A Fascial Reinterpretation of the Classical Female Pelvic Surgical Anatomy: Seeing Things from a Different Angle

Abstract

The classical surgical anatomy of the female pelvis was born with radical hysterectomy [1] and focused on the pivotal role of the lateral parametrium, a conceptually complex structure, an artifact of surgical anatomy [2] without which the whole classical model would collapse. Here, using natural planes, we tried to simplify the puzzle of the virtual spaces surrounding this structure [3,4]. With the aim of better conceptualizing the classical model of the female pelvic surgical anatomy, we broadened its perspective, which had been narrowly focused on the historic gynecologic setting, by developing a comprehensive model of pelvic retroperitoneal compartmentalization. This dissection was based on the invariable anatomic (fasciae) rather than the surgical-anatomic (parametrium) structures and aimed at providing a holistic, more user-friendly approach intended for surgical and educational purposes [5]. Because each compartment has its own surgical function (hence the name), the excavation of a single compartment may be used as a rational guide to tailor surgery to the site of the pathologic condition to be treated or the type of procedure required, whereas the compartments' sequential development may be useful in planning surgical strategies. Redefining the classical model according to the anatomic fascial planes of dissection potentially allows for an intrinsic surgical reproducibility, minimizing dissective bias. A reinterpretation of the known anatomy is required to enhance education. The breaking down of such a complex system (the pelvis) into smaller parts (compartments) will hopefully provide a useful guide for conceptualization and navigation; surgical navigation requires a holistic mental map and a few invariable anatomic reference points or landmarks. Design: A step-by-step laparoscopic demonstration of the fascial model, developed on a fresh frozen female pelvis, and its correlation with the classical female retroperitoneal surgical anatomy.

Anatomical Location of the Vesical Branches of the Inferior Hypogastric Plexus in Human Cadavers

“…The variability in pelvic ganglion diameter may make locating the ganglion during nerve transfer more difficult in some cases. While the ureter can be used as a major landmark to reach the ureteral orifice and vesical branches [10], the medial umbilical ligaments can also be used as a landmark (personal communication from Dr. Elise De, co-author [44,45]).…”

“…Another limitation is that we used only the ureteral orifice, ureter, and bladder as landmarks for identification and localization of the vesical nerve branches. During different radical pelvic surgeries (radical hysterectomy or prostatectomy), surgeons often use other anatomical landmarks, such as the vesicovaginal ligament, vesicovaginal venous plexus, [6,27,28,34], and medial umbilical ligaments, as mentioned earlier [44,45].…”

Laparoscopic resection of retroperitoneal leiomyosarcoma involving the right ureter and internal iliac artery

“…Laparoscopic resection of retroperitoneal leiomyosarcoma from the obturator fossa was achieved successfully in a logical way (Online Supplemental Tables 1, 2). The critical point of the procedure is to have a good knowledge of the key anatomic landmarks of the pelvis 1…”