back with attracted to
belly and bent at the knees
feet. Anesthesia:
short-term anesthesia or local
infiltration anesthesia. Technique
intervention. Mirrors wide
open the vagina, bullet
grasp the posterior lip with forceps
cervix and lead to the pubic
fusion. Posterior fornix of the vagina
treated with alcohol and iodine
tincture. Long Kocher clamp
engulf the mucosa of the posterior
vaginal vault 1-1.5 cm below the cervix
uterus and slightly pulled forward.
Produce a puncture of the fornix enough
long needle (at least 10 cm) with
wide lumen, while the needle
directed parallel to the wire axis
pelvis (to avoid damage to the wall
rectum) to a depth of 2-3 cm.
Puncture of the recto-uterine cavity of the peritoneal cavity through the posterior fornix of the vagina (from: Savelyeva G.M., Breusenko V.G.,
ed., 2006) Amputation of the uterus (subtotal, supravaginalsupravaginal amputation of the uterus without appendages) surgery to remove the body of the uterus: with preservation of the cervix
(high amputation), with preservation of the body and supravaginal
parts of the cervix (supravaginal amputation).
Extended extirpation of the uterus with appendages (syn.:
Wertheim operation, total hysterectomy) - operation
complete removal of the uterus with appendages, the upper third
vagina, parauterine tissue with regional
lymph nodes (indicated for cervical cancer).
Cystomectomy - removal of a tumor or cyst on the ovary
leg.
Tubectomy - an operation to remove the fallopian tube, more often
only in the presence of a tubal pregnancy.
OPERATIONS ON THE RECTUM
Amputation of the rectum is an operation to remove the distal part of the rectum frombringing down its central stump to the level of the perineosacral wound.
Unnatural anus (syn.: anus praeternaturalis) - artificially
created anus, in which the contents of the colon are completely
stands out.
Resection of the rectum - an operation to remove part of the rectum with restoration or
without restoring its continuity, as well as the entire rectum while maintaining
anus and sphincter.
Resection of the rectum according to the Hartmann method - intraperitoneal resection of the rectum and
sigmoid colon with the imposition of a single-barreled artificial anus.
Extirpation of the rectum - an operation to remove the rectum without recovery
continuity, with removal of the closing apparatus and sewing in of the central end
into the abdominal wall.
Extirpation of the rectum according to the Quenu-Miles method is a one-stage abdominoperineal extirpation of the rectum, in which the entire rectum is removed from
anus and anal sphincter, surrounding tissue and lymphatic
nodes, and from the central segment of the sigmoid colon form a permanent
single-barreled artificial anus. The surgeon makes 1 small puncture in the posterior wall of the vagina, through which
the cavity of the small pelvis is introduced a special conductor. Along it into the cavity of the small
pelvis is injected with a small amount of sterile fluid (to improve
images), a small video camera, and a light source.
The image from the video camera is transmitted to the monitor screen, which allows the surgeon to
assess the condition of the uterus, ovaries and fallopian tubes. In addition, it is carried out
assessment of patency of the fallopian tubes.
Topographic anatomy of the perineum
The perineum is limited in front by the angle formed by the pubicbones, behind - the top of the coccyx, outside - ischial tubercles,
makes up the floor of the pelvis. The perineum is rhombus shaped; line,
connecting the ischial tuberosities, is divided into two triangles:
the anterior is the genitourinary region, and the posterior is the anal region. Anal area
Anal area
bounded in front by a line,
connecting ischial
tubercles, behind - coccyx, with
sides - sacrotuberous
bundles. Within the area
an anus is located. The layered topography of the anal area in men and women is the same.
1. The skin of the anal region is thicker on the periphery and thinner in the center,
contains sweat and sebaceous glands, covered with hair.
2. Fat deposits are well developed on the periphery of the area, in them to the skin of the anus
area superficial vessels and nerves:
Perineal nerves (nn. perineales).
Perineal branches of the posterior cutaneous nerve of the thigh (rr. perineales n. cutaneus femori posterior).
Skin branches of the lower gluteal (a. et v. glutea inferior) and rectal (a. et v. rectalis inferior) arteries and veins;
subcutaneous veins forming a plexus around the anus.
Under the skin of the central part of the region is the external sphincter of the anus, in front
attached to the tendon center of the perineum, and behind - to the anal-coccygeal ligament.
3. The superficial fascia of the perineum within the anal triangle is very
thin.
4. The fat body of the ischiorectal fossa fills the fossa of the same name.
5. The lower fascia of the pelvic diaphragm from below lines the muscle that lifts the anus,
limits the ischiorectal fossa from above. 6. The muscle that raises the anus (m. Levator ani), presented in this area
iliococcygeal muscle (m. iliococcygeus), starts from the tendon arch
fascia of the pelvis, located on the inner surface of the internal obturator
muscles. The muscle is woven with its medial bundles into the external sphincter
anus, the upper and lower fasciae are attached to the latter in front
urogenital diaphragm, forming the tendon center of the perineum. Behind
anal canal, the levator ani muscle attaches to
analococcygeal ligament.
7. Upper fascia of the pelvic diaphragm - part of the parietal fascia of the pelvis, lines
the muscle that lifts the anus, from above.
8. The subperitoneal cavity of the pelvis contains the extraperitoneal part of the ampulla of the rectum,
pararectal, retrorectal and lateral
cellular space of the pelvis.
9. Parietal peritoneum.
10. Peritoneal cavity of the pelvis. Ischiorectal fossa (fossa ischiorectalis) limited in front
superficial transverse muscle of the perineum, behind - the lower edge
gluteus maximus, laterally - obturator fascia;
located on the internal obturator muscle, above and medially -
lower fascia of the pelvic diaphragm, lining the lower surface of the muscle,
elevating the anus. Ischiorectal fossa anteriorly
forms a pubic pocket (recessus pubicus),
located between the deep transverse muscle
perineum and levator ani muscle,
behind - gluteal pocket (recessus glutealis),
located under the edge of the gluteus maximus muscle.
At the lateral wall of the ischiorectal fossa
located between the layers of the obturator fascia
genital canal (canalis pudendalis); pass in it
pudendal nerve and internal pudendal artery and vein,
entering the ischiorectal fossa through
lesser sciatic foramen and the inferior
rectal vessels and nerve, suitable for
anal canal. Genitourinary area
Genitourinary area is limited: in front
pubic arch (subpubic angle),
behind - a line connecting
ischial tubercles, from the sides - lower
branches of the pubis and branches of the ischial
bones. Layered topography of the genitourinary region
Women
Men
1. Skin
2. Body fat
3. Superficial fascia of the perineum
4. The superficial space of the perineum, containing:
Superficial muscles of the perineum: superficial transverse muscle
perineum (m. transversum perinei superficialis), ischiocavernosus muscle
(m. Ischiocavernosus) bulbous spongy muscle (m. bulbospongiosus)
Legs and bulb of the penis
Clitoris peduncles and vestibular bulb
5. Inferior fascia of the urogenital diaphragm (perineal membrane) 6. Deep space of the perineum containing the deep transverse muscle
perineum and sphincter of the urethra (m. transversus perinei
profundus et m. sphincter urethrae).
7. Superior fascia of the urogenital diaphragm.
8. Inferior fascia of the pelvic diaphragm.
9. The muscle that raises the anus (m. Levator ani), presented in
genitourinary region with the pubic-coccygeal muscle (m. pubococcygeus).
10. Superior fascia of the pelvic diaphragm.
11. Capsule of the prostate.
12. Prostate.
13. The bottom of the bladder.
11. No.
12. No. Genitourinary area
men
Within the genitourinary region
men's scrotum is located
(scrotum) and penis (penis). Scrotum
Scrotum (scrotum) - a bag of skin and fleshy
shells. The skin is thin, highly pigmented
compared to surrounding areas, has sebaceous
glands. The fleshy membrane lines the skin of the scrotum
from the inside, is a continuation of the subcutaneous
connective tissue, devoid of fat, contains
a large number of smooth muscle cells and
elastic fibres. The fleshy membrane forms
scrotal septum (septum scroti), which separates it
into two parts, into each of them in the process of lowering
testicles enter the testis surrounded by shells (testis) with
epididymis and spermatic cord
(funiculus spermaticus). Layered structure of the scrotum
1. Skin.
2. A fleshy shell that gathers the skin into folds.
3. External seminal fascia - descending into the scrotum superficial
fascia.
4. Fascia of the muscle that lifts the testicle - descended into the scrotum
own fascia of the external oblique muscle of the abdomen.
5. The muscle that lifts the testicle (m. cremaster), a derivative of the internal
oblique and
transverse abdominal muscles.
6. The internal seminal fascia is a derivative of the transverse fascia.
7. The vaginal membrane of the testicle, a derivative of the peritoneum, has
parietal and visceral plates, between which there is
serous cavity of the testis.
8. White shell of the testicle. Testicle
Testicle (testis), located in the scrotum, covered
dense protein shell, has an oval shape.
The average size of the testicle is 4x3x2 cm. In the testicle
allocate lateral and medial surfaces,
front and rear edges, top and bottom end.
Lateral and medial surfaces, upper end
and the anterior margin of the testis are covered with a visceral layer
vaginal membrane. On the posterior edge is
testicular mediastinum (mediastinum testis), out of it
testicular efferent tubules (ductuli efferentes testis),
stretching to the epididymis. epididymis
The epididymis (epididymis) has
head, body and tail and lies on
posterior margin of the testicle. head and body
epididymis covers
visceral layer of the vaginal
shells. Tail of the epididymis
passes into the ovary
vas deferens, which
located in the scrotum at the level
testicles and has a convoluted course. On the head
appendage there is an appendage of the appendage
testicles (appendix epididymidis) -
rudiment of the mesonephric duct. spermatic cord
The spermatic cord (funiculus spermaticus) stretches from the upper end of the testicle to the deep
inguinal ring.
The location of the elements of the spermatic cord is as follows: in its posterior section lies
vas deferens (ductus deferens); anterior to it is the testicular artery
(a. testicularis); behind - the artery of the vas deferens (a. deferentialis); namesake
veins accompany arterial trunks. Lymphatic vessels in abundance
pass with the anterior group of veins. These
education covers the inner
seminal fascia, levator muscle
testicle (m. cremaster), muscle fascia,
levator testis and external
seminal fascia, forming a rounded strand
pinky thick. blood supply
In the blood supply of the testicle, epididymis, spermatic cord and scrotum take part
the following arteries:
Testicular artery (a. testicularis), extending from the abdominal aorta. testicular artery through
a deep inguinal ring enters the inguinal canal and into the spermatic cord, where it lies on everything
along the anterior surface of the vas deferens.
Artery of the vas deferens (a. ductus deferentis), extending from the umbilical artery (a.
umbilicalis) - branches of the internal iliac artery (a. iliaca interna). Artery
vas deferens accompanies the vas deferens, usually located on its
back surface.
Artery of the muscle that raises the testicle (a. cremasterica), extending from the lower epigastric
arteries
(a. epigastric inferior). The artery in the region of the deep inguinal ring approaches the spermatic
cord and accompanies it, branching widely in its shell.
External pudendal arteries (aa. pudendae externae), extending from the femoral artery (a.
femoralis), give off the anterior scrotal branches (aa. scrotales anteriores), supplying blood
anterior part of the scrotum.
Posterior scrotal branches (aa. scrotales posteriores), extending from the perineal artery
(a. perinealis), branches of the internal pudendal artery (a. pudenda interna). The veins of the testis and epididymis form the pampiniform plexus (plexus pampiniformis),
consisting of many intertwining and anastomosing with each other
venous vessels.
The veins of this plexus ascend upward, gradually merging, the venous trunks
form
testicular vein (v. testicularis). The right testicular vein (v. testicularis dextra) flows into
inferior vena cava (v. cava inferior) directly, and the left testicular vein
(v. testicularis sinistra) flows into the left renal vein (v. renalis). At the point of entry
the right testicular vein forms a valve, and the left valve does not form, therefore
varicose veins of the spermatic cord occurs on the left much more often
than right.
Collateral outflow from the testicle and spermatic cord is possible along the external
sexual
veins (vv. pudendae externae) into the femoral vein (v. femoralis), along the posterior scrotal
veins (vv. scrotales posteriores) into the internal pudendal vein (v. pudenda interna), along
vein of the muscle that lifts the testicle (v. cremasterica), and the vein of the vas deferens (v.
Ductus deferentis) - into the lower epigastric vein (v. epigastrica inferior). Lymph drainage
Lymphatic vessels of the integument of the testis flow into
inguinal lymph nodes
inguinales), while the lymphatic vessels
the testicle itself is sent to the lumbar
lymph nodes (nodi lymphatici lumbales). Innervation of the testis, spermatic cord and scrotum.
The innervation of the testis is carried out by the testicular plexus (plexus testicularis),
accompanying the testicular artery and surrounding the indicated vessel is solid
network.
The testicular plexus is a derivative of the abdominal aortic
plexus
(plexus aorticus abdominalis), receiving sympathetic and sensitive
nervous
fibers in the composition of the small and lower splanchnic nerves.
The innervation of the vas deferens is carried out by the same name
plexus (plexus deferentialis) surrounding the artery of the vas deferens
duct. Plexus
vas deferens - a derivative of the lower hypogastric plexus (plexus
hypogastricus inferior), receiving sympathetic fibers from the sacral nodes
sympathetic trunk. Parasympathetic innervation of the vas deferens
duct
carried out by the pelvic splanchnic nerves (nn. splanchnici pelvini). Somatic innervation of the scrotum and spermatic cord is carried out
branches of the lumbar and sacral plexuses.
The ilioinguinal nerve (n. ilioinguinalis) passes in the inguinal canal along
anterior surface of the spermatic cord and gives off the anterior scrotal nerves
(nn. Scrotales anteriores), innervating the skin of the pubis and scrotum.
Perineal nerve (n. perinealis), extending from the pudendal nerve (n. pudendus),
passes in the superficial space of the perineum and gives to the back
surface of the scrotum posterior scrotal nerves (nn. scrotales posteriores).
Sexual branch of the genitofemoral nerve (r. genitalis n. genitofemoralis), branch
lumbar plexus, in the inguinal canal lies behind the spermatic cord,
innervates the muscle that lifts the testicle, the skin of the scrotum and the fleshy membrane. Penis
The penis consists of
from two cavernous bodies and
spongy body. Cavernous and
spongy body of the penis
covered with dense protein
shell. From squirrel
shells deep into the bodies
penis recede
processes - trabeculae, between
they are cells. The cavernous bodies of the penis begin with legs (crura penis) from the inner surface
inferior branches of the pubic bones. At the level of the pubic fusion of the peduncle of the penis
connect to form the septum of the penis (septum penis) and continue
into the body of the penis (corpus penis), located on its back side and forming it
back of the penis (dorsum penis).
Spongy body of the penis (corpus spongiosum penis) lies in the groove between
cavernous bodies and forms the urethral surface of the penis (facies
urethralis). The spongy body of the penis is permeated throughout
urethra, opening with an external opening on the head.
The proximal part of the spongy body is thickened and is referred to as the bulb of the genital
member (bulbus penis). Its distal part forms the head of the penis (glans penis).
The head of the penis is shaped like a cone and resembles a mushroom cap. Into the recess
the base of the head includes the pointed ends of the cavernous bodies fused together
penis. The posterior section of the head passes into the crown of the head (corona glandis), behind
the latter is the neck of the head (collum glandis). From the bottom surface of the head
the septum of the head (septum glandis) is directed into its thickness. The skin of the penis is elastic, mobile, contains a lot of sebaceous
glands. On
the back of the penis (dorsum penis) is so thin that you can see through it
branching
superficial veins. In the area of the head of the penis, the skin directly
adjacent to the spongy body of the penis and fuses with it. Behind the neck
head is the foreskin of the penis (praeputium penis) -
a fold of skin, usually freely advancing on the head and its
closing. The inner surface of the foreskin contains glands
foreskin (glandulae praeputiales), which secrete a special secret -
preputial lubrication (smegma praeputialis). The foreskin on the urethra
surface of the penis passes into the frenulum of the foreskin (frenulum
praeputii), fixed to the lower surface of the head. The blood supply to the penis is provided by the deep and dorsal arteries of the penis.
member (a. profunda penis et a. dorsalis penis) - branches of the internal pudendal artery
(a. pudenda interna). Blood outflow from the penis occurs along the deep dorsal
vein of the penis (v. dorsalis penis profunda), into the prostatic venous plexus
(plexus venosus prostaticus), and along the superficial dorsal veins of the penis
(vv. dorsales penis superficiales) through the external pudendal veins (vv. pudendae externae) in
femoral vein (v. femoralis).
Lymph outflow from the penis occurs in the inguinal and external iliac
lymph nodes (nodi lymphatici inguinales et iliaci externi).
The innervation of the penis is carried out by the dorsal nerve of the penis (n. dorsalis
penis), extending from the pudendal nerve (n. pudendus) and containing sensitive and
parasympathetic fibers. Sympathetic fibers from the inferior hypogastric plexus
approach the penis along the internal pudendal artery. URETHRA
male urethra
channel starts internal
hole and consists of three
parts: prostate,
membranous and spongy. 1. The prostate is about 4 cm long. It has a narrowing
the level of the internal opening due to the muscular membrane of the bladder, which plays
role of the involuntary urethral sphincter. In extended
the prostatic part opens the ejaculatory ducts (ductus ejaculatorii) and
prostatic ducts (ductuli prostatici).
2. The membranous part has a length of about 2 cm and is
the most narrowed part of the urethra, since it is located here
external sphincter (m. sphincter urethrae). Behind this part of the urethra
canal contains the bulbourethral glands.
3. The spongy part has a length of about 15 cm. It forms two extensions: in
the area of the bulb of the penis where the excretory ducts open
bulbourethral glands (ductus gl. bulbourethralis), and in the region of the navicular fossa
urethra located in the head
penis. The spongy part ends with an outer hole
urethra, having a smaller diameter along
compared to the navicular fossa. Genitourinary area of a woman
female genital area
located within
urogenital
areas. middle area
occupies the genital gap (rima
pudendi), limited laterally
labia majora (labia
majora pudendi), front and back -
anterior and posterior lip commissures
(comissura labiorum anterior et
posterior). The bulb of the vestibule (bulbus vestibuli) is an unpaired cavernous formation,
consisting of the right and left lobes measuring about 3.5x1.5x1 cm, located in
thicker than the labia majora (labia majora pudendi) joined at the front
intermediate part of the bulb, consisting mainly of the venous
plexus located between the external opening of the urethra and
clitoris.
The labia minora (labia minora pudendi) is located between the labia majora.
lips, laterally limit the vestibule of the vagina (vestibulum vaginae), and
in front lie on the clitoris (clitoris) and form its foreskin (preputium clitoridis)
and frenulum (frenulum clitoridis). Behind the vestibule of the vagina is limited by the frenulum
labia (frenulum labiorum pudendi). The clitoris (clitoris) consists of two cavernous bodies that form the head
clitoris, clitoral body and clitoral legs attached to lower branches
pubic bones. On the eve of the vagina behind the clitoris, the external
opening of the urethra.
The large gland of the vestibule (gl. vestibularis major, Bartholin's) is located in
the base of the labia minora, lies at the posterior edge of the bulbs of the vestibule of the vagina,
projected onto the back of the labia majora. The excretory duct opens
on the threshold of the vagina on the border of the middle and posterior thirds of the labia minora. The blood supply to the external female genital organs is carried out by the branches of the internal and
external genital arteries (aa. pudendae interna et externae).
From the internal pudendal artery (a. pudenda interna) depart the posterior labial branches (aa. labiales
posteriores), blood supply to the posterior sections of the labia majora and labia minora, deep and
dorsal artery of the clitoris (a. profunda clitoridis et a. dorsalis clitoridis).
External pudendal arteries (aa. pudendae externae) depart from the femoral artery (a.
femoralis) and give off the anterior labial arteries (aa. labiales anteriores), which supply blood
anterior sections of the labia majora and minora.
Outflow of blood from the external female genital organs through the anterior labial veins (vv. labiales
anteriores) into the external genital veins and further into the femoral vein; along the posterior labial veins (vv.
labiales posteriores) - into the internal pudendal vein and further into the internal iliac
vein; along the deep dorsal vein of the clitoris (v. dorsalis clitoridis profunda) - into the cystic
venous plexus (plexus venosus vesicalis) and further along the bladder veins into the internal
iliac vein. Lymph drainage from the external female genital organs occurs in the inguinal
lymph nodes (nodi lymphatici inguinales) and into the internal iliac
lymph nodes (nodi lymphatici iliaci interni).
The innervation of the external female genital organs is carried out by the following
nerves.
Anterior labial nerves (nn. labiales anteriores), extending from the ilio-inguinal nerve (n. iliohypogastricaus) - from the lumbar plexus (plexus lumbalis).
Sexual branch of the genital-femoral nerve (r. genitalis n. genitofemoralis) from
lumbar plexus.
Posterior labial nerves (nn. labiales posteriores), extending from the perineal
nerves (nn. perineales) - branches of the pudendal nerve from the sacral plexus.
Operative surgery of the perineum
Labiaplasty
The aesthetic surgery of the labia has a very longhistory and is generally accepted in gynecology. Is probably
one of the most requested operational corrections.
This is due to the fact that the anatomical asymmetry of small
labia is the physiological norm of the female
organism, which begins to be realized from the period
puberty. Quite often too long
the labia minora protrude and hang down below the large ones
labia, which creates aesthetic or functional
inconvenience. In this case, resort to their partial
resection. Features of the operation. Operation
performed under local anesthesia,
duration - 30-40 minutes. Small genital
lips pull outward, mark out
excess and removed. Stitches are being applied
special threads that
dissolve on their own. Footprints
surgical intervention is not visible. postoperative period. First
a few days after the operation
slight soreness and discomfort
area of operation. Stitches disappear or fall off
themselves in 2-3 weeks, after which you can
resume sexual activity.
Reducing the entrance to the vagina
Operation to reduce the entrance to the vaginausually used for the purpose
improving the quality of sexual life
women with extended access to
vagina. This situation often occurs after childbirth.
through the natural birth canal or any manipulations in this area. Synonyms
frequently used by patients: colporrhaphy
and vaginoplasty. Kolporrhaphy in translation
suturing the vagina does not reflect well
the essence of the operation, and vaginoplasty is quite
fits.
entrance to the vagina
The entrance to the vagina is very interesting precisely from the point of viewimprove sensations and sexual performance. Through the muscles
which normally limit it and achieve their
uncontrolled contraction during intercourse, which provides
close contact with the partner's penis, moreover, in this
area is concentrated a huge number of sensitive
endings, including the notorious G-Spot. The rest
part of the vagina is already controlled by other muscle
structures that are not damaged by childbirth.
The essence of the operation
So, the concept of reducing the volume of the vagina andconsists in narrowing the entrance for about 8 cm.
This part is actively involved in sex and the rest of the departments
are never damaged, so this operation is always
effective. Always excised the excess of the posterior mucosa
walls of the vagina and torn muscles stand out, then
they are sutured. This so-called
colpoperineolevathoroplasty, also if necessary
a decision is made on an additional "front
plastic", but this is already more traumatic and in most cases
cases an unnecessary procedure.
When is additional anterior plastic needed?
Some women mayhave a cystocele, or
prolapse of the anterior wall
vagina. Occurs due to
damage to the vesical fascia, the plate separating these two
organ. Basically it's a bladder hernia.
bubble, which, under certain
tests, and in severe cases
at rest protrudes into the lumen
vagina or beyond. This
condition may lead to
urinary incontinence, or increased
urination, and
does not look very aesthetically pleasing. essence
intervention in the excision of excess
"Net"
In severe cases with anterior plasty orcolpoperineolevathoroplasty has to use a mesh
prosthesis, more often it is called the term mesh. But don't abuse it
worth it, as unreasonable use can lead to severe
complications. Mesh is not considered a priority material though
some surgeons still use it despite
medical studies that report that in at least 20%
cases, there are sexual problems caused by rejection
tissue, or dyspareunia, pain in the vaginal area during or after
sexual intercourse. This is due to the fact that the use of this implant
facilitates and simplifies the work of the surgeon.
Common mistakes and complications of vaginoplasty
So, the most dangerous are damage to the rectum orbladder, after such errors, a long
recovery and additional intervention, perhaps more than one.
Sewing up the entrance without restoring the muscular frame of the perineum
will provide pain during intercourse and the absence of the effect of surgery in
subsequent. Dyspareunia, or more simply pain, occurs when
mesh use and due to excessive surgical
activity. Inflammation and suppuration leads to divergence of the seams and
the formation of purulent abscesses, again subject to the rules
preparation, postoperative management with the appointment
antibacterial drugs, this complication occurs extremely
rarely.
Modern technologies
Currently, various moderndevices, these are laser scalpels, radiofrequency needles, and
others, however instrument choice for vaginoplasty
depends only on the surgeon and each stage of the operation requires
your type of equipment. The real problem is
skills of a surgeon, and you can cope with this task with
using a quality standard set
microsurgical instruments, again better and
sharper than a scalpel and they came up with it. And of course quality
suture material.
Thank you for your attention.
1) Suprapubic puncture is a percutaneous puncture of the bladder-in the midline of the abdomen
- along the oblique line of the abdomen
- along the lower horizontal line of the abdomen
2) Indications for suprapubic capillary puncture
-evacuation of urine from the bladder if it is impossible or available
contraindications for catheterization
- trauma to the urethra
- burns of the external genitalia
3) Contraindications to Suprapubic capillary puncture
- acute cystitis or paracystitis
- acute urinary retention
-burns of the external genitalia
4) High cystotomy is performed in the area
- apex of the bladder
- bladder body
- the bottom of the bladder 5) Operative access to the female genital organs in the pelvic cavity
- vaginal
-abdominal-wall
- posterior colpotomy
6) According to the technology of performing operations on the uterus, they are divided into
-traditional;
-laparoscopic;
- endoscopic.
7) Types of hysterectomy
-Subtotal
- Total
- Hysterosalpingo-oophorectomy
- Radical hysterectomy
- laparoscopic; 8) Cystomectomy - removal
- tumors of the ovary on the leg.
- ovarian cysts on the leg
- all are correct
9) What wall of the inguinal canal is weakened in direct inguinal hernia?
- top
-front
- rear
10) The hernial sac in congenital inguinal hernia is formed
- vaginal process of the peritoneum
- parietal peritoneum
-mesentery of the small intestine 11. The supporting apparatus of the uterus includes:
1. Pelvic diaphragm
2. Broad ligaments of the uterus
3. Vagina
4. Urogenital diaphragm
5. Cardinal ligaments
12. Arteries supplying the uterus:
1. Royal
2. Inferior vesical
3. Arteries of the round uterine ligament
4. Ovarian
5. Lower epigastric
13. In the fixation of the ovaries take part:
1. Ligaments that suspend the ovaries
2. Cardinal ligaments
3. Round uterine ligaments
4. Mesentery of the ovaries
5. Own ligaments of the ovaries 14. Arteries supplying blood to the ovaries:
1. Royal
2. Arteries of round uterine ligaments
3. Lower epigastric
4. Ovarian
15. Bladder in relation to the prostate
located:
1. Front
2. Top
3. Bottom
4. Behind 16. The narrowest part of the male urethra
is:
1. Outer hole
2. Intermediate (webbed) part
3. Inner hole
17. The sequence of the layers of the scrotum and testicular membranes,
starting with the skin:
1. The vaginal membrane of the testicle
2. Internal seminal fascia
3. External seminal fascia
4. Meaty shell
5. The muscle that raises the testicle, with its fascia
6. Skin 18. The superior rectal artery is a branch of:
1. Internal pudendal artery
2. Internal iliac artery
3. Superior mesenteric artery
4. External iliac artery
5. Inferior mesenteric artery
19. The peritoneum covers the supraampullary part of the rectum:
1. Front only
2. Three sides
3. From all sides
20. From the lower part of the ampulla of the rectum, in the subperitoneal floor
pelvis, lymph flows into the lymph nodes:
1. Inguinal
2. sacral
3. Superior mesenteric
4. Upper rectal and further to the lower mesenteric
5. Internal iliac 1-1;
2-1,2,3;
3- 1;
4-1;
5-1;
6-1,2,3;
7-1,2,3,4;
8-3;
9- 3;
10-1.
1,4
1,3,4
1,4
1,4
2
2
6,4,3,5,2,1
5
3
2,51) U K., 26 years old, fracture of the pubic bone with extraperitoneal injury
walls of the urinary
bladder. What principles should be the basis of surgical
wound treatment
in this situation?
2) When extraperitoneal damage to the bladder occurs
necessity
drainage of the retropubic (prevesical) space. What methods
drainage can be used in patients with phlegmon of this
space?
3) The urologist performs suturing of the wound of the bladder wall. What
anatomical relationships of this organ with the peritoneum
the difference in the technique of suturing the wound of its wall is determined? How many
rows of sutures should be placed on the wall of the bladder? What layers
body capture in the seam? 4) Patient I., aged 26, was diagnosed with parametritis. From the anamnesis: 1.5.
months Before contacting the gynecologist, the patient was under treatment for
about cystitis. What is the structure of the urethra
the frequency of cystitis in women is determined? Explain the relationship
cystitis and parametritis.
5). Patient 3., 18 years old, to clarify the diagnosis: “Impaired
ectopic pregnancy” a puncture of the posterior fornix was performed
vagina. In which case this study will confirm
diagnosis? What is the strategy for confirming the diagnosis? 1) 1) Suture the wound of the bladder (if possible) with a two-row suture without grasping
mucous membrane;
2) ensure the diversion of urine from the bladder (cystostomy);
3) provide drainage (pubic-femoral or pubic-perineal method of conducting
drainage) retropubic (prevesical) space.
2).1) Abdominal - through the anterior abdominal wall (transverse or longitudinal extra-abdominal
access);
2) access to the subperitoneal cavity of the pelvis through the obturator foramen (away from the obturator canal)
from the side of the medial surface of the thigh (adductor muscle bed) according to I. V. Buyalsky - McWhorter;
3) removal of drainage to the perineum according to P. A. Kupriyanov;
4) removal of drainage pararectally through the sciatic-anal fossa (with combined injuries
bladder and rectum).
3) In the emptied state, the bladder is located subperitoneally (the serosa is covered
partially in front, from the sides, and behind), when filling - mesoperitoneally. Therefore, a distinction is made between peritoneal and
extraperitoneal parts of this organ. The wound of the peritoneal section is sutured with a two-row suture: 1st row - with a thread from
absorbable material with the capture of the muscle membrane (the mucous membrane is not captured!); 2nd row - a thin non-absorbable thread serous-muscular. Introduce into the bladder for several days
indwelling catheter. In case of injuries of the extraperitoneal section, the available sections of the bladder are subjected to
double stitch. In the second row, the visceral (pre-vesical) > fascia and muscular membrane are captured.
The operation is completed by the imposition of a urinary fistula. 4) In women, the urethra is koropish, straight, wide.
Lymphatic vessels and veins of bladder urine have direct connections with
vessels of the uterus and vagina (at the base of the broad ligament and internal
iliac lymph nodes).
5) A disturbed ectopic pregnancy is confirmed by the presence of blood
from the abdomen and not from a blood vessel (the resulting blood
examined on a white background: dark-colored blood from the abdominal cavity with
fine granularity (coagulation outside the vascular bed); blood from a vessel
(fresh) granularity should not have. When receiving blood from the abdominal
cavity is performed laparotomy.
The bone base of the pelvis is formed by two pelvic bones, the sacrum and the coccyx. The pelvic cavity is the receptacle for loops of the small and part of the large intestine, as well as the genitourinary system. The upper external landmarks of the pelvis are the pubic and iliac bones, the sacrum. The lower part is limited by the coccyx, ischial tubercles. The exit from the pelvis is closed by the muscles and fasciae of the perineum, which form the diaphragm of the pelvis.
In the region of the pelvic floor, formed by fascia and muscles, the pelvic diaphragm and the urogenital diaphragm are isolated. The diaphragm of the pelvis is formed mainly by the muscle that lifts the anus. Its muscle fibers, connecting with the bundles of the opposite side, cover the wall of the lower part of the rectum and intertwine with the muscle fibers of the external sphincter of the anus.
The urogenital diaphragm is a deep transverse perineal muscle that fills the angle between the inferior rami of the pubic and ischial bones. Below the diaphragm is the perineum.
Separate the large and small pelvis. The boundary between them is the boundary line. The pelvic cavity is divided into three sections (floors): peritoneal, subperitoneal and subcutaneous.
In women, the peritoneum, when moving from the posterior surface of the bladder to the anterior surface of the uterus, forms a shallow vesicouterine depression. In front, the cervix and vagina are located subperitoneally. Covering the bottom, body and cervix from behind, the peritoneum descends to the posterior fornix of the vagina and passes to the rectum, forming a deep recto-uterine cavity.
Duplications of the peritoneum, directed away from the uterus to the side walls of the pelvis, are called the wide ligament of the uterus. Between the leaves of the broad ligament of the uterus are the fallopian tube, the proper ligament of the ovary, the round ligament of the uterus and the ovarian artery and vein that go to the ovary and lie in the ligament that supports the ovary. At the base of the ligament lie the ureter, uterine artery, venous plexus, and uterovaginal nerve plexus. In addition to the wide ligaments, the uterus in its position is strengthened by round ligaments, recto-uterine and sacro-uterine ligaments and muscles of the urogenital diaphragm, to which the vagina is fixed.
The ovaries are located behind the broad ligament of the uterus closer to the side walls of the pelvis. With the help of ligaments, the ovaries are connected to the corners of the uterus, and with the help of suspensory ligaments, they are fixed to the side walls of the pelvis.
The subperitoneal pelvis is located between the peritoneum and the parietal fascia, it contains parts of organs that do not have a peritoneal cover, the end parts of the ureters, the vas deferens, seminal vesicles, the prostate, in women - the cervix and part of the vagina, blood vessels, nerves, lymph nodes and the surrounding loose fatty tissue.
In the subperitoneal part of the small pelvis, two spurs of the fascia pass in the sagittal plane; in front they are attached at the medial edge of the internal opening of the obturator canal, then, following from front to back, they merge with the fascia of the bladder, rectum and are attached to the anterior surface of the sacrum, closer to the sacroiliac joint. In each of the spurs there are visceral branches of vessels and nerves going to the pelvic organs.
In the frontal plane, as noted, between the bladder, prostate and rectum in men, between the rectum and vagina in women, there is a peritoneal-perineal aponeurosis, which, having reached the sagittal spurs, merges with them and reaches the anterior surface of the sacrum. Thus, the following parietal cellular spaces can be distinguished; prevesical, retrovesical, retrorectal and two lateral.
The retropubic cellular space is located between the pubic symphysis and the visceral fascia of the bladder. It is divided into preperitoneal (anterior) and prevesical spaces.
The prevesical space is relatively closed, triangular in shape, bounded anteriorly by the pubic symphysis, and posteriorly by the prevesical fascia, laterally fixed by obliterated umbilical arteries. The prevesical space of the pelvis along the femoral canal communicates with the tissue of the anterior surface of the thigh, and along the course of the cystic vessels - with the lateral cellular space of the pelvis. Through the prevesical space, an extraperitoneal access to the bladder is carried out when a suprapubic fistula is applied.
The retrovesical cellular space is located between the posterior wall of the bladder, covered with a visceral sheet of the prevesical fascia, and the peritoneal-perineal aponeurosis. From the sides, this space is limited by the already described sagittal fascial spurs. The bottom is the urogenital diaphragm of the pelvis. In men, the prostate gland is located here, which has a strong fascial capsule, the end parts of the ureters, the vas deferens with their ampoules, seminal vesicles, loose fiber and the prostate venous plexus.
Purulent streaks from the retrovesical cellular space can spread into the cellular space of the bladder, into the region of the inguinal canal along the vas deferens, into the retroperitoneal cellular space along the ureters, into the urethra, and into the rectum.
The lateral cellular space of the pelvis (right and left) is located between the parietal and visceral fascia of the pelvis. The lower boundary of this space is the parietal fascia, which covers the levator ani muscle from above. Behind there is a message with the retrointestinal parietal space. From below, the lateral cellular spaces can communicate with the ischiorectal tissue if there are gaps in the thickness of the levator ani muscle, or through the gap between this muscle and the internal obturator.
Thus, the lateral cellular spaces communicate with the visceral cellular spaces of all pelvic organs.
The posterior rectal cellular space is located between the rectum with its fascial capsule in front and the sacrum in the back. This cellular space is delimited from the lateral spaces of the pelvis by sagittal spurs running in the direction of the sacroiliac joint. Its lower border is formed by the coccygeal muscle.
In the fatty tissue behind the rectal space, the upper rectal artery is located at the top, then the median and branches of the lateral sacral arteries, the sacral sympathetic trunk, branches from the parasympathetic centers of the sacral spinal cord, sacral lymph nodes.
The spread of purulent streaks from the retrorectal space is possible in the retroperitoneal cellular space, lateral parietal cellular spaces of the pelvis, visceral cellular space of the rectum (between the intestinal wall and its fascia).
Operative access to the posterior rectal cellular space of the pelvis is carried out through an arcuate or median incision between the coccyx and the anus, or the coccyx and sacrum are resected no higher than the third sacral vertebra.
Vessels of the subperitoneal region
At the level of the sacroiliac joint, the common iliac arteries divide into external and internal branches. The internal iliac artery goes down - back and after 1.5-5 cm is divided into the anterior and posterior branches. The superior and inferior cystic arteries, uterine, middle rectal and parietal arteries depart from the anterior branch (umbilical, obturator, inferior gluteal, internal genital). Parietal arteries depart from the posterior branch (ilio-lumbar, lateral sacral, superior gluteal). The internal pudendal arteries pass through the small sciatic foramen into the ischiorectal fossa.
Venous blood from the pelvic organs flows into the venous plexus (vesical, prostatic, uterine, vaginal). The latter give rise to arteries of the same name, usually double, veins, which, together with the parietal veins (superior and inferior gluteal, obturator, lateral sacral, internal pudendal) form the internal iliac vein. Blood from the rectal venous plexus through the superior rectal vein partially flows into the portal vein system.
The lymph nodes of the pelvis are represented by the iliac and sacral nodes. The iliac nodes are located along the external (lower) and common (upper) iliac arteries and veins (from 3 to 16 nodes) and receive lymph from the lower limb, external genital organs, and the lower half of the anterior abdominal wall.
Rectum
The rectum is the end part of the intestinal tube and begins at the level of II or the upper edge of the III sacral vertebra, where the colon loses the mesentery and the longitudinal muscle fibers are evenly distributed over the entire surface of the intestine, and not in the form of three ribbons. The intestine ends with an anus.
The length of the rectum does not exceed 15 cm. Anterior to it in men are the bladder and prostate, ampullae of the vas deferens, seminal vesicles and the final parts of the ureters, in women - the vagina and cervix. The rectum in the sagittal plane forms a bend according to the curvature of the sacrum, first in the direction from front to back (sacral bend), then in the opposite direction (perineal bend). At the same level, the rectum also bends in the frontal plane, forming an angle open to the right.
In the rectum, two main parts are distinguished: the pelvic and perineal. The pelvic part (10–12 cm long) lies above the pelvic diaphragm and has a nadampular part and an ampulla (the wide part of the rectum. The nadampular part of the rectum, together with the final part of the sigmoid colon, is called the rectosigmoid colon.
The anal canal (the perineal part of the rectum) is 2.5–3 cm long and lies above the pelvic diaphragm. The fatty body of the sciatic-anal fossa adjoins it from the sides, in front - the bulb of the penis, covered with muscle and fascia, the posterior edge of the urogenital diaphragm and the tendinous center of the perineum.
The rectum is covered in the upper part of the peritoneum from all sides, below - in front and from the sides, and at the level of the IV sacral vertebra (and partially V) - only in front. In the subperitoneal part, the rectum has a well-defined visceral fascia - its own fascia of the rectum.
The mucous membrane of the upper part of the ampoule of the rectum forms 2-4 transverse folds. In the anal canal, the longitudinal folds are separated by sinuses, the number of which varies from 5 to 13, and the depth is often 3-4 mm. From below, the sinuses are limited by anal flaps located 1.5 - 2 cm above the anus. The purpose of these folds is to relieve the pressure of feces on the pelvic floor.
The muscular layer of the rectum consists of the outer longitudinal and inner circular layers. The outlet part of the rectum is annularly covered under the skin by the external sphincter of the anus, consisting of striated muscle fibers (arbitrary sphincter). At a distance of 3 - 4 cm from the anus, annular smooth muscle bundles, thickening, form an internal sphincter (involuntary). Between the fibers of the external and internal sphincter, the fibers of the muscle that lifts the rectum are woven. At a distance of 10 cm from the anus, the annular muscles form another thickening - the third (involuntary) sphincter.
The arterial blood supply to the rectum is carried out mainly by the superior rectal artery (unpaired, terminal branch of the inferior mesenteric artery), which runs at the root of the mesentery of the sigmoid colon and is divided posteriorly at the level of the beginning of the intestine into 2–3 (sometimes 4) branches, which along the posterior and lateral surfaces the intestines reach its lower part, where they connect with the branches of the middle and lower rectal arteries.
The middle rectal arteries (paired, from the internal iliac artery) supply blood to the lower parts of the rectum. They may be of large caliber, and sometimes absent altogether.
The lower rectal arteries (paired) in the amount of 1-4 on each side depart from the internal genital arteries and, having passed through the tissue of the ischio-anal fossa, enter the wall of the rectum in the region of the external sphincter.
The veins corresponding to the arteries form plexuses in the wall of the rectum (rectal venous plexuses). There are subcutaneous plexus (around the anus), submucosal, which in the lower part consists of tangles of veins penetrating between bundles of circular muscles (hemorrhoidal zone), and subfascial (between the muscle layer and its own fascia). Venous outflow is carried out through the superior rectal vein (it is the beginning of the inferior mesenteric vein), the middle rectal vein (flows into the internal iliac vein), the inferior rectal vein (flows into the internal pudendal vein). Thus, in the wall of the rectum there is one of the porto-caval anastomoses.
Lymphatic vessels from the subcutaneous lymphatic network around the anus below the anal flaps are sent to the inguinal lymph nodes. From the back of this network and from the networks of lymphatic capillaries of the posterior wall of the rectum in the area of attachment of the muscle that lifts the anus, the lymphatic vessels are sent to the sacral lymph nodes.
From the area of the rectum within 5 - 6 cm from the anus, the lymphatic vessels are sent on the one hand - along the lower and middle rectal blood vessels to the internal iliac lymph nodes, on the other - along the upper rectal artery to the nodes located along this vessel, up to the lower mesenteric lymph nodes.
Lymph flows into these nodes from parts of the rectum lying above 5-6 cm from the anus. Thus, from the lower part of the rectum, the lymphatic vessels go up and to the sides, and from the upper - up.
The rectum is innervated by parasympathetic, sympathetic and spinal nerves. Sympathetic branches to the intestine come along the superior rectal artery in the form of the superior rectal plexus (from the inferior mesenteric plexus) and along the middle rectal arteries, and independently in the form of the middle rectal plexus from the inferior hypogastric plexus. Through the same perivascular plexuses, parasympathetic branches coming from the sacral part of the parasympathetic system in the form of pelvic splanchnic nerves approach the rectum. As part of the sacral spinal nerves are sensory nerves that convey the feeling of filling the rectum.
The anal canal, external sphincter, and skin around the anus are innervated by the inferior rectal nerves, which arise from the pudendal nerve. These nerves contain sympathetic fibers that innervate the deep muscles of the rectum, and in particular the internal sphincter of the anus.
Bladder
It is located in the anterior part of the small pelvis. The anterior surface of the bladder is adjacent to the pubic symphysis and the upper branches of the pubic bones, separated from them by a layer of loose connective tissue. The posterior surface of the bladder is bordered by the ampulla of the rectum, the ampullae of the vas deferens, the seminal vesicles, and the terminal parts of the ureters. From above and from the sides to the bladder, the loops of the thin, sigmoid, and sometimes transverse colon and caecum, separated from it by the peritoneum, are adjacent. The lower surface of the bladder and the initial part of the urethra is covered by the prostate. The vas deferens adjoins the lateral surfaces of the bladder for some length.
The bladder is divided into the apex, body, fundus and neck (the part of the bladder that passes into the urethra). The bladder has well-defined muscular and submucosal layers, as a result of which the mucous membrane forms folds. There are no folds and a submucosal layer in the region of the bottom of the bladder, a triangular platform is formed here, in the front part of which there is an internal opening of the urethra. At the base of the triangle there is a fold connecting the orifices of both ureters. The involuntary sphincter of the bladder covers the initial part of the urethra, the arbitrary sphincter is located at the level of the membranous part of the urethra.
The blood supply to the bladder is carried out by the superior artery coming from the umbilical artery and the inferior artery coming directly from the anterior trunk of the internal iliac artery.
Veins of the bladder form plexuses in the wall and on the surface of the bladder. They enter the internal iliac vein. The outflow of lymph is carried out in the lymph nodes located along the vessels.
The upper and lower hypogastric nerve plexuses, the pelvic splanchnic nerves and the pudendal nerve take part in the innervation of the bladder.
Prostate
It is located in the subperitoneal part of the small pelvis, covers with its shares the initial part of the urethra. The prostate has a well-defined fascial capsule, from which ligaments go to the pubic bones. In the gland, two lobes and an isthmus (third lobe) are distinguished. The ducts of the prostate open into the prostate urethra.
The prostate is supplied by branches from the inferior cystic arteries and the middle rectal arteries (from the internal iliac artery). The veins form the prostatic venous plexus, which merges with the vesical plexus and empties into the internal iliac vein.
The pelvic part of the vas deferens is located in the subperitoneal part of the small pelvis and is directed from the internal opening of the inguinal canal downwards and backwards, forming the ampulla of the vas deferens. Behind the ampoules are the seminal vesicles. The duct of the ampoule, merging with the duct of the seminal vesicle, penetrates the body of the prostate and opens into the prostatic part of the urethra. The vas deferens are supplied with blood through the arteries of the vas deferens.
