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Reconstructive and Reproductive
Surgery in Gynecology
Second Edition
Volume One: Fundamentals and Conditions

Edited by
Malcolm G. Munro
Victor Gomel
CRC Press
Taylor & Francis Group
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Library of Congress Cataloging‑in‑Publication Data

Names: Munro, Malcolm G., editor. | Gomel, Victor, editor.

Title: Reconstructive and reproductive surgery in gynecology / edited by Malcolm G. Munro and Victor Gomel.
Description: Second edition. | Boca Raton, FL : CRC Press, [2019] | Includes bibliographical references and index.
Identifiers: LCCN 2018015240| ISBN 9781138035010 (pack- hardback and ebook : alk. paper) | ISBN 9781315269801 (ebook)
Subjects: | MESH: Gynecologic Surgical Procedures | Genital Diseases, Female--surgery | Infertility, Female--prevention & control |
Reconstructive Surgical Procedures
Classification: LCC RG104 | NLM WP 660 | DDC 618.1/059--dc23
LC record available at https://lccn.loc.gov/2018015240

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Contents

Editors v
Contributors vii
Introduction xi

Volume One: Fundamentals and Conditions

1 Anatomy and surgical dissection of the female pelvis: For the gynecologic surgeon 1
Andrew I. Brill, Robert M. Rogers, Jr., and Victor Gomel
2 Reproductive physiology for the gynecological surgeon 17
Victor Gomel, Malcolm G. Munro, and Peter F. McComb, with Prof. Hans Frangeinheim
3 Energy-based surgical devices 27
Andrew I. Brill and Malcolm G. Munro
4 Principles of laparoscopic surgery 47
Sukhbir S. Singh, Olga Bougie, and Malcolm G. Munro, with Artan Ternamium
5 Principles of microprocessor-assisted laparoscopic (“robotic”) surgery 73
Erica Dun, Vadim V. Morozov, and Ceana Nezhat
6 Principles of laparotomic and vaginal surgery 85
Victor Gomel and Malcolm G. Munro
7 Principles of hysteroscopic surgery 105
Barry H. Sanders and Malcolm G. Munro
8 Imaging for the gynecologic surgeon 121
Caterina Exacoustos and Margit Dueholm
9 Preservation of fertility in gynecologic surgery: Strategies and techniques 153
Victor Gomel, Mohamed A. Bedaiwy, and Recai Pabuçcu
10 Complications of surgery of the female reproductive tract 159
Nyia Noel, Christina Alicia Salazar, Keith Isaacson, and Malcolm G. Munro, with John Thiel
11 Congenital anomalies of the female reproductive tract 181
Joseph S. Sanfilippo and Kathryn D. Peticca
12 Ectopic pregnancy 195
Victor Gomel and Malcolm G. Munro
13 Endometrial polyps 207
Marit Lieng and Jason A. Abbott
14 Adenomyosis: Uterus-sparing treatment 213
Grigoris F. Grimbizis and Themistoklis Mikos
15 Endometriosis: General principles 227
Sukhbir S. Singh, Catherine Allaire, and David L. Olive
16 Uterine leiomyomas 241
Levent Mutlu, Kimberly W. Keefe, and Hugh S. Taylor
17 Pathogenesis of pelvic floor disorders 255
Geoffrey W. Cundiff
18 Pelvic infections and their sequelae 267
Jorma Paavonen
19 Fallopian tube disorders 275
Victor Gomel
20 Postoperative adhesions 283
Victor Gomel and Philippe R. Koninckx
21 Pathogenesis, pathology, and clinical significance of intrauterine adhesions 297
Miriam M.F. Hanstede, Mark Hans Emanuel, and Jason A. Abbott
22 Malignancy 307
Denis Querleu
23 Chronic pelvic pain 323
Fred M. Howard and Malcolm G. Munro
24 Abnormal uterine bleeding 341
Malcolm G. Munro

iii
iv Contents

25 The adnexal mass 361

Denis Querleu
26 Diagnosis, investigation, and nonsurgical management of pelvic organ prolapse and urinary incontinence 371
Yaël Levy-Zauberman and Hervé Fernandez
27 Infertility: Mechanisms and investigation 381
Victor Gomel
28 Recurrent pregnancy loss: A new strategy for evaluation based on genetic testing 399
William H. Kutteh, Carolyn R. Jaslow, Paul R. Brezina, Raymond W. Ke, Amelia P. Bailey, and Mary D. Stephenson

Index 407

Volume Two: Gynecological Surgery

29 Surgery for congenital anomalies: Hysteroscopic, laparoscopic, laparotomic, and vaginal 433
Joseph S. Sanfilippo, Kathryn D. Peticca, and Fabiola Balmir
30 Surgery for vulvar disorders 443
Howard T. Sharp
31 Endometrial sampling and uterine curettage 451
Yaël Levy-Zauberman, Perrine Capmas, and Hervé Fernandez
32 Management of endometrial polyps 457
Jason A. Abbott and Marit Lieng
33 Endometrial ablation 461
Malcolm G. Munro
34 Surgery for intrauterine adhesions 473
Mark Hans Emanuel and Miriam M.F. Hanstede
35 Leiomyomas I: Hysteroscopic and other transvaginal approaches 481
Barry H. Sanders and Malcolm G. Munro
36 Leiomyomas II: Abdominal approaches 493
William H. Parker, Tommaso Falcone, and Malcolm G. Munro
37 Leiomyomas III: Image-guided surgery and procedures 507
Scott Chudnoff, Sukrant Mehta, and Eleanor Hawkins
38 Hysterectomy 521
Jon Ivar Einarsson and Mobolaji O. Ajao
39 Reconstructive surgery of the fallopian tube 533
Victor Gomel
40 Ectopic pregnancy: Surgical management 557
Victor Gomel
41 Ovarian surgery 567
Victor Gomel and Mohamed A. Bedaiwy
42 Endometriosis I: Surgery for endometriosis associated with pain 579
Nicola Berlanda and Paolo P. Vercellini
43 Endometriosis II: Surgical treatment of endometriosis associated with infertility 591
David L. Olive and Mauro Busaca
44 Endometriosis III: Deep infiltrating endometriosis 597
Sukhbir S. Singh and Sugandha Agarwal
45 Procedures specific for chronic pelvic pain 613
Fred M. Howard
46 Surgical treatment of urinary incontinence 619
Yaël Levy-Zauberman, Xavier Deffieux, and Hervé Fernandez
47 Management of pelvic organ prolapse 629
Geoffrey W. Cundiff
48 Surgery during intrauterine pregnancy 645
Michel Canis, Nicolas Bourdel, Céline Houlle, Benoit Rabischong, Revaz Botchorishvili, and Jean L. Pouly
49 Preservation of fertility in malignancy 653
Denis Querleu, Sophie Deutsch-Bringer, and Alejandra Martínez
50 Oocyte and embryo cryopreservation for fertility preservation 665
Ana Cobo and José Remohi

Index 671
Editors
Malcolm G. Munro, MD, is a clinical professor at the
Department of Obstetrics and Gynecology, David
Geffen School of Medicine at UCLA, and the director
of Gynecologic Services, Department of Obstetrics and
Gynecology, Kaiser Permanente, Los Angeles, California,
USA. He was a cofounder of the FIGO Menstrual Disorders
Committee, which has been responsible for the develop-
ment and publication of the FIGO Nomenclature and
Classification Systems for causes of abnormal bleeding
in reproductive years, created to facilitate the design and
interpretation of related clinical trials. He has published
more than 100 papers, 30 chapters, and 4 books. He is an
editor, on the editorial board, or a reviewer for numer-
ous peer-reviewed specialty journals. He has served the
American Association of Gynecologic Laparoscopists
(AAGL) as a member of the Board of Trustees (2000–
2002) and was the inaugural chair of the AAGL Practice
Committee, in charge with the development of evidence-
based practice guidelines related to minimally invasive
approaches to gynecology.
Victor Gomel, MD, is a professor and former head of the
Department of Obstetrics and Gynecology, in the Faculty
of Medicine, University of British Columbia, Vancouver,
Canada. He has served as the president of several societ-
ies, including the Society of Reproductive Surgeons, the
American Association of Gynecologic Laparoscopists,
the Canadian Fertility and Andrology Society, and the
International Society of In Vitro Fertilization. He is inter-
nationally recognized for pioneering work in reproductive
microsurgery and operative laparoscopy. With his team,
he obtained the first IVF baby in Canada. He has received
many prestigious awards including the honorary degree of
Doctor of Science from the Simon Fraser University and
the Salat-Baroux prize in reproduction from the French
National Academy of Medicine, to which he was elected
as a foreign member. He was elected as a fellow to the
Academy of Art and Sciences and was awarded the Légion
d’Honneur by the president of France.
v
http://taylorandfrancis.com
Contributors

Jason A. Abbott MD PhD Revaz Botchorishvili MD

Professor, Gynaecological Surgery Department of Gynecologic Surgery
University of New South Wales University of Clermont-Auvergne
Royal Hospital for Women CHU Estaing
Sydney, Australia Clermont-Ferrand, France

Sugandha Agarwal MBBS MS Olga Bougie MD MPH

Senior Research Officer, Department of Obstetrics and Assistant Professor, Department of Obstetrics and
Gynecology Gynaecology
Vardhman Mahavir Medical College Queen’s University
Safdarjung Hospital Kingston, Canada
New Delhi, India
Nicolas Bourdel MD PhD
Mobolaji O. Ajao MD MPH Department of Gynecologic Surgery
Instructor, Department of Obstetrics, Gynecology and University of Clermont-Auvergne
Reproductive Biology CHU Estaing
Division of Minimally Invasive Gynecologic Surgery Clermont-Ferrand, France
Harvard Medical School
Brigham and Women’s Hospital Mauro Busaca MD
Boston, Massachusetts Professor, Department of Gynecology and Obstetrics
University of Milan
Catherine Allaire MD Milan, Italy
Clinical Professor, Department of Obstetrics and Gynecology
Division of Gynaecologic Specialties Paul R. Brezina MD MBA
University of British Columbia Clinical Assistant Professor, Department of Obstetrics and
Vancouver, Canada Gynecology
Vanderbilt University
Amelia P. Bailey MD Memphis, Tennessee
Clinical Assistant Professor, Department of Obstetrics and
Gynecology Andrew I. Brill MD
Vanderbilt University Medical School Director, Minimally Invasive Gynecology
Memphis, Tennessee California Pacific Medical Center
San Francisco, California
Fabiola Balmir MD
Fellow, Department of Obstetrics and Gynecology Michel Canis MD
Division of Reproductive Endocrinology and Infertility Professor, Department of Gynecologic Surgery
University of Pittsburgh University of Clermont-Auvergne
Pittsburgh, Pennsylvania CHU Estaing
Clermont-Ferrand, France
Mohamed A. Bedaiwy MD PhD
Professor and head, Department of Obstetrics and Perrine Capmas MD PhD
Gynecology Department of Gynecology and Obstetrics
Division of Reproductive Endocrinology and Infertility Service de Gynécologie-Obstétrique
University of British Columbia University of Paris-Sud
Vancouver, Canada Hôpital Bicêtre
Paris, France
Nicola Berlanda MD
Adjunct Professor, Department of Gynecology and Obstetrics
Gynecologic Surgery Unit
University of Milan
Milan, Italy

vii
viii Contributors

Scott Chudnoff MD MSc Caterina Exacoustos MD

Clinical Professor, Department of Obstetrics and Gynecology Associated Professor, Department of Biomedicine and
Columbia University Irving College of Physicians and Prevention
Surgeons University of Rome “Tor Vergata”
Stamford Health Rome, Italy
Stamford, Connecticut
Tommaso Falcone MD
Ana Cobo PhD Professor, Department of Surgery
Director of Cryopreservation Unit Cleveland Clinic Lerner College of Medicine
IVI, Valencia Case Western Reserve University
Valencia, Spain Medical Director
Cleveland Clinic London
Geoffrey W. Cundiff MD London, England
Professor and Head, Department of Obstetrics and
Gynecology Hervé Fernandez MD PhD
University of British Columbia Professor and Head, Department of Gynecology and Obstetrics
Vancouver, Canada University of Paris-Sud
Hôpital Bicêtre
Xavier Deffieux MD PhD Paris, France
Department of Gynecology and Obstetrics
Service de Gynécologie-Obstétrique Victor Gomel MD
University of Paris-Sud Professor Emeritus, Former Head, Department of Obstetrics
Antoine Béclère Hospital and Gynecology
Paris, France Faculty of Medicine
University of British Columbia
Sophie Deutsch-Bringer MD Vancouver, Canada
Department of Obstetrics and Gynecology
University Hospital Grigoris F. Grimbizis MD PhD
Montpellier, France Associate Professor, 1st Department of Obstetrics and
Gynecology
Margit Dueholm MD PhD Medical School
Associate Professor, Department of Obstetrics and Aristotle University of Thessaloniki
Gynecology “Papageorgiou” General Hospital
Aarhus University Thessaloniki, Greece
Aarhus, Denmark
Miriam M.F. Hanstede MD
Erica Dun MD MPH Consultant, Department of Obstetrics and Gynecology
Assistant Professor, Department of Obstetrics, Gynecology Spaarne Gasthuis Hoofddorp/Haarlem
and Reproductive Sciences Amsterdam, The Netherlands
Yale School of Medicine
New Haven, Connecticut Eleanor Hawkins MD
The Women’s Health Center
Jon Ivar Einarsson MD MPH PhD Fountain Valley, California
Professor, Department of Obstetrics, Gynecology and
Reproductive Biology Céline Houlle MD
Harvard Medical School Department of Gynecologic Surgery
Division of Minimally Invasive Gynecologic Surgery University of Clermont-Auvergne
Brigham and Women’s Hospital CHU Estaing
Boston, Massachusetts Clermont-Ferrand, France

Mark Hans Emanuel MD PhD Fred M. Howard MS MD

Visiting Professor, Department of Gynaecology Former Professor Emeritus, Department of Obstetrics and
University of Utrecht Gynecology
Senior Consultant University of Rochester School of Medicine and Dentistry
University Medical Center Rochester, New York
Utrecht, The Netherlands
 Contributors ix

Keith Isaacson MD Peter F. McComb MB BS

Associated Professor, Department of Obstetrics and Gynecology Professor Emeritus, Department of Obstetrics and Gynecology
Harvard Medical School Faculty of Medicine
Minimally Invasive Surgery University of British Columbia
Newton Wellesley Hospital Vancouver, Canada
Newton, Massachusetts
Sukrant Mehta MD
Carolyn R. Jaslow PhD Assistant Clinical Professor, Department of Obstetrics and
Associate Professor, Department of Biology Gynecology
Rhodes College David Geffen School of Medicine at UCLA
Memphis, Tennessee University of California, Los Angeles
Los Angeles, California
Raymond W. Ke MD
Clinical Professor, Department of Obstetrics and Gynecology Themistoklis Mikos MD PhD
Vanderbilt University Lecturer, 1st Department of Obstetrics and Gynecology
Memphis, Tennessee Medical School
Aristotle University of Thessaloniki
Kimberly W. Keefe MD “Papageorgiou” General Hospital
Clinical Professor, Department of Obstetrics, Gynecology and Thessaloniki, Greece
Reproductive Sciences
Yale School of Medicine Vadim V. Morozov MD
New Haven, Connecticut Associate Professor, Department of Obstetrics and
Gynecology
Philippe R. Koninckx MD PhD Georgetown University
Professor Emeritus, Department of Obstetrics and Gynecology Minimally Invasive Gynecology
Catholic University Leuven MedStar Washington Medical Center
University Hospital, Gasthuisberg Washington DC
Leuven, Belgium
Malcolm G. Munro MD
William H. Kutteh MD PhD Clinical Professor, Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA
Clinical Professor of Obstetrics and Gynecology, Vanderbilt University of California, Los Angeles
University Medical Center Kaiser Permanente Los Angeles Medical Center
Director of Recurrent Pregnancy Loss Center, Fertility Los Angeles, California
Associates of Memphis
Memphis, Tennessee Levent Mutlu MD
Clinical Professor, Department of Obstetrics, Gynecology and
Yaël Levy-Zauberman MD Reproductive Sciences
Department of Gynecology and Obstetrics Yale School of Medicine
University of Paris-Sud New Haven, Connecticut
Hôpital Bicêtre
Paris, France Ceana Nezhat MD
Adjunct Professor, Department of Gynecology and Obstetrics
Marit Lieng MD PhD Emory University School of Medicine
Associate Professor, Department of Obstetrics and Northside Hospital
Gynecology Atlanta, Georgia
University of Oslo
Oslo University Hospital Nyia Noel MD MPH
Oslo, Norway Assistant Professor, Department of Obstetrics and Gynecology
Minimally Invasive Gynecology
Alejandra Martinez MD Boston University School of Medicine
Department of Surgery Boston, Massachusetts
Institut Claudius Regaud
Institut Universitaire du Cancer de Toulouse
Toulouse, France
x Contributors

David L. Olive MD Christina Alicia Salazar MD MSc

Wisconsin Fertility Institute Assistant Professor, Department of Obstetrics and Gynecology
Middleton, Wisconsin Dell Medical School
University of Texas, Austin
Jorma Paavonen MD Austin, Texas,
Professor Emeritus, Department of Obstetrics and Gynecology
Helsinki University Barry H. Sanders MD
Helsinki University Hospital Clinical Professor, Department of Obstetrics and Gynecology
Helsinki, Finland Faculty of Medicine
University of British Columbia
Recai Pabuçcu MD Vancouver, Canada
Professor, Department of Obstetrics and Gynecology
Ufuk University School of Medicine Joseph S. Sanfilippo MD MBA
Ankara, Turkey Professor, Department of Obstetrics, Gynecology and
Reproductive Sciences
William H. Parker MD Division of Reproductive Endocrinology and Infertility
Clinical Professor, Department of Obstetrics, Gynecology and University of Pittsburgh
Reproductive Sciences Pittsburgh, Pennsylvania
University of California, San Diego School of Medicine
La Jolla, California Howard T. Sharp MD
Professor, Department of Obstetrics and Gynecology
Kathryn D. Peticca MD University of Utah
Graduate Medical Resident, Department of Obstetrics, University of Utah Health Sciences Center
Gynecology and Reproductive Sciences Salt Lake City, Utah
University of Pittsburgh
Pittsburgh, Pennsylvania Sukhbir S. Singh MD
Associate Professor, Department of Obstetrics and
Jean L. Pouly MD Gynecology
Department of Gynecologic Surgery University of Ottawa
University of Clermont-Auvergne The Ottawa Hospital Research Institute
CHU Estaing Ottawa, Canada
Clermont-Ferrand, France
Mary D. Stephenson MD MSc
Denis Querleu MD Professor and Head, Department of Obstetrics and
Honorary Professor of Oncology Gynecology
University of Toulouse Recurrent Pregnancy Loss Program
Toulouse, France University of Illinois
Institut Bergonié Cancer Center Chicago, Illinois
Bordeaux, France
Hugh S. Taylor MD
Benoit Rabischong MD Professor and Chair, Department of Obstetrics, Gynecology
Department of Gynecologic Surgery and Reproductive Sciences
University of Clermont-Auvergne Yale School of Medicine
CHU Estaing Yale-New Haven Hospital
Clermont-Ferrand, France New Haven, Connecticut

José Remohí MD PhD Paolo P. Vercellini MD

Professor of Obstetrics and Gynaecology Professor of Gynecology and Obstetrics
School of Medicine University of Milan
University of Valencia Department of Clinical Sciences and Community Health
IVI Fertility Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico
Valencia, Spain Milan, Italy

Robert M. Rogers, Jr. MD

Northwest Women’s Healthcare
Kalispell Regional Medical Center
Kalispell, Montana
Introduction
Performed for other than trauma, congenital defects and
cosmetics, “surgery” represents the failure of medicine;
failure of elucidating the etiology of the disease and devel-
oping specific and effective preventive and therapeutic
measures.
Victor Gomel
A CHANGING DEMOGRAPHIC
During the last four decades, we have witnessed rapid and
significant innovations in various scientific and techno-
logical fields that have changed the practice of medicine
including our own specialty. In parallel fashion, there
have been important demographic and social changes that
affect both the world in which we live and the nature of
our medical practice.
In the short span of 30 years from 1987 to 2017, the
world population has increased from 5 billion to over
7 billion, a growth rate that shows no signs of relenting
and a circumstance that challenges both the resources and
the environmental conditions of our planet and its inhab-
itants. This population growth occurred despite the simul-
taneous decline in the birth rate of industrialized nations.
Together with the continuous prolongation of mean life
expectancy, this reduced population growth is signifi-
cantly increasing both the absolute and relative numbers
of elderly individuals in the developed world, a dramatic
change with important social, economic, and political
consequences.
The environmental “new normal” will be characterized
by a population of women who will live increasingly lon-
ger, prolong their stay in the workforce, and likely continue
to delay childbearing to the later reproductive years, and
even beyond. These trends, in themselves, have important
repercussions for medical practice in general, and our
specialty in particular. Women will require medical care
during a much longer postmenopausal life span. They
will increasingly seek anti-aging treatment, more often
undergo cosmetic surgery, and more frequently require
reconstructive procedures for various conditions such as
stress incontinence and genital prolapse. Indeed, there are
already many gynecologists who include cosmetic surgery
as part of their practice.
Women who enter and stay in workforce typically delay
childbearing—a circumstance that contributes to trends
evident today. The total fertility rate (estimated number
of births over a woman’s lifetime) in the United States is
about 1.84 births per 1,000 women, which is below the rate
of 2.1 births per 1,000 women necessary for a generation to
exactly replace itself. The average age of the proportion of
U.S. women who had their first child when they were over
30 years of age increased from 5% in 1975 to 22% in 1995,
reaching 30.3% by 2015.1
Delay in childbearing will increase demand for assisted
reproductive technology (ART) services. Already, over 60%
of those using ART are 35 years of age and older. ART ser-
vices have become industrialized; the number of reporting
clinics in the United States has increased from 267 in 1995
to 464 in 2015. Similarly, the number of annual cycles per-
formed has increased from 34,000 in 1995 to 134,260 in 2005
to 231,936 in 2015,2,3 an increasing trend that will likely con-
tinue, as will the attendant-associated costs. The demand has
already resulted in an annual economic burden of about $2.5
billion in the United States and more than €5 billion euros
in the European Union, where more than 500,000 cycles are
performed annually. There will also be an increasing desire
for techniques designed to preserve fertility; embryo, oocyte,
ovarian tissue, and stem cell banking is already in use. These
techniques, and others, will undoubtedly be improved and
expanded to respond to the increasing demand.
EVOLVING TRENDS IN GYNECOLOGY
Gynecologic practice, like medicine as a whole, continues
to evolve. The gynecological surgeon of the twenty-first
century is typically different from many of those of other
surgical specialties. Unlike most specialists, gynecologists
must function as both the “internist” and the “surgeon”
for women with reproductive disorders. Consequently, it
is important that a sound understanding of physiology,
anatomy, and the pathogenesis of diseases and disorders
be combined with the expanding set of requisite skills at
clinical assessment necessary to formulate a complete set
of management options for consideration by the patient.
Knowledge of the role for expectant management and the
entire spectrum of appropriate medical, procedural, and
surgical interventions is important.
The technical aspects of gynecological practice have dra-
matically changed as a result of progress in many scientific
fields: physics, immunology, biochemistry, DNA technol-
ogy, microprocessor technology, mechanical engineering,
medical imaging, cell and molecular biology, and others.
Especially important to contemporary gynecological
practice is progress in imaging technologies, including
ultrasonography, computed tomography (CT), positron
emission tomography (PET) scanning, and magnetic reso-
nance imaging (MRI) that have collectively reduced the
need for surgery-based diagnosis. In addition, interventions
directed by imaging (“interventional radiology”) include
targeted biopsy and treatment of lesions such as adenomyo-
sis or leiomyomas by vascular embolization, radiofrequency
and cryogenic probes, and trackless ablation with focused
ultrasound have collectively provided options to traditional
surgery that have the potential to reduce treatment related
morbidity.4,5 Uterine artery embolization has proven to be
a good alternative to surgery in selected instances of acute
hemorrhage and symptomatic uterine leiomyomas.4
xi
xii Introduction
Scientific developments and technical inventions are
permitting treatment of many conditions medically,
avoiding procedures including traditional surgery alto-
gether. Already, innovations, such as progesterone recep-
tor modulators for leiomyomas, various progestins and
GnRH agonists and antagonists for endometriosis, and
intrauterine progestin releasing systems for a number
of causes of abnormal uterine bleeding, are contribut-
ing to the decline in hysterectomy rates. Early diagnosis
of ectopic pregnancy, combined with the use of systemic
methotrexate, has resulted in a dramatic reduction in
the surgical management of this condition. Ultrasound
imaging allows the identification of adnexal cysts that
are known to be benign, therefore obviating the need for
surgical removal for diagnosis. Recognition of the role of
the human papilloma virus in the pathogenesis of cervical
neoplasia, including cervical cancer, has allowed for the
development of vaccines designed to prevent this ubiqui-
tous disorder.6,7
The face of gynecology has been dramatically changed
by the gender of applicants to obstetrics and gynecology
training programs in the developed world, the major-
ity now being women. Once in practice, they tend to be
much more rational in their working habits and work
fewer hours per week than their male counterparts, and
they appear to retire earlier.8–10 These changes may have
significant impact on the availability of obstetrical and
gynecological specialists.
TECHNOLOGY AND THE GYNECOLOGIC SURGEON
The transition of gynecological surgical practice, from one
largely based on laparotomy to an approach largely based
on hysteroscopic and laparoscopically directed proce-
dures, has been both dramatic and uneven. It is apparent
that specialty training programs are inconsistent, and, as a
result, not all women are able to access the entire spectrum
of options. Furthermore, the development of laparoscopic
technique has eroded training in vaginal surgery, the
original minimally invasive technique for hysterectomy in
particular.
Technical innovations had a very important role in each
of the steps of the development of endoscopy, including
the initiation and acceptance of operative procedures, and
in making it possible for more complex operations to be
performed with greater efficiency and safety. These techni-
cal developments included more sophisticated insufflators,
endoscopes with improved optics, refined energy-based
surgical instruments, and the development of television
imaging systems adapted for medical use.
Perhaps the most important technological advance
facilitating the widespread use of endoscopic surgery was
the charge-coupled device (CCD), the chip that revolution-
ized imaging by allowing television cameras to be reduced
to fingernail dimensions, and for which the inventors, W S
Boyle and G E Smith, received the 2009 Nobel prize in
physics.11 When attached to an endoscope, these miniatur-
ized cameras, coupled with television monitors, quickly
became an integral part of surgical imaging systems that
have quickly evolved to provide high definition or higher
resolution of the surgical field.
The ability to operate by viewing the operative field on
TV monitors enabled the surgeon, surgical assistant, and
operating room personnel to work as an efficient team.
These innovations, introduced in the early 1980s, permitted
the rapid evolution of minimal access surgery. Indeed, even
the most complex gynecological procedures are now being
routinely and successfully performed by laparoscopy.
While hysteroscopic procedures have been documented
in the medical literature since 1869,12 worldwide adop-
tion has been uneven, despite the obvious advantages of
incision-less surgery. Until the 1970s, hysteroscopy was
portrayed by many as “a technique looking for an indi-
cation” and was typically confined to a diagnostic role,
practiced by only a relative handful of surgeons. However,
in the last part of the twentieth century, innovation took
hold and the hysteroscope and its cousin, the uterine
resectoscope, became instruments of radical change in the
surgical approach to intrauterine pathology. Many pro-
cedures that previously required a laparotomy and a hys-
terotomy to access the uterine cavity could be performed
absent any abdominal incision (e.g., lysis of severe uter-
ine synechiae, metroplasty for septate uterus, and exci-
sion of symptomatic intrauterine fibroids).13–15 Not only
was there an improved cosmetic result, with low morbid-
ity and reduced cost, but also most procedures became
amenable to performance in an office environment under
local anesthesia.16–18 The evolution of imaging procedures,
such as three-dimensional vaginal ultrasound and MRI,
has allowed the hysteroscopic surgeon to forego diagnos-
tic laparoscopy to evaluate Müllerian anomalies, while
intraoperative transvaginal ultrasound allows for the safe
performance of difficult dissections of intrauterine adhe-
sions and leiomyomas that involve the myometrium.19
Intrauterine surgery has evolved even further with the
development of endometrial ablation devices for the
treatment of selected causes of chronic abnormal uterine
bleeding,20 and intrauterine ultrasound directed radiofre-
quency electrosurgical ablation for deep FIGO Type 2 and
Type 3 leiomyomas.21
THE MEDICAL DEVICE INDUSTRY: FRIEND OR FOE?
The rapid technological development of endoscopic and
image-guided surgery has required the investment and
innovation possible only with the support and leadership
of the medical device industry. Indeed, identification of
clinical requirements and design concepts as well as the
need for the performance of clinical trials to evaluate effi-
cacy and safety requires that industry and gynecologi-
cal surgeons work together to bring effective products to
market. Once new surgical devices become available, it
is necessary to train clinicians and support staff in their
appropriate, safe, and effective use in patients. This pro-
cess frequently requires the presence of company repre-
sentatives in the clinical environment. While absolutely
necessary, this partnership between the medical and
industrial communities is a source of controversy, as there

exist opportunities for corporate influence over medical
decision-making.22–24
Indeed, regulatory agencies in the United States and
elsewhere now require public disclosures of the nature and
extent of relationships of clinicians and hospitals with the
industry. While this transparency is generally considered
to be appropriate and healthy, unintended consequences
include a reluctance of institutions, including universi-
ties and hospitals, to have their names, or those of their
faculty, appear on these public disclosures. Consequently,
these measures can threaten the integrity of the crucible
of creative cooperation that exists between the industry
and the medical profession in a way that is detrimental to
both patients and society at large. Moving forward, it will
be important to establish a climate of transparency that
does not undermine the innovation necessary to advance
medical care.
It is also important for the medical profession to use evi-
dence to counter the notion, where appropriate, that new
drugs or devices necessarily result in better outcomes for
patients. Care must be taken to ensure that new drugs with
higher cost do not replace established agents that are less
expensive yet highly efficacious. And it is important that
costly, single-use devices are not used when reusable and
less expensive systems provide the same outcome quality.
The same applies to capital equipment, particularly
exemplified by the Da Vinci® system, a complex and
expensive device designed to assist the performance of
laparoscopic surgery. It may facilitate the provision of
laparoscopic instead of laparotomic procedures by less
trained individuals, and it allows the surgeon to carry out
the procedure remote from the surgical field without even
scrubbing—quite an accomplishment. However, available
evidence suggests that the use of such equipment, at least
in its current manifestation, only adds to the cost of lapa-
roscopic procedures without improving any measurable
clinical outcome. A previously published large U.S. study
demonstrated that da Vinci–assisted laparoscopic sur-
gery added $2,189 (95% CI $2,030 to $2,349) to the cost of
each case,25 perhaps reduced to $1,617 if only benign cases
were included,26 and a Finnish-based systematic review
and meta-analysis showed that da Vinci–assisted laparo-
scopic hysterectomy increased costs by 1.5 to 3 times with-
out improvement in any measurable clinical outcome.27
Avoidance of being captured by such technology will be a
continuing goal that is made more difficult by the need to
simultaneously foster its development. For example, when
microprocessor-based systems like da Vinci can create
“virtual ports” through a single and small umbilical inci-
sion and deliver the surgical result with some combination
of reduced risk, maintained efficacy, and lower cost, the
technology will have provided us with true value.
GYNECOLOGICAL SURGICAL TRAINING
IN THE TWENTY-FIRST CENTURY
While these advances contribute to an overall reduction
in the number of gynecologic surgical procedures per
population, the complexity of those surgical procedures
Introduction xiii
that are performed is increasing.28 Indeed, there is already
evidence that complication rates associated with hysterec-
tomy are on the rise.29,30
This shrinking overall pool of surgical interventions,
combined with the increasing variety of procedures, chal-
lenges gynecologic surgeons to acquire a wider spectrum
of competencies. Consequently, there is a greater, not
lesser, need for surgeons with optimal training and skill
and the ability to perform safe, effective, and minimally
invasive gynecological procedures by the most appropriate
route, be it hysteroscopic, vaginal, laparoscopic, or via lap-
arotomy. This situation confronts contemporary gyneco-
logical surgical educators with a related challenge: finding
ways to foster the development of competency despite this
diluted procedural environment. The problem is ampli-
fied as the training period for specialization has been sig-
nificantly shortened by reducing the working hours of the
trainees, the residents, or the registrars, including the fre-
quency of nights and weekends “on call.”
One suggested solution to the issues described above
has been the use of surgical simulation, where psychomo-
tor skills are learned and honed in an inanimate environ-
ment.31 Inherent in the concept of surgical simulation is
the notion that training for many surgical skills and tech-
niques can be more effectively and safely accomplished
without incurring the costs associated with inefficiency
and avoidable complications. Surgical efficiency is increas-
ingly under scrutiny, as the cost of surgical time is rising
disproportionate to inflation. Operating room charges or
costs are estimated by the minute and, in the United States
at least, can exceed $100 for 60 seconds of surgery. Safety
is a major issue as well. Indeed, the Institute of Medicine
(IOM) has charged the healthcare industry to include sim-
ulation in surgical training and credentialing as a critical
component of an overall strategy to reduce surgical risks.32
Duration of specialty training is another approach
that could result in surgeons who are better prepared to
provide the spectrum of minimally invasive approaches.
While training programs in the United States are only
4 years long, those in other developed countries are fre-
quently 5 to 7 years in duration, or, in some, even based on
competency, with no established program duration. Even
in these environments there is frequently an inadequate
case load for surgical training, as the specialty includes
training in obstetrics and, at least in the United States, pri-
mary care—a circumstance that further dilutes exposure
to surgical interventions.
Case dilution, a particular problem in the United States,
is further enhanced with the increasing numbers of sub-
specialty trainees competing for the limited hospital and
patient resources. These formally defined subspecialty
training programs began in the second half of the last cen-
tury with official recognition of maternal fetal medicine,
gynecologic oncology, and reproductive endocrinology and
infertility as official subspecialties. More recently, urogyne-
cology, in the United States called “female pelvic medicine
and reconstructive surgery,” has been accepted into the fold.
But these subspecialties do not encompass the large group
xiv Introduction
of surgical procedures for benign disease that involve the
uterus and adnexa, and the increasing trend of reproductive
endocrinologists to eschew infertility surgery can add to the
case mix for the gynecologic surgeon.
Perhaps the most logical approach to improving the
training of gynecologic surgeons would be the addition
of a new subspecialty: post-residency training programs
in minimally invasive gynecologic surgery. Proliferating
in a number of countries, including Australia, Canada,
the United States, and others, these fellowships remain
inconsistent, with variable training in the spectrum of
minimally invasive approaches including vaginal, hystero-
scopic, laparoscopic, and image-guided procedures. Many
such programs tend to favor one approach over another,
and the production of surgeons with the expert ability to
offer all of the approaches remains limited. Obviously, for
such programs to produce a consistent surgeon “product,”
it will be necessary to apply rigid standards on the spec-
trum of cases required for certification.
The addition of sub-specialization to the “core” resi-
dency training programs in obstetrics and gynecology
clearly prolongs the duration of training. Some have sug-
gested that a solution to this problem would be the sepa-
ration of obstetrics and gynecology, a process that, to an
extent, is already occurring as those who specialize in
maternal fetal medicine rarely, if ever, practice gynecology.
We contend that whatever the “core” training, the gyne-
cologist offering care to women who have gynecological
disorders that may require medical, procedural, or com-
bination therapy should possess the spectrum of diagnos-
tic and therapeutic skills to provide the most appropriate
options in a safe and effective fashion. Being “comfortable
with” only some approaches means that the individual
may be uncomfortable with or unable to provide the type
of care most appropriate for a given patient. If access is
limited or if the surgeon recognizes that he or she is unable
to provide some of the options, the patient should be so
counseled, and, if necessary, attempts should be made to
access that needed resources elsewhere.
AND SO, THIS BOOK
This extensively revised and rewritten textbook is designed
to educate current and future gynecologic surgeons on the
pathogenesis, investigation, and medical and procedural
management of disorders affecting the female reproduc-
tive tract. Whereas the focus is on reconstructive vagi-
nal, hysteroscopic, laparoscopic, and laparotomic surgery
designed to preserve or enhance fertility, others such as
hysterectomy and endometrial ablation are included.
Section I, “Fundamentals,” includes chapters designed
to foster a sound understanding of pelvic anatomy, repro-
ductive physiology, pelvic imaging, and core components
of the various surgical approaches as well as the preven-
tion and management of related adverse events. Section II,
“Gynecologic Disorders,” covers the pathogenesis, inves-
tigation, and medical management of the disorders likely
encountered that have a potential surgical solution. It is
designed to ensure that the role of procedures or surgery
is placed in proper perspective. The pathway from a symp-
tom or a finding to the appropriate management options
is critically important and is the focus of chapters that
comprise Section III. Section IV presents the spectrum of
surgical procedures using text, graphics, and video clips
designed to demonstrate examples of surgical technique.
Each chapter is introduced with “Key Points.” Referencing
is extensive but confined to the electronic version of the
text.
We hope that these multimedia volumes, approach-
ing gynecological disorders from multiple perspectives
(pathogenesis, presenting symptoms or findings, and
medical and procedural management), will be useful tools
and aid the education of contemporary surgeons of the
female reproductive tract. However, it should be remem-
bered that since science is not static, the gynecological
surgeon should continuously and critically scrutinize the
newly revealed evidence, with the goal of providing the
best options for care delivered in the safest and most effec-
tive fashion possible.
Change alone is eternal, perpetual, immortal.
Arthur Schopenhauer
1788–1860
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http://taylorandfrancis.com
Anatomy and surgical dissection
of the female pelvis
1
For the gynecologic surgeon
ANDREW I. BRILL, ROBERT M. ROGERS, JR., and VICTOR GOMEL

Key points
•• Surgical outcome is closely linked to techniques of tissue dissection coupled with a working knowledge of surgical anatomy.
•• The dynamics of surgical teamwork are inseparably related to the technical and cognitive aspects of pelvic surgery.
•• Providing surgical dissection in spaces without visceral or vascular structures, the pelvic sidewall structures are found in three
layers that are separated by two avascular dissection planes.
•• Given that the pelvic brim is usually spared from chronic inflammatory conditions of the pelvis such as endometriosis, it is
typically the best anatomical area to begin a retroperitoneal sidewall dissection.
•• When the pelvic brim is anatomically obliterated, the round ligament can be used to reach the uterine artery by following the
obliterated umbilical artery to the base of the internal iliac artery where the uterine artery is the medial branch.
•• The ureter is only 2 to 3 cm superior and medial to the ischial spine where it passes just posterior to the uterine artery and
then continues across the pubocervical fascia to enter the bladder at the junction of the middle and upper third of the vagina.
•• The anatomical support of the uterus is provided by the pubocervical fascia anteriorly, cardinal and uterosacral ligaments
posteriorly and apically.
•• The sensory and sympathetic nerve supply of the female pelvic organs are found in the inferior hypogastric nerve, whereas
the parasympathetics emanate from the pelvic splanchnic nerves from the S2 to S4 roots of the sacral plexus.

INTRODUCTION
Apart from anatomy relevant to surgical dissection in spe-
cific areas of the female pelvis, the bridge between knowl-
edge of pelvic anatomy and efficient surgical practice
requires mastery of several techniques of surgical dissec-
tion. This chapter describes three fundamental areas that
are essential to the successful surgeon: key techniques of
tissue dissection, the dynamics of surgical teamwork, and a
working knowledge of surgical anatomy. Proper tissue dis-
section frequently requires restitution to normal anatomy by
lysis of adhesions and by systematic exploration within vari-
ous areas of the pelvic retroperitoneum. As collaboration is
essential to optimally perform successful surgery, teamwork
relies on leadership skills to coordinate the roles of all team
members to achieve a “synergy of purpose.” In addition to
key visceral and structural pelvic anatomy, the pre-sacral
space, the pelvic brim, the pelvic sidewall, the base of the
broad ligament/cardinal ligament, the paravesical space,
the retropubic space, the vesicovaginal space, the pararectal
space, and the rectovaginal space will be reviewed.
SURGICAL DISSECTION: THEORY AND DISCUSSION
OF TECHNIQUES
The purpose of deliberate surgical dissection is to do no harm
to the patient, while safeguarding vital anatomic structures
and blood vessels. The goal is to perform the dissection in
order to avoid injuring the viscera, ureter, and somatic nerves
and to limit blood loss. Most surgeons read, study, and strive
to master knowledge of surgical anatomy. However, they
assume that skilled dissection techniques will soon follow.
Not so! Tissue dissection techniques must be learned, under-
stood, and practiced as rigorously and consistently as any sur-
gical skill, such as laparoscopic suturing or use of new surgical
instrumentation. Correct knowledge and focused practice
gradually result in safe and efficient dissection techniques.
Importantly, the surgeon must acknowledge that he/she can-
not operate alone and must have assistants to aid her/him in
the surgical procedure. The surgeon is only one part of a sur-
gical TEAM that can accomplish any surgery when working
in an environment of experience and mutual respect.
The purpose of surgical dissection is to thin out adhe-
sions, scar tissue, and/or visceral connective tissues in
order to visualize the anatomic structures contained
nearby or therein. In the pelvic cavity itself, adhesions
can be fine and filmy, to denser and shorter, and then to
very thick, nodular, and hard. Some cases require minor
surgical lysis. In other more challenging cases, the denser
and harder scarring can result in the dangers of surgi-
cal dissections in a “frozen pelvis.” Adhesions can and
do adhere from the female organs to the bladder perito-
neum, to the serosa of the colon and intestines, and to the
parietal peritoneum of the cul-de-sac and sidewall. In the

1
2 Anatomy and surgical dissection of the female pelvis
retroperitoneal areas and spaces, both normal visceral
connective tissues and scar tissue can coexist to challenge
the dissection skills of the surgeon. Dissections in both
the pelvic cavity and the retroperitoneum utilize the same
techniques.
In the retroperitoneum, the visceral connective tissues
serve two important purposes.1 One is to envelope and
mechanically support the visceral blood vessels, nerves,
and lymph nodes and channels that service the viscera.
The other is to follow these visceral structures to their vis-
cera for the purposes of mechanical suspension of these
organs, such as the bladder, cervix and vagina, and the rec-
tum. The visceral connective tissues anchor the pelvic vis-
cera to the parietal fascia of the back wall and sidewall of
the pelvis. For example, the cardinal ligament/uterosacral
ligament complex of visceral connective tissue envelopes
the internal iliac artery and vein and is led to the paracer-
vical ring by the uterine artery. The cardinal ligaments and
uterosacral ligaments are anchored to the back wall and
sidewall of the pelvis. They suspend the cervix and upper
vagina over the tendinous levator plate. The levator plate
is the dynamic backstop that functions to help prevent
uterine and vaginal prolapse during episodes of increased
intrapelvic (Valsalva) pressure.
The first and most important principle of surgical
dissection is exposure of anatomic structures. Ideally,
the surgeon should not cut into tissues that he/she does
not understand AND cannot see with her/his own eyes.
Therefore, sharp and blunt dissections must literally pro-
ceed “millimeter by millimeter.” The dissection carefully
spreads out and thins the adhesion, the scar, or the vis-
ceral connective tissues so that the operator can visualize
the structures enveloped within. Surgical dissection must
reveal structures, not obscure or confuse them. Therefore,
knowledge of the structures contained in the area to be
dissected and anatomic orientation during dissection are
essential to meticulous and safe dissection techniques.
This also requires the operator to think spatially in three
dimensions. Additionally, the surgeon must learn the pal-
pable “feel” of dissection. Remember, the operator only
employs two of the five senses when performing a surgi-
cal procedure: sight and palpation. These two senses are
equally important. These senses must be consciously
developed, practiced, and improved by repetition and
experience.
By dissecting “millimeter by millimeter,” the surgeon
achieves four goals. First is the maintenance of correct
anatomic orientation and direction of dissection. Second
is the allowance for reevaluation of dissection techniques
and use of instrumentation. The surgeon has time to
think from dissection step to dissection step, and change
techniques, approach, or instrumentation, if needed.
Flexibility, ingenuity, and experience are essential charac-
teristics of the accomplished surgeon. Third is proceeding
in small steps under direct visualization in order to safely
reveal the vital anatomic structures to be safeguarded.
Fourth is limitation of any injury to an anatomic struc-
ture by 1 mm or less. By dissecting deliberately and slowly,
in most cases the operator can readily control any bleed-
ing encountered or see an unavoidable injury to a viscus
or anatomic structure. Therefore, major bleeding or gross
visceral injury should be minimized.
There are several techniques that the operator must
master. These techniques of surgical dissection are the
same in any area of the pelvis no matter the route of
entry to that anatomic area, whether by laparotomy,
laparoscopy, or per vaginum. They are grasp and tent;
“­millimeter” incisions under clear visual control; push
and spread; traction and countertraction; rotation and
counterrotation of the grasped tissue; and gentle wiping
of tissue by judicious blunt dissection. Some of these tech-
niques can be facilitated by the technique of hydrodissec-
tion. Hydrodissection is the injection of sterile fluid into
the tissues to be dissected in order to tent and thin these
tissues. Again, these dissection techniques must be per-
formed slowly and deliberately in small 1-mm increments.
By grasping and tenting the adhesion, scar, peritoneum,
or visceral connective tissue, the operator in most cases
elevates or moves the grasped tissue away from a viscus
or vital anatomic structure, even if that distance is only
1 or 2 mm. Grasping and tenting also helps to thin out
the grasped tissue so that an edge of bowel serosa may
be seen, a ureter can be seen to undergo peristalsis, or an
artery can be seen pulsating. With tenting and with ana-
tomic knowledge and orientation, the surgeon can then
incise the grasped tissue with a knife, scissors, or laser by
1 mm. The incision should be placed on the side away from
any vital anatomic structure or organ. For example, adhe-
sions from the uterus to the bowel should be incised on
the uterine serosa, and not toward the bowel serosa. The
techniques of tenting and traction–countertraction would
be useful in this case.
With reevaluation of the incision, he/she can then care-
fully use a push and spread technique “millimeter by milli-
meter” to further expose the contents of the adhesion, scar,
or visceral connective tissue. The tissue is further spread out
and thinned by grasping the edges of the dissected tissues
and gently pulling them apart by using traction and coun-
tertraction. Obviously, there is a “feel” to these maneuvers.
In some situations, gentle rotation of the grasped tissue
will further thin the tissues and may reveal the underly-
ing structures. Rotation and counterrotation can further
fracture scars and adhesions to thin them out. In dense
adhesions or scar tissue, sharp dissection with the knife
or scissors or laser “millimeter by millimeter” can be aug-
mented with gentle localized wiping “millimeter by mil-
limeter” as a form of traction and countertraction. This
technique is also known as “teasing the tissues.” Broad,
blunt strokes of the wiping technique are not to be used.
Such quick, sweeping moves do not allow for controlled
dissection. This is an uncontrolled, “blind” method of
dissection that can tear into blood vessels, the bladder, or
bowel. Another technique is the directed injection of ster-
ile saline or other physiologic fluid into the dissection field.
This technique, hydrodissection, further spreads, thins,
and tents the tissues in a gentle manner. Hydrodissection

can and does facilitate vaginal dissections in the vesico-
vaginal, paravaginal, rectovaginal, and paravaginal spaces.
YOU CANNOT OPERATE WITHOUT A “TEAM”
No matter how skilled and experienced you are as a surgeon,
you cannot operate safely, efficiently, and effectively with-
out an experienced team in the operating room. This team
consists of you, your surgical assistant, scrub nurse, nurse
circulator, and of course, your anesthesiologist. You cannot
operate without a properly anesthetized, comfortable patient
who has adequate muscle relaxation and does not move. You
would waste your time if you had to take the time to gather
your own instruments, sterilize them, and set them up on a
sterile table. You would not be able to prep and drape your
patient yourself and then insert cords into the machines
surrounding the operating table without breaking scrub. In
many cases, you cannot assist yourself during surgical dis-
sections. In more challenging surgical cases, you will require
additional personnel for retraction. You are the leader of a
team that allows you to perform your best surgical tech-
niques and procedures. You are a clumsy, grossly inefficient
surgeon without them. The team allows you to shine forth.
Better surgical results are achieved when there is a “synergy
of purpose,” with the members of the team working together
to achieve a common purpose of safety and efficiency.
When the individual members of a team work indepen-
dently or at odds with one another, the loss of cohesive
respect fractures the quality and efficiency of the working
environment. A tense, uncomfortable atmosphere in the
operating room does not allow the optimal surgical result.
First, do no harm. Professionals care about their behavior
and performance. The entire team must be dedicated to
patient safety and procedural efficiency.
Learn to be an appreciative leader. Your surgery will
become smoother and better in a pleasant professional
environment. Accept suggestions and compromise in
order to improve surgical safety and procedural flow.
Ischiocavernosus
muscle
Bulbocavernosus
muscle
Adipose
tissue
External
anal
sphincter
Anococcygeal
ligament
Coccyx
Figure 1.1 Structures of the female urogenital diaphragm. (From DeCherney A, et al., Current Diagnosis and Treatment: Obstetrics
and Gynecology, 11th edition, McGraw-Hill Education, 2012. With permission.)
Key structural anatomy 3
Be mindful of the comfort of the team members, espe-
cially those who assist and retract. Appreciate team input
during your surgeries. Your team members may give you
information or reminders that you may not have noticed
or remembered. You cannot observe everything that is
going on in the operating room when you are focused on
a small field of dissection. Your assistant may see some-
thing around the dissection field that you may not have
seen. You may have been distracted when manipulating an
instrument or performing a dissection.
Remember, there is no “I” in “TEAM,” unless you are
saying, “I am proud of our team.” You have spent years
in learning and developing your knowledge and skills in
surgical anatomy, dissections, accepted procedures, judg-
ment, and management of complications. However, you
must remember you did very little of this development
on your own. You had teachers, mentors, and experi-
enced operating personnel to guide you and encourage
you. Therefore, in return, you must develop an attitude of
appreciation and respect for your team members—past,
present, and future. Positive motivation should come will-
ingly from within the individuals of the surgical team, not
by fear of embarrassment or verbal punishment. The more
you give to others in courtesy and respect, the more these
people will give back by facilitating your surgeries. The
atmosphere in the operating room will become respect-
ful and comfortable. The members of the surgical team
are your colleagues. Respect them. Teach them. Listen to
them. Complement them. Everyone in surgery responds
positively when part of a respected and successful team
that brings the best care to each patient.
KEY STRUCTURAL ANATOMY
The vagina
The vagina is 8 to 10 cm in length and extends from the
introitus through the urogenital diaphragm (Figure 1.1)2
Bulb of
vestibule
Superficial
transverse
perineal
muscle
Levator
ani muscle group
Gluteus maximus
muscle
4 Anatomy and surgical dissection of the female pelvis
Endopelvic fascia Pubocervical
(pubovesical)
ligament
Transverse
Bladder
cervical
(cardinal)
ligament
Cervix
Rectum
Pubocervical
ligament
Transverse
cervical
ligament
Uterosacral
ligament
Uterosacral
ligament
Figure 1.2 Key supportive fascial structures of the pelvis.
(From Lawrence-Watt D, et al., Applied anatomy and imaging
of the bladder, ureter, urethra, anus and perineum, in Flinders
A, Thilaganathan B, eds., MRCOG Part One: Your Essential
Revision Guide, 2nd edition, CUP, 2016. With permission.)
to the uterus. It can be divided into three essential parts
including the vestibule between the labia minora, the
vault up to the upper end of the vagina, and the forni-
ces (anterior, posterior, lateral) or recesses formed as the
vagina surrounds the cervix. The anterior and posterior
vaginal walls are usually closely applied to each other,
diverging at the vaginal vault and fornices. It is supported
by various structures including the levator ani, the car-
dinal, pubocervical, and uterosacral ligaments; and the
perineal membrane and body (Figure 1.2).3 The vagina
is anatomically related anteriorly to the cervix, bladder,
and urethra, posteriorly to the pouch of Douglas and the
perineal body, and laterally to the levator ani; pelvic fas-
cia, and ureters. The arterial blood supply is complex from
the vaginal, uterine, internal pudendal, and middle rectal
arteries (Figure 1.3),4 whereas venous drainage is via the
vaginal venous plexus that drains into the internal iliac
veins. The lymphatic supply of the vagina is by the internal
and external iliac nodes for the upper three quarters and
by the superficial inguinal nodes for the lower quarter. The
nerve supply of the upper vagina is by parasympathetic
fibers from the pelvic splanchnic nerves (S2 to S4), and by
the pudendal nerve for the lower 2 to 3 cm (Figure 1.4).3
The uterus
The uterine corpus
Shaped like an inverted pear, the uterus is a hollow and
muscular organ, measuring 7.5 cm in length, 5 cm wide at
its upper part, and nearly 2.5 cm in thickness. As thin as
5 mm at the cornu, accidental perforation during sound-
ing, dilation, or intrauterine surgery is more apt to occur
at this location. In the normal uterus, the cavity is 4 to
5 cm long and 3 cm wide at the cornu. The upper expanded
part is termed the corpus or body, the area of insertion of
each fallopian tube is termed the cornu, and the part of
Ovarian a.
Ovary A
Ureter
Ureterine a.
Vaginal a.
B
Internal iliac a. Middle rectal a.
Internal
pudendal a.
C
D
Figure 1.3 Blood supply of the vaginal uterus, and fallo-
pian tubes. (From Skandalakis’ Surgical Anatomy, Paschalidis
Medical Publications, Athens, 2004.)
the body above the cornu is termed the fundus. Given the
broad horizon extending across the fundus to both cornu,
a 30° optic is best suited to inspection of the uterine cav-
ity. Anatomically, it is divided into the body, or corpus, and
the cervix, with an interval narrowing known as the isth-
mus. The proximity of the ascending and descending uter-
ine vessels at this anatomical junction magnifies the risk
of hemorrhage during hysteroscopic resection procedures.
The part of the body that lies above a plane passing through
the points of entrance of the uterine tubes is known as the
fundus. The cavity of the body is triangular and essentially
flattened in contact anteroposteriorly. The uterine corpus
comprises three layers: the outer serosal layer, which is the
peritoneal covering of the uterus; the middle smooth mus-
cle layer, the myometrium; and the inner mucous layer, the
endometrium. The myometrium comprises an inner layer
(junctional zone) and an outer layer, and represents the safe
distance between any intrauterine instrument and the adja-
cent visceral and vascular structures. The transverse junc-
tion of the vesicouterine peritoneum with the uterine serosa
forms a recognizable white line, above which the parietal
peritoneum is fused while caudally is mobile and overlies
loose fibrofatty tissue. Correspondingly, bladder flap devel-
opment during hysterectomy is best performed below this
white line and more apt to cause bleeding whenever mobili-
zation is initiated above this white line.
The arterial blood supply of the uterus comes from both
the uterine and ovarian arteries (Figure 1.3). The uterine
artery is a branch of the anterior division of the hypogas-
tric artery. It runs medially in the pelvis, within the base
of the broad ligament to the outer surface of the uterus
(Figure 1.5).5 From lateral to medial, it has a descending,
transverse, and ascending portion. The ascending portion
runs alongside the uterus and passes anterior to the ureter
(Figure 1.5) (Video 1.1). While this artery can be surgically

Celiac ganglion
Aorticorenal
ganglion
Fibers of ovarian plexus
carried along ovarian artery
Right hypogastric
nerve
Pudendal nerve
Sympathetic fibers
Figure 1.4 Innervation of the pelvic viscera. (From Lawrence-Watt D, et al., Applied anatomy and imaging of the bladder, ureter,
urethra, anus and perineum, in Flinders A, Thilaganathan B, eds., MRCOG Part One: Your Essential Revision Guide, 2nd edition, CUP,
2016. With permission.)
skeletonized along its entire course up to the uterus, its
close anatomical relationship to the lower uterine segment
truncates accessibility and limits how well it can be iso-
lated, compressed, and ultimately secured. Branches of the
uterine artery include serpiginous offshoots to supply the
uterus, a vaginal branch to the vagina, an ovarian branch
to the ovary, and a terminal tubal branch to the fallopian
tubes (Figure 1.3). The terminal branches of these ves-
sels unite and form an anastomotic trunk from which the
branches are given off to supply the uterus and fallopian
tubes. The myometrium and endometrium are perfused
by the progressive ramification and eventual penetration
of the uterine artery into arcuate, radial, spiral, and basal
branches to the level of the endometrium (Figure 1.6).
The circumferential course assumed by the arcuate vas-
culature may argue for a transverse rather than midline
myometrial incision during laparotomic or laparoscopic
myomectomy procedures.
Afferent nerves from the uterus are to T11 and T12. The
sympathetic supply is derived from the hypogastric and
ovarian plexuses (Video 1.2), whereas the parasympathetic
from the second, third, and fourth sacral nerves (Figure
1.4).
The lymphatic drainage of the uterus is to the para-
aortic nodes for the fundus, the internal and external iliac
Key structural anatomy 5
Preganglionic sympathetic fibers from
thorax
Lumbar sympathetic chain
Superior hypogastric plexus
Left hypogastric nerve
Uterovaginal and inferior hypogastric
plexuses
Lowest point of peritoneum
Pelvic splanchnic nerves—blue
Parasympathetic fibers Afferent fibers
nodes from the uterine body and cervix, and via the super-
ficial inguinal nodes from the round ligament.
The biodynamics and anatomical support of the uterus
are provided by the pubocervical fascia to the pubic bone
anteriorly, the cardinal ligaments to the ischial spines lat-
erally, and the uterosacral ligaments both posteriorly and
apically to the anterior surface of the sacrum. Various
pelvic support defects including uterine prolapse can be
directly attributed to fundamental disruptions of these
supportive structures and their key relationships (Figure
1.2). The uterus is juxtaposed anteriorly by the bladder and
vesicouterine pouch; posteriorly by the rectum and pouch
of Douglas; laterally by the proximal fallopian tubes,
broad ligament, and uterine vessels; and inferiorly by the
fornices of the vaginal canal (Figure 1.5).
Other than intrinsic anatomical propensity, the posi-
tion of the uterus is susceptible to significant variation,
depending upon the length of the uterosacral ligaments
and the relative content of the bladder and the rectum.
The uterine cervix
The cervix is the lower component of the uterus projecting
through the anterior wall of the vagina, which divides it
into an upper, supravaginal portion and a lower, vaginal
portion. The supravaginal portion is separated in front
6 Anatomy and surgical dissection of the female pelvis

Right ureter displaced anterolaterally

Ao
r ta

(a) (b)
Right common iliac artery Left common iliac artery

Right round
ligament
Right Left round
external ligament
Bladder
iliac artery (transected)

Right
fallopian Uterine corpus
tube (posterior)
Right ovary er
et
Ur Uterine
Right Pouch o
f Dougla cervix
infundibulo- (d) s
(c) posterior
pelvic
ligament Uterine artery
Right
ovary
Bladder Uterine corpus
(posterior) Right
r
ete

Ure

Uterine fallopian
Ur

ter

cervix tube
anterior Uterine cervix
L uterosacral
(posterior)
Uterine corpus ligament
(anterior)
ter

Ure

Cul-de-sac
Ure

ter

(pouch of
(e) (f ) Sigmoid colon Douglas)

Figure 1.5 Topical and retroperitoneal anatomy. (a and b) Dissection at the aortic bifurcation. The right ureter has been
lifted off the right common iliac artery. The uterus and surrounding structures are shown in the context of a laparotomic
hysterectomy. The panel (c) demonstrates the superior attachments to the right pelvic sidewall including the right round and
infundibulopelvic ligaments. The presumed course of the ureters is demonstrated with an overlay in the panels (d through f).
(From Abu-Rustum NR, et al., eds., Atlas of Procedures in Gynecologic Oncology, 3rd edition, CRC Press, Boca Raton, 2013. With
permission.)

from the bladder by the parametrium, which extends also
onto its sides and laterally between the layers of the fibrous
broad ligaments. The uterine arteries reach the margins of
the cervix in this fibrous tissue, while on either side the
ureter runs downward and anteriorly, coursing as close
as 1 cm to the cervix (Figure 1.5) (Video 1.1). Posteriorly,
the supravaginal cervix is covered by peritoneum, which
extends to the posterior vaginal wall, where it is reflected
onto the rectum forming the pouch of Douglas (Figure
1.5). The vaginal portion freely projects into the anterior
wall of the vagina between the anterior and posterior
fornices. The external os is bounded by the anterior and
posterior lips, which normally are in contact with the pos-
terior vaginal wall. The afferent nerve supply of the cervix
travels back along the pelvic splanchnics (S2 to S4) and on
the pudendal nerve (Figure 1.4).
The ovary
The ovaries lie within the ovarian fossa on the poste-
rior wall of the true pelvis (Figure 1.5). The suspensory

Ovarian artery
Arcuate artery
Radial artery
Basal artery
Spiral artery
Endometrium
Myometrium
Uterine artery
Figure 1.6 Myometrial and endometrial blood supplies.
(Adapted from Robertson WB, J Clin Pathol Suppl (R Coll Pathol).,
1976;10:9-17.)
ligament of the ovary, a fold of peritoneum, runs from the
sidewall of the pelvis to the ovary. The ovarian vessels run
in this ligament, crossing over the external iliac vessels.
Each ovary is attached to the back of the broad ligament by
the mesovarium, which is continuous with its outer coat.
The ovarian ligament attaches the ovary to the side of the
uterus.
The arterial blood supply to the ovary is via the ovarian
artery (Figure 1.3), whereas venous drainage is complex
through the pampiniform plexus to the ovarian veins; the
right drains into the inferior vena cava, whereas the left
into the left renal vein.
Lymphatics travel with the ovarian vessels to the pre-
aortic nodes. The nervous innervation of the ovaries is from
aortic, renal, and superior and inferior hypogastric plexuses
to form the ovarian plexus (Figure 1.4). The ovarian ves-
sels typically arise from the aorta just inferior to the renal
arteries and superior to the inferior mesenteric artery. They
descend caudally in the retroperitoneum on the psoas major
with the ovarian vein and ureter, into the pelvis anterior to
the iliac vessels, and then in the pelvis along a medial path
toward the uterus (Figure 1.5). They anastomose with the
ovarian branch of the uterine artery at the uterus.
The fallopian tube
Bridging the ovary and uterus, the fallopian tube is a tubu-
lar structure of approximately 9 to 11 cm length. There
is wide inter-individual variation. It is the site of ovum
retrieval, ovum and sperm transport, sperm capacitation,
fertilization, and later embryo transport.7 The tubal envi-
ronment also provides vital nutrient support for the divid-
ing embryo. These mechanisms occur in various anatomic
sections of the normal tube.
Cyclical changes in anatomic (ciliation, epithelial
height), endocrinologic, and mechanical patterns8–11 have
been postulated or proven.12 Although studies have eluci-
dated certain aspects of tubo-ovarian interaction, not all
have been verified in humans.7,12–16
Key structural anatomy 7
The oviduct is made up of the fimbriae, infundibulum,
ampulla, isthmus, and intramural (interstitial) tube. The
fimbriae, the most distal portion of the oviduct, are rela-
tively free and motile. The only attachment to the ovary is
via the fimbria ovarica, one of about 25 fimbrial folds. Even
this attachment is inconstant. The fimbriae attach to the
infundibulum, a trumpet-shaped portion of the fallopian
tube of 1 cm length. Like the fimbriae, it is thin-walled, is
densely ciliated (60% to 80%),17,18 and has a complex pat-
tern of mucosal folds (Figure 1.7). Ovum retrieval and ini-
tial transport are affected by the close spatial relationship
of the fimbriae to the site of ovulation.
The ampulla comprises approximately two-thirds of the
total tubal length. Its luminal diameter decreases from
1 cm at the ampullary–infundibular junction to 1 to 2 mm
at the ampullary–isthmic junction. The seromuscular layer
is thin and composed of an incomplete internal longitudi-
nal, a middle circular, and an external longitudinal layer.
The mucosal folds within the ampulla are complex. The
lumen is packed with these folds. Approximately 40% to
50% of ampullary cells are ciliated, while the remainder
are serous secreting19 (Figures 1.8 to 1.13). The inner longi-
tudinal spiral myosalpingeal layer found in the ampulla is
lost at the ampullary–isthmic junction.
The isthmus represents approximately one-third of
tubal length (3 to 3.5 cm) and the lumen is considerably
narrower than that of the ampulla (0.1 to 0.5 mm). The
muscular layers are well developed. Isthmic ciliation is less
profuse (25% to 30%) compared to the ampulla.20 The isth-
mus has four primary mucosal folds (Figures 1.14 and 1.15).
The intramural or interstitial segment of the tube is
short (10 mm) and narrow with a straight, arched, or
convoluted course through the myometrium. It has been
described as the junction between tube and uterus or,
erroneously, as a sphincter, although no anatomic corre-
late to a sphincter has been documented. At the site of the
junction of the endometrial funnel with the intramural
portion of the tube, an abrupt change from endometrial to
Figure 1.7 Light microscopy: cross sections of fimbria
(right), ampulla (left), and isthmus (center) (hematoxylin and
eosin stain).
8 Anatomy and surgical dissection of the female pelvis

Figure 1.8 Light microscopy: cross section of human Figure 1.11 Light microscopy: detail of human ampullary
ampulla demonstrating complex folds of ciliated endosalpinx endosalpinx showing ciliated cells (hematoxylin and eosin stain).
that fill the lumen (hematoxylin and eosin stain).

Figure 1.9 Scanning electron microscopy: ampulla of rab-

bit oviduct. Rugal fold of endosalpinx showing populations of Figure 1.12 Scanning electron microscopy: detail of
ciliated and secretory cells. Magnification: 1700×. human ampullary endosalpinx showing ciliated cells.

Figure 1.10 Light microscopy: cross section of ampullary Figure 1.13 Microphotograph: cut surface of human
fold of human endosalpinx. isthmus.

Isthmus Ampulla
Circular
Longitudinal
Figure 1.14 Sketch demonstrating the isthmic musculature.
Figure 1.15 Light microscopy: vessels in the mesosalpinx
of the human fallopian tube derived from the ovarian and uter-
ine arteries (hematoxylin and eosin stain).
tubal mucosa occurs.18 A well-developed, inner longitudi-
nal muscle layer surrounded by a circular layer is present
in the intramural segment.
The vascular supply to the oviduct is derived from the
uterine and ovarian arteries. There is a capillary bed within
the lateral mesosalpinx and oviduct where the two supplies
meet, culminating in a rich vascularity7 (Figure 1.3).
This vascular bed responds to vasoconstrictor solutions
(used, for example, for removal of an ectopic pregnancy).
The uterine artery ascends to supply the cornu and to then
course laterally beneath the isthmus to dissipate in the lat-
eral mesosalpinx (Figure 1.3). At tubal surgery, the most
prominent and easily injured vessels are those underlying
the isthmus.
The function of the autonomic nerve supply to the ovi-
duct is uncertain. It is notable that oviductal transplan-
tation procedures with attendant denervation of the tube
have yielded successful pregnancies.21–23
Key structural anatomy 9
The pelvic ureter
The pelvic ureter begins its descent to the bladder by run-
ning along the medial aspect of the psoas muscle. It enters
the pelvis anteriorly to the sacroiliac joint at the bifur-
cation of the common iliac vessels (at the pelvic brim)
(Video 1.3) and then courses anteriorly to the internal
iliac artery down the lateral pelvic sidewall (Figure 1.5)
(Video 1.1).
At the level of the ischial spine, it turns forward and
medially to enter the posterolateral wall of the bladder,
where it runs an oblique 1 to 2 cm course, before open-
ing into the bladder at the ureteric orifice. The anatomical
relationships to the ureter are complex due to the differ-
ences between the left and right sides of the pelvic cav-
ity including the relatively immobile peritoneal reflection
of the rectosigmoid (Video 1.3). These include the sacro-
iliac joint and internal iliac artery posteriorly, the lateral
fornix of the vagina inferiorly, the uterine artery anteri-
orly, and the cervix laterally. The only structure passing
anteriorly over the ureter is the uterine artery (Video 1.1).
The arterial blood supply is complex and rich from upper
abdominal branches and various pelvic vessels including
the ovarian, middle rectal, and uterine arteries. This helps
protect the ureter from ischemic injury after retroperito-
neal ureterolysis.
Innervation of the pelvic viscera
The autonomic innervation of the pelvic structures is
especially important during radical surgery for can-
cer and whenever extensive dissection is employed for
deeply infiltrating endometriosis. The nerves for the pel-
vic organs can be sensory, sympathetic, or parasympa-
thetic. The sympathetic and sensory fibers are found in
the inferior hypogastric nerve (Video 1.2), whereas the
parasympathetics emanate from the pelvic splanchnic
nerves from the sacral plexus (Figure 1.4). The supe-
rior hypogastric nerves form the superior hypogastric
plexus at the level of the sacral promontory. The inferior
hypogastric nerves originate at the same level and travel
downward to cross the uterosacral ligament in a medio-
lateral direction to converge with the ureter. These
nerves lie in the lateral part of the uterosacral ligament
about 2 cm from the uterus. Parallel to the uterosacral
ligament, a nervous structure can be surgically isolated
from the underlying visceral endopelvic fascia. These
nerves carry the sensory and sympathetic fibers provid-
ing accommodation of the detrusor muscle and con-
traction of the urethral sphincter. The pelvic splanchnic
nerves run from the S2 to S4 roots of the sacral plexus
and join in the inferior hypogastric plexus at the level of
the lateral part of the uterosacral ligaments, then travel
anterior and lateral to the rectum. These nerves carry
parasympathetic fibers responsible for the voiding func-
tion and accommodation of the rectum. The inferior
hypogastric plexus, also called Frankenhauser’s gan-
glion, runs lateral to the vagina and the base of the blad-
der and is cranially related to the uterosacral ligaments.
10 Anatomy and surgical dissection of the female pelvis

Most of these fibers run in the parametrium between the innervation from the cavernous nerves, derived from the
medial rectal artery ventrally and the levator ani muscle uterovaginal plexus.
dorsally.
Areas of anatomic dissection in the female pelvis
The vulva The areas of dissection in the female pelvis relevant to the
The vulvae comprise many different anatomical struc- gynecologic surgeon are the presacral space, the pelvic
tures. The most important of which include a fat pad at the brim, the pelvic sidewall, the base of the broad ligament/
anterior vulva called the mons pubis, two external folds base of the cardinal ligament, the paravesical space, the
called the labia majora that fuse posteriorly and extend retropubic space, the vesicovaginal space, the pararec-
anteriorly to the mons pubis, and two hairless folds of skin tal space, and the rectovaginal space. The paravesical
lying within the labia majora called the labia minora that (paravaginal), vesicovaginal, and rectovaginal spaces are
fuse anteriorly to form the hood or prepuce of the clitoris discussed from both the intrapelvic route and the intra-
and extend posteriorly on either side of the vaginal open- vaginal route. Mention of surgical dissections in each of
ing (Figure 1.16).24 The area between and surrounding these areas refers to the dissection techniques already dis-
the labia is called the vestibule through which the exter- cussed. The reader should actively review and learn them.
nal vaginal orifice and urethra open. Located under the
prepuce, the clitoris is formed of erectile corpora caver- The presacral space
nosa tissue, which becomes engorged with blood during The presacral space is the area of surgical dissection and
sexual stimulation. More deeply, the Bartholin’s glands are performance of the “presacral neurectomy” for women
located on either side of the vaginal orifice. with “central” chronic pelvic pain, severe dysmenorrhea,
The arterial blood supply to the vulva is supplied by the and proven endometriosis.26,27 However, heated contro-
pudendal arteries and venous drainage by the pudendal versy and continuing debates exist concerning the real use
veins including smaller labial veins as tributaries. The lym- of this procedure in the gynecologist’s armamentarium of
phatic drainage is to the superficial inguinal lymph nodes. operations for patients with pelvic pain issues.28
The vulva receives both sensory and parasympathetic This space is also known as the prelumbar space, since
nervous supply (Figure 1.17).25 With regard to sensory it lies over the anterior longitudinal ligament on the fourth
innervation, the vulva can be split into anterior and poste- and fifth lumbar vertebrae (Figure 1.18). This potential space
rior sections. The anterior portion is supplied by the ilioin- is bordered superiorly by the bifurcation of the aorta at the
guinal nerve and a branch of the genitofemoral nerve. The level of the fourth lumbar vertebra and inferiorly by the
posterior portion of the vulva is supplied by the pudendal promontory of the first sacral vertebra. Laterally to the right
nerve and by the posterior cutaneous nerve of the thigh. travels the right common iliac artery and right ureter, while
The clitoris and the vestibule also receive parasympathetic on the left courses the left common iliac vein and left ureter.
Anteriorly, covering the presacral space is the peritoneum.
Posteriorly, the middle sacral artery (from the aorta) and a
plexus of fragile veins on the anterior longitudinal ligament
are found.
Between the peritoneum and the posterior border of the
M presacral space, several fused sheets of visceral connec-
F tive tissue enveloping the multiple visceral nerves coursing
G
through this area are found. These nerves emanate from
B L2 B
preaortic ganglia and eventually enter into the right and left
hypogastric nerves (Video 1.2), which then travel in the pel-
D U L
D vic sidewalls to feed into the respective inferior hypogastric
I plexuses, also known as the pelvic plexuses of visceral nerves.
These presacral nerves, or visceral nerves of the superior
V hypogastric plexus, are very fine or invisible to the naked eye.
C They are enveloped in and obscured by the fatty areolar tissue
R within the sheets of visceral connective tissue. The presacral
plexus forms a geometric webbing, which is very variable in
location, formation, and size. This webbing of unseen nerves
can even be found overlying the left common iliac vein and
artery, lateral and away from the presacral space (Figure 1.19).
Dissection must utilize the tenting of tissues as well as
Figure 1.16 External and vulvar female anatomy: G, glans gentle traction and countertraction to thin out the several
of clitoris; I, introitus; L, labia minora; L2, labia maiora; M, mons layers of visceral connective tissues to see the larger struc-
pubis; R, perineal raphe; U, urethral opening; V, vestibular fossa. tures bordering this space while lifting the visceral connec-
(Modified from Micali G, et al., Vulval Dermatologic Diagnosis, tive tissues away from very vascular posterior border. The
CRC Press, Boca Raton, 2016. With permission.) operator then removes these visceral connective tissues,

Genital branch of genitofemoral nerve
Branch of ilioinguinal nerve
Pudendal branch of posterior
femoral cutaneous nerve
Branches of pudendal nerve
Inferior hemorrhoidal nerve
Perforating cutaneous nerves
Figure 1.17 Nervous innervation of the vulva. (Courtesy of Clinical Gate.)
Abdominal aorta
Inferior
vena cava
Extraperitoneal
(subserous) fat
Common iliac
vessels and plexus
Ureter
Sacral
promontory
Right sympathetic
trunk
Figure 1.18 Key anatomical structures and boundaries of the presacral space.
which contain the visceral nerves of the presacral plexus.
Remember, these fine nerves can only be seen if some of
the nerves have physically coalesced together. Even then,
some or many nerves may not be removed since the bulk
of the plexus may pass laterally to the left, as noted. Tissue
should not be excised from this space unless the operator
has positively seen all the bordering anatomic structures.
If this rule is not followed, the potential for massive hem-
orrhage or injury to the ureters is very real.
The pelvic brim
This is the area most likely to be untouched by endome-
triosis, ovarian remnant presence, infection, and subse-
quent scarring and adhesion formation. Therefore, this
is the area most ideally suited to begin a retroperitoneal
sidewall dissection in order to find the ureter and major
Key structural anatomy 11
Ischial tuberosity
Peritoneum
Superior
hypogastric
plexus
Right and left
hypogastric
nerves
blood vessels entering into the pelvis. This is especially so
on the patient’s right side. On the left side, the mesentery
of the sigmoid colon adds more layers of areolar tissue that
must be dissected in order to expose the anatomic struc-
tures (Figures 1.5 and 1.20) (Video 1.3). The structures
of the pelvic brim enter into the pelvis, one over another
in a vertical orientation, and then rotate 90° to form the
three surgical layers of the pelvic sidewall (Video 1.4). The
parietal peritoneum covers the ovarian vessels in the infun-
dibulopelvic ligament, which course over the ureter, that,
in turn, passes over the bifurcation of the common iliac
artery located at the pelvic brim overlying the sacroiliac
joint. Between the bifurcation of the common iliac artery
and sacroiliac joint, the common iliac vein, the medial edge
of the psoas muscle, and the obturator nerve overlying the
parietal fascia over the capsule of the sacroiliac joint are
12 Anatomy and surgical dissection of the female pelvis
Figure 1.19 Anatomical locale of the presacral plexus.
Ovarian vessels
Bifurcation of
common iliac artery
Ureter
Figure 1.20 Key anatomical structures and relationships at
the pelvic brim.
found. The common iliac artery bifurcates into the inter-
nal iliac artery (hypogastric artery) and the external iliac
artery, which courses on the medial portion of the anterior
surface of the psoas muscle. The external iliac vein courses
on the medial edge of the psoas muscle, just medial and
posterior to the external iliac artery.
Ureteral injury or occlusion can occur in this area dur-
ing ligation or coagulation of the infundibulopelvic liga-
ment when performing oophorectomy. All the discussed
dissection techniques are safely used in this area to the
surgeon’s great advantage to see and isolate the ureter,
great vessels, and obturator nerve. These same techniques
are essential for sampling and excision of the lymph nodes
along the common, external, and internal iliac vessels.
The pelvic sidewall
The pelvic sidewall is that area of the pelvic retroperito-
neum that starts at the pelvic brim and extends to the base
of the broad ligament where the ureter courses just poste-
rior to the uterine blood vessels. It is bordered medially by
the parietal peritoneum and laterally by the parietal fascia
of the obturator internus muscle. Sandwiched in between
are the multiple, fused sheets of visceral connective tissues
that envelope the visceral vessels, nerves, lymph nodes,
and channels that service the bladder, uterus, cervix and
vagina, and the lower rectum. From a surgical need to dis-
sect in avascular planes, the pelvic sidewall structures are
found in three layers, which are separated by two avascu-
lar dissection planes (Figure 1.21) (Video 1.4).
The first layer, the ureteral layer, is the ureter and its sur-
rounding visceral connective tissue sheath attached to the
parietal peritoneum. The second, the visceral layer, is the
internal iliac artery and vein ensheathed by the multiple
sheets of the visceral connective tissue of the cardinal liga-
ment. The third layer, the parietal layer, is the external iliac
artery and vein on the medial aspect of the psoas muscle,
and the obturator nerve and the obturator artery and vein,
found coursing along the anterior aspect of the obturator
internus muscle. The avascular dissection planes are found
between each of these three layers unless there is signifi-
cant scarring from prior disease processes or former side-
wall dissections. The goal of dissections here is to identify
the ureter and the parietal structures of the third layer.
Then, because of the rich vascular collateral circulation in
the pelvis, the visceral blood vessels in the second layer
can be clamped, sutured, and coagulated safely without
injuring other pelvic structures (Video 1.5).
Also found in the second surgical layer of the pelvic side-
wall are the visceral branches of the internal iliac artery and
vein (Figure 1.22): the uterine; superior vesical, leading to
the obliterated umbilical; the inferior vesical; the vaginal;
the middle rectal; and the gluteal (Video 1.6). The operator
must be aware that these vessels may originate from sur-
rounding parietal vessels but may still be safely clamped,
tied, and coagulated. Another way to find the internal iliac
2
3
1
Figure 1.21 Three surgical layers of pelvic sidewall:
(1) parietal peritoneum and ureter; (2) internal iliac vessels
and their tributaries: uterine, superior and inferior vesical,
vaginal, internal pudendal, and inferior gluteal vessels; and
(3) obturator internus muscle, obturator nerve artery and
vein, and external iliac artery and vein.
Another random document with
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 Then the educator should “time” himself in forming habits? How
long may it take to cure a bad habit, and form the contrary good
one?
Perhaps a month or six weeks of careful incessant treatment may
be enough.
But such treatment requires an impossible amount of care and
watchfulness on the part of the educator?
Yes; but not more than is given to the cure of any bodily disease
—measles, or scarlet fever, for example.
Then the thoughts and actions of a human being may be
regulated mechanically, so to speak, by setting up the right nerve
currents in the brain?
This is true only so far as it is true to say that the keys of a piano
produce music.
But the thoughts, which may be represented by the fingers of the
player, do they not also run their course without the consciousness
of the thinker?
They do; not merely vague, inconsequent musings, but thoughts
which follow each other with more or less logical sequence,
according to the previous training of the thinker.
Would you illustrate this?
Mathematicians have been known to think out abstruse problems
in their sleep; the bard improvises, authors “reel off” without
premeditation, without any deliberate intention to write such and
such things. The thoughts follow each other according to the habit of
thinking previously set up in the brain of the thinker.
Is it that the thoughts go round and round a subject like a horse in
a mill?
No; the horse is rather drawing a carriage along the same high
road, but into ever new developments of the landscape.
In this light, the important thing is how you begin to think on any
subject?
 Precisely so; the initial thought or suggestion touches as it were
the spring which sets in motion a possibly endless succession or
train of ideas; thoughts which are, so to speak, elaborated in the
brain almost without the consciousness of the thinker.
Are these thoughts, or successive ideas, random, or do they
make for any conclusion?
They make for the logical conclusion which should follow the
initial idea.
Then the reasoning power may be set to work involuntarily?
Yes; the sole concern of this power is, apparently, to work out the
rational conclusion from any idea presented to it.
But surely this power of arriving at logical rational conclusions
almost unconsciously is the result of education, most likely of
generations of culture?
It exists in greater or less degree according as it is disciplined and
exercised; but it is by no means the result of education as the word
is commonly understood: witness the following anecdote:[17]
“When Captain Head was travelling across the Pampas of South
America, his guide one day suddenly stopped him, and, pointing high
into the air, cried out, ‘A lion!’ Surprised at such an exclamation,
accompanied with such an act, he turned up his eyes, and with
difficulty perceived, at an immeasurable height, a flight of condors
soaring in circles in a particular spot. Beneath this spot, far out of
sight of himself or guide, lay the carcass of a horse, and over this
carcass stood, as the guide well knew, a lion, whom the condors
were eyeing with envy from their airy height. The sight of the birds
was to him what the sight of the lion alone would have been to the
traveller, a full assurance of its existence. Here was an act of thought
which cost the thinker no trouble, which was as easy to him as to
cast his eyes upward, yet which from us, unaccustomed to the
subject, would require many steps and some labour.”
Then is what is called “the reason” innate in human beings?
 Yes, it is innate, and is exercised without volition by all, but gains
in power and precision, according as it is cultivated.
If the reason, especially the trained reason, arrives at the right
conclusion without any effort of volition on the part of the thinker, it is
practically an infallible guide to conduct?
On the contrary, the reason is pledged to pursue a suggestion to
its logical conclusion only. Much of the history of religious
persecutions and of family and international feuds turns on the
confusion which exists in most minds between that which is logically
inevitable and that which is morally right.
But according to this doctrine any theory whatever may be shown
to be logically inevitable?
Exactly so; the initial idea once received, the difficulty is, not to
prove that it is tenable, but to restrain the mind from proving that it is
so.
Can you illustrate this point?
The child who lets himself be jealous of his brother is almost
startled by the flood of convincing proofs that he does well to be
angry, which rush in upon him. Beginning with a mere flash of
suspicion in the morning, the little Cain finds himself in the evening
possessed of irrefragable proofs that his brother is unjustly preferred
to him: and
“All seems infected that the infected spy
As all looks yellow to the jaundiced eye.”

But supposing it is true that the child has cause for jealousy?
Given, the starting idea, and his reason is equally capable of
proving a logical certainty, whether it is true or whether it is not true.
Is there any historical proof of this startling theory?
Perhaps every failure in conduct, in individuals, and in nations, is
due to the confusion which exists as to that which is logically right,
as established by the reason, and that which is morally right, as
established by external law.
 Is any such distinction recognised in the Bible?
Distinctly so; the transgressors of the Bible are those who do that
which is right in their own eyes—that is, that of which their reason
approves. Modern thought considers, on the contrary, that all men
are justified in doing that which is right in their own eyes, acting “up
to their lights,” “obeying the dictates of their reason.”
For example?
A mother whose cruel usage had caused the death of her child
was morally exonerated lately in a court of justice because she acted
“from a mistaken sense of duty.”
But it is not possible to err from a mistaken sense of duty?
Not only possible, but inevitable, if a man accept his “own reason”
as his lawgiver and judge. Take a test case, the case of the
superlative crime that has been done upon the earth. There can be
no doubt that the persons who caused the death of our Lord and
Saviour Jesus Christ acted under a mistaken sense of duty. “It is
expedient that one man die for the people, and that the whole nation
perish not,” said, most reasonably, those patriotic leaders of the
Jews; and they relentlessly hunted to death this Man whose
ascendency over the common people and whose whispered claims
to kingship were full of elements of danger to the subject race. “They
know not what they do,” He said, Who is the Truth.
All this may be of importance to philosophers; but what has it to
do with the bringing up of children?
It is time we reverted to the teaching of Socrates. “Know thyself,”
exhorted the wise man, in season and out of season; and it will be
well with us when we understand that to acquaint a child with himself
—what he is as a human being—is a great part of education.
It is difficult to see why; surely much harm comes of morbid
introspection?
Introspection is morbid or diseased when the person imagines
that all which he finds within him is peculiar to him as an individual.
To know what is common to all men is a sound cure for unhealthy
self-contemplation.
How does it work?
To recognise the limitations of the reason is a safeguard in all the
duties and relations of life. The man who knows that loyalty is his
first duty in every relation, and that if he admit doubting, grudging,
unlovely thoughts, he cannot possibly be loyal, because such
thoughts once admitted will prove themselves to be right and fill the
whole field of thought, why, he is on his guard, and writes up “no
admittance” to every manner of mistrustful fancy.
That rule of life should affect the Supreme relationship?
Truly, yes; if a man will admit no beginning of mistrustful surmise
concerning his father and mother, his child and his wife, shall he do
so of Him who is more than they, and more than all, the “Lord of his
heart”? “Loyalty forbids” is the answer to every questioning of His
truth that would intrude.
But when others, whom you must needs revere, question and tell
you of their “honest doubt”?
You know the history of their doubt, and can take it for what it is
worth—its origin in the suggestion, which, once admitted, must
needs reach a logical conclusion even to the bitter end. “Take heed
that ye enter not into temptation,” He said, Who needed not that any
should tell Him, for He knew what was in men.
If man is the creature of those habits he forms with care or allows
in negligence, if his very thoughts are involuntary and his
conclusions inevitable, he ceases to be a free agent. One might as
well concede at once that “thought is a mode of motion,” and cease
to regard man as a spiritual being capable of self-regulation!
It is hardly possible to concede too wide a field to biological
research, if we keep well to the front the fact, that man is a spiritual
being whose material organs act in obedience to spiritual
suggestion; that, for example, as the hand writes, so the brain thinks,
in obedience to suggestions.
 Is the suggestion self originated?
Probably not; it would appear that, as the material life is sustained
upon its appropriate food from without, so the immaterial life is
sustained upon its food,—ideas or suggestions spiritually conveyed.
May the words “idea” and “suggestion” be used as synonymous
terms?
Only in so far as that ideas convey suggestions to be effected in
acts.
What part does the man himself play in the reception of this
immaterial food?
It is as though one stood on the threshold to admit or reject the
viands which should sustain the family.
Is this free-will in the reception or rejection of ideas the limit of
man’s responsibility in the conduct of his life?
Probably it is; for an idea once received must run its course,
unless it be superseded by another idea, in the reception of which
volition is again exercised.
How do ideas originate?
They appear to be spiritual emanations from spiritual beings; thus,
one man conveys to another the idea which is a very part of himself.
Is the intervention of a bodily presence necessary for the
transmission of an idea?
By no means; ideas may be conveyed through picture or printed
page; absent friends would appear to communicate ideas without the
intervention of means; natural objects convey ideas, but, perhaps,
the initial idea in this case may always be traced to another mind.
Then the spiritual sustenance of ideas is derived directly or
indirectly from other human beings?
No; and here is the great recognition which the educator is called
upon to make. God, the Holy Spirit, is Himself the supreme Educator
of mankind.
 How?
He openeth man’s ear morning by morning, to hear so much of
the best as the man is able to bear.
Are the ideas suggested by the Holy Spirit confined to the sphere
of the religious life?
No; Coleridge, speaking of Columbus and the discovery of
America, ascribes the origin of great inventions and discoveries to
the fact that “certain ideas of the natural world are presented to
minds, already prepared to receive them, by a higher Power than
Nature herself.”
Is there any teaching in the Bible to support this view?
Yes; very much. Isaiah, for example, says that the ploughman
knows how to carry on the successive operations of husbandry, “for
his God doth instruct him and doth teach him.”
Are all ideas which have a purely spiritual origin ideas of good?
Unhappily, no; it is the sad experience of mankind that
suggestions of evil also are spiritually conveyed.
What is the part of the man?
To choose the good and refuse the evil.
Does this doctrine of ideas as the spiritual food needful to sustain
the immaterial life throw any light on the doctrines of the Christian
religion?
Yes; the Bread of Life, the Water of Life, the Word by which man
lives, the “meat to eat which ye know not of,” and much more, cease
to be figurative expressions, except that we must use the same
words to name the corporeal and the incorporeal sustenance of man.
We understand, moreover, how suggestions emanating from our
Lord and Saviour, which are of His essence, are the spiritual meat
and drink of His believing people. We find it no longer a “hard
saying,” nor a dark saying, that we must sustain our spiritual selves
upon Him, even as our bodies upon bread.
 What practical bearing upon the educator has this doctrine of
ideas?
He knows that it is his part to place before the child daily
nourishment of ideas; that he may give the child the right initial idea
in every study, and respecting each relation and duty of life; above
all, he recognises the divine co-operation in the direction, teaching,
and training of the child.
How would you summarise the functions of education?
Education is a discipline—that is, the discipline of the good habits
in which the child is trained. Education is a life, nourished upon
ideas; and education is an atmosphere—that is, the child breathes
the atmosphere emanating from his parents; that of the ideas which
rule their own lives.
What part do lessons and the general work of the schoolroom
play in education thus regarded?
They should afford opportunity for the discipline of many good
habits, and should convey to the child such initial ideas of interest in
his various studies as to make the pursuit of knowledge on those
lines an object in life and a delight to him.
What duty lies upon parents and others who regard education
thus seriously, as a lever by means of which character may be
elevated, almost indefinitely?
Perhaps it is incumbent upon them to make conscientious
endeavours to further all means used to spread the views they hold;
believing that there is such “progress in character and virtue”
possible to the redeemed human race as has not yet been realised,
or even imagined. “Education is an atmosphere, a discipline, a
life.”[18]

FOOTNOTES:
[17] From Archbishop Thompson’s Laws of Thought.
[18] Matthew Arnold.
 CHAPTER XXIV

WHENCE AND WHITHER

Part I
“The P.N.E.U. goes on,” an observer writes, “without puff or fuss, by
its own inherent force;” and it is making singularly rapid progress. At
the present moment not less than ten thousand children of thinking,
educated parents, are being brought up, more or less consciously
and definitely, upon the line of the Union. Parents who read the
Parents’ Review, or other literature of the Society, parents who
belong to our various branches, or our other agencies, parents who
are influenced by these parents, are becoming multitudinous; and all
have one note in common,—the ardour of persons working out
inspiring ideas.
It is hardly possible to over-estimate the force of this league of
educated parents. When we think of the part that the children being
brought up under these influences will one day play in the leading
and ruling of the land, we are solemnised with the sense of a great
responsibility, and it behoves us to put to ourselves, once again, the
two searching queries by which every movement should, from time
to time, be adjudged,—Whence? and Whither?
Whence? The man who is satisfied with his dwelling-place has no
wish to move, and the mere fact of a “movement” is a declaration
that we are not satisfied, and that we are definitely on our way to
some other ends than those commonly accepted. In one respect
only we venture boldly to hark back. Exceedingly fine men and
women were brought up by our grandfathers and grandmothers,
even by our mothers and fathers, and the wise and old amongst us,
though they look on with great sympathy, yet have an unexpressed
feeling that men and women were made on the old lines of a stamp
which we shall find it hard to improve upon. This was no mere
chance result, nor did it come out of the spelling-book or the
Pinnock’s Catechisms which we have long ago consigned to the
limbo they deserve.
The teaching of the old days was as bad as it could be, the
training was haphazard work, reckless alike of physiology and
psychology; but our grandfathers and grandmothers had one saving
principle, which, for the last two or three decades, we have been, of
set purpose, labouring to lose. They, of the older generation,
recognised children as reasonable beings, persons of mind and
conscience like themselves, but needing their guidance and control,
as having neither knowledge nor experience. Witness the queer old
children’s books which have come down to us; before all things,
these addressed children as reasonable, intelligent and responsible
(terribly responsible!) persons. This fairly represents the note of
home-life in the last generation. So soon as the baby realised his
surroundings, he found himself a morally and intellectually
responsible person. Now one of the secrets of power in dealing with
our fellow beings is, to understand that human nature does that
which it is expected to do and is that which it is expected to be. We
do not mean, believed to do and to be, with the fond and foolish faith
which Mrs. Hardcastle bestowed on her dear Tony Lumpkin.
Expectation strikes another chord, the chord of “I am, I can, I ought,”
which must vibrate in every human breast, for, “’tis our nature to.”
The capable, dependable men and women whom we all know were
reared upon this principle.
But now? Now, many children in many homes are still brought up
on the old lines, but not with quite the unfaltering certitude of the old
times. Other thoughts are in the air. A baby is a huge oyster (says
one eminent psychologist) whose business is to feed, and to sleep,
and to grow. Even Professor Sully, in his most delightful book,[19] is
torn in two. The children have conquered him, have convinced him
beyond doubt that they are as ourselves, only more so. But then he
is an evolutionist, and feels himself pledged to accommodate the
child to the principles of evolution. Therefore, the little person is
supposed to go through a thousand stages of moral and intellectual
development, leading him from the condition of the savage or ape to
that of the intelligent and cultivated human being. If children will not
accommodate themselves pleasantly to this theory, why, that is their
fault, and Professor Sully is too true a child-lover not to give us the
children as they are, with little interludes of the theory upon which
they ought to evolve. Now we have absolutely no theory to advance,
and are, on scientific grounds, disposed to accept the theories of the
evolutionary psychologists. But facts are too strong for us. When we
consider the enormous intellectual labour the infant goes through
during his first year in accommodating himself to the conditions of a
new world, in learning to discern between far and near, solid and flat,
large and small, and a thousand other qualifications and limitations
of this perplexing world, why, we are not surprised that John Stuart
Mill should be well on in his Greek at five; that Arnold at three should
know all the Kings and Queens of England by their portraits; or that a
musical baby should have an extensive repertoire of the musical
classics.
We were once emphasising the fact that every child could learn to
speak two languages at once with equal facility, when a gentleman in
the audience stated that he had a son who was a missionary in
Bagdad, married to a German lady, and their little son of three
expressed all he had to say with equal fluency in three languages—
German, English, and Arabic, using each in speaking to those
persons whose language it was. “Nana, which does God love best,
little girls or little boys?” said a meditative little girl of four. “Oh, little
girls, to be sure,” said Nana, with a good-natured wish to please.
“Then if God loves little girls best, why was not God Himself a little
girl?” Which of us who have reached the later stages of evolution
would have hit upon a more conclusive argument? If the same little
girl asked on another occasion, watching the blackbirds at the
cherries: “Nana, if the bees make honey, do the birds make jam?” it
was by no means an inane question, and only proves that we older
persons are dull and inappreciative of such mysteries of nature as
that bees should make honey.
 This is how we find children—with intelligence more acute, logic
more keen, observing powers more alert, moral sensibilities more
quick, love and faith and hope more abounding; in fact, in all points
like as we are, only much more so, but absolutely ignorant of the
world and its belongings, of us and our ways, and, above all, of how
to control and direct and manifest the infinite possibilities with which
they are born.
Our conception of a child rules our relations towards him. Pour
s’amuser is the rule of child-life proper for the “oyster” theory, and
most of our children’s books and many of our theories of child-
education are based upon this rule. “Oh! he’s so happy,” we say, and
are content, believing that if he is happy he will be good; and it is so
to a great extent; but in the older days the theory was, if you are
good you will be happy; and this is a principle which strikes the
keynote of endeavour, and holds good, not only through the childish
“stage of evolution,” but for the whole of life, here and hereafter. The
child who has learned to “endeavour himself” (as the Prayer Book
has it) has learned to live.
If our conception of Whence? as regards the child, as of—
“A Being, breathing thoughtful breath,
A traveller betwixt life and death,”—

is old, that of our grandfathers; our conception of the aims and

methods of education, is new, only made possible within the very last
decades of the century; because it rests one foot upon the latest
advances in the science of Biology and the other upon the potent
secret of these latter days, that matter is the all-serviceable agent of
spirit, and that spirit forms, moulds, is absolute lord, over matter, as
capable of affecting the material convolutions of the brain as of
influencing what used to be called the heart.
Knowing that the brain is the physical seat of habit, and that
conduct and character, alike, are the outcome of the habits we allow:
knowing, too, that an inspiring idea initiates a new habit of thought,
and, hence, a new habit of life; we perceive that the great work of
education is to inspire children with vitalising ideas as to the relations
of life, departments of knowledge, subjects of thought: and to give
deliberate care to the formation of those habits of the good life which
are the outcome of vitalising ideas.
In this great work we seek and assuredly find the co-operation of
the Divine Spirit, whom we recognise, in a sense rather new to
modern thought, as the Supreme Educator of mankind in things that
have been called secular, fully as much as in those that have been
called sacred. We are free to give our whole force to these two great
educational labours, of the inspiration of ideas and the formation of
habits, because, except in the case of children somewhat mentally
deficient, we do not consider that the “development of faculties” is
any part of our work; seeing that the children’s so-called faculties are
already greatly more acute than our own.
We have, too, in our possession, a test for systems that are
brought under our notice, and can pronounce upon their educational
value. For example, a little while ago, the London Board Schools
held an exhibition of work; and great interest was excited by an
exhibit which came from New York representing a week’s work in a
school. The children worked for a week upon “an apple.” They
modelled it in clay, they painted it in brushwork, they stitched the
outline on cardboard, they pricked it, they laid it in sticks (the
pentagonal form of the seed vessel). Older boys and girls modelled
an apple-tree and made a little ladder on which to run up the apple-
tree and gather the apples, and a wheel-barrow to carry the apples
away, and a great deal more of the same kind. Everybody said, “How
pretty, how ingenious, what a good idea!” and went away with the
notion that here, at last, was education. But we ask, “What was the
informing idea?” The external shape, the internal contents of an
apple,—matters with which the children were already exceedingly
well acquainted. What mental habitudes were gained by this week’s
work? They certainly learned to look at the apple, but think how
many things they might have got familiar acquaintance with in the
time. Probably the children were not consciously bored, because the
impulse of the teachers enthusiasm carried them on. But, think of
it—
“Rabbits hot and rabbits cold,
Rabbits young and rabbits old,
 Rabbits tender and rabbits tough,”—

no doubt those children had enough—of apples anyway. This “apple”

course is most instructive to us as emphasising the tendency in the
human mind to accept and rejoice in any neat system which will
produce immediate results, rather than to bring every such little
course to the test of whether it does or does not further either or both
of our great educational principles.
Whither? Our “whence” opens to us a “whither” of infinitely
delightful possibilities. Seeing that each of us is labouring for the
advance of the human race through the individual child we are
educating, we consider carefully in what directions this advance is
due, and indicated, and we proceed of set purpose and, endeavour
to educate our children so that they shall advance with the tide. “Can
ye not discern the signs of the times?” A new Renaissance is coming
upon us, of unspeakably higher import than the last; and we are
bringing up our children to lead and guide, and, by every means help
in the progress—progress by leaps and bounds—which the world is
about to make. But “whither” is too large a question for the close of a
chapter.

FOOTNOTES:
[19] “Studies of Childhood,” by Professor Sully (Longmans,
10s. 6d.).
 CHAPTER XXV

WHENCE AND WHITHER

Part II
The morphologist, the biologist, leave many without hesitation in
following the great bouleversement of thought, summed up in the
term evolution. They are no longer able to believe otherwise than
that man is the issue of processes, ages long in their development;
and what is more, and even more curious, that each individual child,
from the moment of his conception to that of his birth, appears in his
own person to mark an incredible number of the stages of this
evolutionary process. The realisation of this truth has made a great
impression on the minds of men. We feel ourselves to be part of a
process, and to be called upon, at the same time, to assist in the
process, not for ourselves exactly, but for any part of the world upon
which our influence bears; especially for the children who are so
peculiarly given over to us. But there comes, as we have seen, a
point where we must arise and make our protest. The physical
evolution of man may admit of no doubt; the psychical evolution, on
the other hand, is not only, not proven, but the whole weight of
existing evidence appears to go into the opposite scale.
The age of materialism has run its course: we recognise matter as
force, but as altogether subject force, and that it is the spirit of a man
which shapes and uses his material substance, in its own ways to its
own ends. Who can tell the way of the spirit? Perhaps this is one of
the ultimate questions upon which man has not yet been able to
speculate to any purpose; but when we consider the almost
unlimited powers of loving and of trusting, of discriminating and of
apprehending, of perceiving and of knowing, which a child
possesses, and compare these with the blunted sensibilities and
slower apprehension of the grown man or woman of the same
calibre, we are certainly not inclined to think that growth from less to
more, and from small to great, is the condition of the spiritual life:
that is, of that part of us which loves and worships, reasons and
thinks, learns and applies knowledge. Rather would it seem to be
true of every child in his degree, as of the divine and typical Child,
that He giveth not the Spirit by measure to him.
It is curious how the philosophy of the Bible is always well in
advance of our latest thought. “He grew in wisdom and in stature,”
we are told. Now what is wisdom—philosophy? Is it not the
recognition of relations? First, we have to understand relations of
time and space and matter, the natural philosophy which made up so
much of the wisdom of Solomon; then, by slow degrees, and more
and more, we learn that moral philosophy which determines our
relations of love and justice and duty to each other: later, perhaps,
we investigate the profound and puzzling subject of the inter-
relations of our own most composite being,—mental philosophy. And
in all these and beyond all these we apprehend slowly and feebly the
highest relation of all, the relation to God, which we call religion. In
this science of the relations of things consists what we call wisdom,
and wisdom is not born in any man,—apparently not even in the Son
of man Himself. He grew in wisdom, in the sweet gradual
apprehension of all the relations of life: but the power of
apprehending, the strong, subtle, discerning spirit, whose function it
is to grasp and understand, appropriate and use, all the relations
which bind all things to all other things—this was not given to Him by
measure; nor, we may reverently believe, is it so given to us.
That there are differences in the measures of men, in their
intellectual and moral stature, is evident enough; but it is well that we
should realise the nature of these differences, that they are
differences in kind and not in degree; depending upon what we glibly
call the laws of heredity, which bring it to pass that man in his various
aspects shall make up that conceivably perfect whole possible to
mankind. This is a quite different thing from the notion of a small and
feeble measure of heart and intellect in the child, to grow by degrees
into the robust and noble spiritual development which, according to
the psychical evolutionist, should distinguish the adult human being.
These are quite practical and simple considerations for every one
entrusted with the bringing up of a child, and are not to be set aside
as abstract principles, the discussion of which should serve little
purpose beyond that of sharpening the wits of the schoolmen. As a
matter of fact, we do not realise children, we under-estimate them; in
the divine words, we “despise” them, with the best intentions in the
world, because we confound the immaturity of their frames, and their
absolute ignorance as to the relations of things, with spiritual
impotence: whereas the fact probably is, that never is intellectual
power so keen, the moral sense so strong, spiritual perception so
piercing, as in those days of childhood which we regard with a
supercilious, if kindly, smile. A child is a person in whom all
possibilities are present—present now at this very moment—not to
be educed after years and efforts manifold on the part of the
educator: but indeed it is a greater thing to direct and use this wealth
of spiritual power than to develop the so-called faculties of the child.
It cannot be too strongly urged that our education of children will
depend, nolens volens, upon the conception we form of them. If we
regard them as instruments fit and capable for the carrying out of the
Divine purpose in the progress of the world, we shall endeavour to
discern the signs of the times, perceive in what directions we are
being led, and prepare the children to carry forward the work of the
world, by giving them vitalising ideas concerning, at any rate, some
departments of that work.
Having settled it with ourselves that we and the children alike live
for the advancement of the race, that our work is immediately with
them, and, through them, mediately for all, and that they are
perfectly fitted to receive those ideas which are for the inspiration of
life, we must next settle it with ourselves in what directions we shall
set up spiritual activities in the children.
We have sought to establish our whence in the potency of the
child, we will look for our whither in the living thought of the day,
which probably indicates the directions in which the race is making
progress. We find that all men everywhere are keenly interested in
science, that the world waits and watches for great discoveries; we,
too, wait and watch, believing that, as Coleridge said long ago, great
ideas of Nature are imparted to minds already prepared to receive
them by a higher Power than Nature herself.
At a late meeting of the British Association, the President
lamented that the progress of science was greatly hindered by the
fact that we no longer have field naturalists—close observers of
Nature as she is. A literary journal made a lamentable remark
thereupon. It is all written in books, said this journal, so we have no
longer any need to go to Nature herself. Now the knowledge of
Nature which we get out of books is not real knowledge; the use of
books is, to help the young student to verify facts he has already
seen for himself. We, of the P.N.E.U., are before all things, Nature-
lovers; we conceive that intimate acquaintance with every natural
object within his reach is the first, and possibly, the best part of a
child’s education. For himself, all his life long, he will be soothed
by—
“The breathing balm,
The silence and the calm,
Of mute insensate things.”

And for science, he is in a position to do just the work which is

most needed; he will be a close loving observer of Nature at first
hand, storing facts, and free from all impatient greed for inferences.
Looking out on the realm of Art again, we think we discern the
signs of the times. Some of us begin to learn the lesson which a
prophet has been raised up to deliver to this generation. We begin to
understand that mere technique, however perfect—whether in the
rendering of flesh tints, or marbles, or of a musical composition of
extreme difficulty—is not necessarily high Art. It is beginning to dawn
upon us that Art is great only in proportion to the greatness of the
idea that it expresses; while, what we ask of the execution, the
technique, is that it shall be adequate to the inspiring idea. But surely
these high themes have nothing to do with the bringing up of
children? Yes, they have; everything. In the first place, we shall
permit no pseudo Art to live in the same house with our children;
next, we shall bring our own facile tastes and opinions to some such
searching test as we have indicated, knowing that the children
imbibe the thoughts that are in us, whether we will or no; and, lastly,
we shall inspire our children with those great ideas which shall
create a demand, anyway, for great Art.
In literature, we have definite ends in view, both for our own
children, and for the world through them. We wish the children to
grow up to find joy and refreshment in the taste, the flavour of a
book. We do not mean by a book any printed matter in a binding, but
a work possessing certain literary qualities able to bring that sensible
delight to the reader which belongs to a literary word fitly spoken. It
is a sad fact that we are losing our joy in literary form. We are in
such haste to be instructed by facts or titillated by theories, that we
have no leisure to linger over the mere putting of a thought. But this
is our error, for words are mighty both to delight and to inspire. If we
were not as blind as bats, we should long ago have discovered a
truth very fully indicated in the Bible—that that which is once said
with perfect fitness can never be said again, and becomes ever
thereafter a living power in the world. But in literature, as in art, we
require more than mere form. Great ideas are brooding over the
chaos of our thought; and it is he who shall say the things we are all
dumbly thinking, who shall be to us as a teacher sent from God.
For the children? They must grow up upon the best. There must
never be a period in their lives when they are allowed to read or
listen to twaddle or reading-made-easy. There is never a time when
they are unequal to worthy thoughts, well put; inspiring tales, well
told. Let Blake’s “Songs of Innocence” represent their standard in
poetry; Defoe and Stevenson, in prose; and we shall train a race of
readers who will demand literature, that is, the fit and beautiful
expression of inspiring ideas and pictures of life. Perhaps a printed
form to the effect that gifts of books to the children will not be
welcome in such and such a family, would greatly assist in this
endeavour!
To instance one more point—there is a reaching out in all
directions after the conception expressed in the words “solidarity of
the race.” We have probably never before felt as now in absolute