Anatomyforthe

LaparoscopicSurgeon
StuartHart,MD,FACOG,FACS
AssistantProfessor
DivisionofFemalePelvicMedicineand ReconstructiveSurgery
DepartmentofObstetricsandGynecology
Director,USFCenterfortheAdvancementof MinimallyInvasivePelvicSurgery(CAMPS)
MedicalDirector,TampaBayResearchand InnovationCenter(TBRIC)
USFHealthCenterforAdvancedMedicalLearningandSimulation(CAMLS)
UniversityofSouthFlorida Morsani CollegeofMedicine
 LaparoscopicAnatomy
Asoundknowledgeofanatomyiscrucialfor
performingsafe,efficientandeffectivesurgery
Thegynecologiclaparoscopistmustdevelopa
thoroughunderstandingoftheanatomyofthe:
Anteriorabdominalwall
Structuralanatomyoftheabdomenandpelvis
Retroperitoneallandmarksandunderlying
structures
Endopelvicfascialsupportivestructures
 LaparoscopicAnatomy
Anterior Abdominal Wall
Structurallandmarksoftheanteriorabdominalwall
Umbilicus
Anteriorsuperioriliacspines
Pubicsymphysis
Vesselsoftheanteriorabdominalwall
Inferiorepigastricvessels
Superficialepigastricvessels
Superficialcircumflexiliacvessels
Layersoftheanteriorabdominalwall
Rectusabdominismuscle
Anteriorandposteriorrectussheath
Arcuateline
 AnteriorAbdominalWallVessels
Inferiorepigastricvessels
Originatefromtheexternaliliacvesselsbeforeentry
beneaththeinguinalligament
Coursesmedialtotheroundligament
Travelsunderneaththelateralthirdoftherectus
abdominismuscles
Typicallynotvisualizedbytransillumination
Superficialepigastricvessels
Courseswithinthesubcutaneoustissueoftheanterior
abdominalwall
Maybevisualizedbytransillumination
Followsasimilarcoursetotheinferiorepigastricvessels
Superficialpelvicandperitonealstructures
Anteriorabdominalwall
Medianumbilicalfold
Peritonealcoveringofthemedianumbilicalligament/urachus
Medialumbilicalfolds
Peritonealcoveringoftheobliteratedumbilicalarteries
Allowlaparoscopicsurgeontoidentifyuterinearterybecauseof
originfrominternaliliacartery
Lateralumbilicalfolds
Peritonealcoveringoftheinferiorepigastricvessels
Directherniasoccursmedialtothelateralumbilicalfold
Indirectherniasoriginateslateraltotheumbilicalfold
Hasselbach'sTriangle: Laterally:InferiorEpigastricsarteryandvein
Medially:RectusSheath
Inferiorly:InguinalLigament
Posteriorly:TransversalisFascia
 AnteriorAbdominalWallAnatomy
Urachus
Coursesfromthebladdertotheumbilicusinthemidline
beneaththeanteriorabdominalwallandmedianumbilical
fold
LiesinthespaceofRetzius,betweenthetransversalis
fasciaanteriorlyandtheperitoneumposteriorly
Lumennormallybecomesobliteratedduringembryonic
development,thusbecomingafunctionlessremnant
Patenturachusisrare
AnteriorAbdominalWallAnatomy
 AnteriorAbdominalWallAnatomy
Anatomic Landmark Lateral to Midline

Inferior Superficial Superficial Lateral Margin

Epigastric Epigastic Circumflex of Rectus
Vessel Vessel Iliac Muscle

3 cm above
symphysis 5.6 +/- 1.0 cm 5.5 +/- 2.0 cm 8.5 +/- 1.0 cm

5 cm above
symphysis 5.2 +/- 1.2 cm 5.2 +/- 1.8 cm 9.5 +/- 1.6 cm

16 cm above
symphysis 4.6 cm 4.6 +/- 1.4 cm 10.7 +/- 1.7 cm 7.6 +/- 1.5cm

Hurd WW. Bude RO. DeLancey JO. Newman JS. The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at
laparoscopy. American Journal of Obstetrics & Gynecology. 171(3):642-6, 1994 Sep.
 Ideal Port Placement
A: 5 cm above symphsis / 8 cm from midline
B: 3 cm above symphsis / 4 cm from midline
C: 16 cm above symphsis / 8cm from midline

Hurd WW. Bude RO. DeLancey JO. Newman JS. The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at
laparoscopy. American Journal of Obstetrics & Gynecology. 171(3):642-6, 1994 Sep.
VariationsinAnatomy
 TypesofUmbilicalLigamentinsertioninto
UmbilicalRing

Four types of umbilical ligaments identified in

57 Korean adult cadavers
Chang-Seok,Hyung-Sun,Choon Hyuck, In-Hyuk. Morphologic Variations of the Umbilical Ring, Umbilical Ligaments and
Ligamentum Teres Hepatis. Yonsei Med J 49(6):1004 - 1007, 2008
 TypesofUmbilicalRings

(oval or round) (obliterated or slitted) (covered by connecting band)

Types of umbilical rings identified in 57 Korean adult cadavers
Chang-Seok,Hyung-Sun,Choon Hyuck, In-Hyuk. Morphologic Variations of the Umbilical Ring, Umbilical Ligaments and
Ligamentum Teres Hepatis. Yonsei Med J 49(6):1004 - 1007, 2008
 TypesofUmbilicalRings
enbloccadavericanteriorabdominalwall

(oval or round) (obliterated or slitted) (covered by connecting band)

Types of umbilical rings identified in 57 Korean adult cadavers
Chang-Seok,Hyung-Sun,Choon Hyuck, In-Hyuk. Morphologic Variations of the Umbilical Ring, Umbilical Ligaments and
Ligamentum Teres Hepatis. Yonsei Med J 49(6):1004 - 1007, 2008
 (obliterated or slitted)
(covered by connecting band)

(oval or round)
 AnteriorAbdominalWallAnatomy
Effect of obesity on location of great
vessels

Isaacson Keith., ed. Complications of Gynecologic Endoscopic Surgery. Philadelphia: Saunders, 2006.
UmbilicalPortPlacement
UmbilicalPortPlacement
 Abdominal/PelvicCavity
Anatomy
Landmarks
Sacralpromontory
Uterus
Ovaries
Ureters
Rectosigmoid
Bladder
Ureters
BonyPelvis
Ilium
Ischium
Pubis

Ilium connected to sacrum at

sacroiliac joint

Pelvic inlet
Anteriorly: Pubic symphysis
Pubic tubercle
Laterally: Iliopectineal line
Linea terminalis
Posteriorly: First sacral vertebra
PelvicFloor
Muscles:
Puborectalis
Pubococcygeus
Iliococcygeus
Coccygeus
Piriformis

BonyLandmarks:
Pubicsymphysis
Ischialspine
Coccyx

Ligaments
Sacrospinousligaments
Sacrotuberous
Pelvic support
Uterosacral ligaments
Cardinal ligaments
Rectovaginal fascia
Pubocervial fascia

Endopelvic fascia
Collagen fibers
Elastin
Smooth muscle
UterosacralLigamentAnatomy
Ureter:
Enters pelvic cavity at the
pelvic brim
Courses superficial to the
common iliac artery and
deep to the
infundibulopelvic ligament
Travels in the medial leaf
of the broad ligament

Pelvic vasculature:
Internal iliac
External iliac
Ovarian vessels
Ureter:
Passes lateral to the uterosacral ligament and beneath the uterine artery lateral to
the cervix
Travels in an endopelvic fascia tunnel medially and anteriorly along the upper part
of the vagina, and enters into the bladder wall and then opens into the trigone
 CourseofUreter

Protectingtheureterduringpelvicsurgery
AbnormalCourseofUreter
 Pelvicvasculature
Hypogastricartery
Anteriorbranch
Obturatorartery
Inferiorglutealartery
Umbilicalartery
Uterineartery
Vaginalartery
Superiorvesicalartery
Inferiorvesicalartery
Middlerectalartery
Internalpudendalartery
Obliteratedumbilical

Posteriorbranch
Iliolumbarartery
Lateralsacralarteries
Superiorglutealartery
SidewallAnatomy
RetroperitonealAnatomy
SacralAnatomy
Hypogastricartery
Anteriorbranch
Obturatorartery
Inferiorglutealartery
Umbilicalartery
Uterineartery
Vaginalartery
Inferiorvesicalartery
Middlerectalartery
Internalpudendalartery

Internalpudendalbranches
Inferiorrectalartery
Perinealartery
Posteriorlabialarteries
Dorsalarteryofclitoris
Deeparteryofclitoris
Arteryofbulbofvestibule
 LaparoscopicAnatomy
Asoundknowledgeofanatomyiscrucialfor
performingsafe,efficientandeffectivesurgery
ThisunderstandingwillkeeptheGynecologic
surgeryoperatinginasafemannerandreduce
complications
 References
NetterAtlasofHumanAnatomy
BaggishM,KarramM.AtlasofPelvicAnatomy
andGynecologicSurgery.2nd edition.
Philadelphia:Saunders,2006
IsaacsonK.ComplicationsofGynecologic
EndoscopicSurgery.Philadelphia:Saunders,
2006.