Surgical anatomy of the pectineal ligament during pectopexy surgery: The relevance to the major vascular structures

Abstract

Objective: During pectopexy surgery, the prolapsed uterus or the vaginal apex is fixed to the pectineal ligament. The anatomic structures found in the lateral part of the prevesical and paravaginal space above the obturator fossa, raise the importance of the surgical steps required to prevent complications. This study was conducted to evaluate the proximity of vascular structures to the pectineal ligament. Materials and Methods: The distances between the surgical suturing area during pectopexy surgery and the external iliac vein, pubic anastomotic vessel (corona mortis) and obturator canal were measured bilaterally in seven fresh female cadavers. Results: The total length of the pectineal ligament was 5.9±0.76 cm on the left and 6.5±1.14 cm on the right side; the midpoint of the pectineal ligament was 2.8±0.52 cm on the left and 3.6±0.47 cm on the right side. From the midpoint of the left pectineal ligament, the mean distance to the left external iliac vein was 1.04±0.23 cm, to the left corona mortis it was 2.15±0.48 cm, and to the left obturator canal it was 3.12±0.95 cm. From the midpoint of the right pectineal ligament, the mean distance to the right external iliac vein was 1.25±0.43 cm, to the right corona mortis it was 2.37±0.63 cm, and to the right obturator canal it was 3.57±0.93 cm. Conclusion: The anatomic findings of the study confirmed that the pectineal ligament was in close association with main vessels. The external iliac vein was measured as the closest anatomic structure to the pectineal ligament. Surgeons must be careful to minimize life-threatening complications because of the proximity of the pectineal ligament to main vessels.

Laparoscopic pectopexy: the learning curve and comparison with laparoscopic sacrocolpopexy

“…2 g). A cadaver study showed that the mean distance from the midpoint of the pectineal ligament to the external iliac vein was 1.04–1.25 cm and to the obturator canal was 3.12–3.57 cm [ 15 ]. The obturator nerve passes below the pectineal ligament and is relatively distant from the dissection plane.…”

“…A vessel that may be encountered during pectineal ligament preparation is the pubic vein, also called the corona mortis (Fig. 2 h), which is the anastomosis of the external iliac vein and obturator vein and lies on the pectineal ligament [ 15 ]. It can simply be cauterized if this vessel is impeding the mesh fixation.…”

Corona mortis, aberrant obturator vessels, accessory obturator vessels: clinical applications in gynaecology

“…Pulatoglu et al measured the total length of the pectineal ligament -5.9±0.76 cm on the left and 6.5±1.14 cm on the right side. From the midpoint of the right pectineal ligament, the mean distance to the right CMOR was 2.37±0.63 cm and the mean distance to the left CMOR was 2.15±0.48 cm [44].…”

“…the external iliac vessels and the pubic spine [43].They reported that during Burch colposuspension stitches should be located near to the iliac vessels and 4 cm lateral to the medial insertion of the ligament, where it has its greatest thickness [43]. According to other study, the medial part of pectineal ligament close to the pubic tubercle was the thickest section and it became thinner while extending laterally [44]. In a study of 11 female unembalmed female cadavers, Kinman et al reported that the mean distance from the most lateral stitch in Cooper's pubic ligament to the obturator bundle was 25.9 ± 7.6 mm and to the external iliac vessels was 28.9 ± 9.3 mm, and in some instances, these structures were less than 15 mm away [39].…”

“…Furthermore, AOVs, ACOVs and CMOR are at risk of damaged during operations for vaginal wall descent, uterovaginal prolapse and neovaginal reconstruction [42,44]. Studies reported that pectopexy for pelvic organ prolapse is feasible procedure because the surgeon used a wide area in the pelvis and the strong nature of the pectineal ligament would decrease the postoperative recurrence rates [44,46]. The pectineal ligament is the target for neovaginal attachment in Mayer-Rokitansky-Küster-Hauser syndrome.…”