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Principles of Gynecologic
Oncology Surgery

PEDRO T. RAMIREZ, MD
Professor
David M. Gershenson Distinguished Professor in Ovarian Cancer Research
Director of Minimally Invasive Surgical Research and Education
Department of Gynecologic Oncology and Reproductive Medicine
The University of Texas MD Anderson Cancer Center
Houston, Texas

MICHAEL FRUMOVITZ, MD, MPH

Professor and Fellowship Director
Department of Gynecologic Oncology and Reproductive Medicine
The University of Texas MD Anderson Cancer Center
Houston, Texas

NADEEM R. ABU-RUSTUM, MD
Chief, Gynecology Service
Professor, Weill Cornell Medical College
Vice Chair Technology
Department of Surgery
Memorial Sloan Kettering Cancer Center
New York, New York
1600 John F. Kennedy Blvd.
Ste 1600
Philadelphia, PA 19103-2899

PRINCIPLES OF GYNECOLOGIC ONCOLOGY SURGERY ISBN: 978-0-323-42878-1

Copyright © 2019 by Elsevier, Inc. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

Names: Ramirez, Pedro T., editor. | Frumovitz, Michael, editor. | Abu-Rustum,

Nadeem R., editor.
Title: Principles of gynecologic oncology surgery / [edited by] Pedro T.
Ramirez, Michael Frumovitz, Nadeem R. Abu-Rustum.
Description: Philadelphia, PA : Elsevier, [2019] | Includes bibliographical
references and index.
Identifiers: LCCN 2018008119 | ISBN 9780323428781 (hardcover : alk. paper)
Subjects: | MESH: Genital Neoplasms, Female—surgery | Gynecologic Surgical
Procedures—methods
Classification: LCC RC280.G5 | NLM WP 145 | DDC 616.99/465—dc23 LC record available
at https://lccn.loc.gov/2018008119

Senior Content Strategist: Sarah Barth

Senior Content Development Specialist: Joanie Milnes
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Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my father, Tomas, and my mother, Juanita, who sacrificed it all so that our family could have
a better future. To my sister, Maria, for her consistent support and loyalty.

To my children, Gabriela, Peter, Johnny, Sofia, and Emma,

for the love and happiness they bring each day.

To my wife, Gloria, for her sacrifices, patience, encouragement, support,

constant inspiration, and most important, her love.

Pedro T. Ramirez

To my wife, Amie, and my children, Robert, Natalie, and Andrew.

Thank you for your love and encouragement.

Nadeem R. Abu-Rustum

To my wife, Karen, and sons, Alex and Jonathan, for enduring countless hours and Sunday
mornings away from home and for my father, Billy, who would have been incredibly proud and
although a general gynecologist, would have read this book cover to cover, relishing every page.

Michael Frumovitz
Contributors

Nadeem R. Abu-Rustum, MD Luis M. Chiva, MD, PhD

Chief, Gynecology Service Chair of Department of Obstetrics and Gynecology
Professor, Weill Cornell Medical College University of Navarra
Vice Chair Technology Madrid, Spain
Department of Surgery
Memorial Sloan Kettering Cancer Center David Cibula, MD, PhD
New York, New York Gynecologic Oncology Center
Department of Obstetrics and Gynecology
David M. Adelman, MD, PhD, FACS First Faculty of Medicine
Associate Professor Charles University in Prague and General University Hospital
Division of Plastic Surgery in Prague
The University of Texas MD Anderson Cancer Center Prague, Czech Republic
Houston, Texas
Kathryn G. Cunningham, MD
Giovanni Aletti, MD Fellow
Associate Professor in Obstetrics and Gynecology Department of Urology
University of Milan The University of Texas MD Anderson Cancer Center
Director, Unit of New Therapeutic Strategies in Ovarian Houston, Texas
Cancer
European Institute of Oncology Pedro F. Escobar, MD, FACOG, FACS
Milan, Italy Instituto Gyneco-Oncológico
San Juan, Puerto Rico
Mara B. Antonoff, MD Associate Clinical Professor of Surgery
Assistant Professor Cleveland Clinic
Department of Thoracic and Cardiovascular Surgery Cleveland, Ohio
The University of Texas MD Anderson Cancer Center
Houston, Texas Ramez N. Eskander, MD
Assistant Clinical Professor
Anne-Sophie Bats, MD Division of Gynecologic Oncology
Paris Descartes University Department of Reproductive Medicine
Sorbonne Paris Cité University of California San Diego
School of Medicine Moores Cancer Center
Assistance Publique–Hôpitaux de Paris La Jolla, California
Hôpital Européen Georges-Pompidou
Gynecological and Breast Cancer Surgery Anna Fagotti, MD
Paris, France Division of Gynecologic Oncology
Catholic University of the Sacred Heart
David M. Boruta, MD Rome, Italy
Associate Professor
Department of Obstetrics and Gynecology Gwenael Ferron, MD, PhD
Tufts University School of Medicine Department of Surgical Oncology
Chief of Gynecologic Oncology Institut Claudius Regaud–Institut Universitaire du Cancer
Steward Health Care System Toulouse, France
Boston, Massachusetts
Katherine Fritton, MD
Robert Bristow, MD, MBA Department of Gynecology and Obstetrics
Professor and Chair The Johns Hopkins University
Obstetrics and Gynecology Baltimore, Maryland
University of California, Irvine School of Medicine
Orange, California Michael Frumovitz, MD, MPH
Professor and Fellowship Director
Jvan Casarin, MD Department of Gynecologic Oncology and Reproductive
Research Fellow Medicine
Division of Gynecologic Surgery The University of Texas MD Anderson Cancer Center
Mayo Clinic Houston, Texas
Rochester, Minnesota

vi
 Contributors vii

Fabio Ghezzi, MD Javier Magrina, MD

Professor and Head Director of Minimally Invasive Gynecologic Surgery
Department of Obstetrics and Gynecology Mayo Clinic
University of Insubria Scottsdale, Arizona
Varese, Italy President, Fellowship Board of Directors
American Association of Gynecologic Laparascopists
Gretchen E. Glaser, MD Cypress, California
Consultant
Division of Gynecologic Surgery Andrea Mariani, MD, MS
Mayo Clinic Professor
Rochester, Minnesota Division of Gynecologic Surgery
Mayo Clinic
Tam T.T. Huynh, MD Rochester, Minnesota
Department of Thoracic and Cardiovascular Surgery
Department of Interventional Radiology Alejandra Martinez, MD
The University of Texas MD Anderson Cancer Center Department of Surgical Oncology
Houston, Texas Institut Claudius Regaud–Institut Universitaire du Cancer
Toulouse, France
Maria D. Iniesta, MD, PhD
Senior Coordinator Clinical Studies Patrice Mathevet, MD, PhD
Department of Gynecologic Oncology and Reproductive Department of Gynecology
Medicine CHU Vadois
The University of Texas MD Anderson Cancer Center Lausanne, Switzerland
Houston, Texas
Reza J. Mehran, MD
Anuja Jhingran, MD Department of Thoracic and Cardiovascular Surgery
Department of Radiation Oncology The University of Texas MD Anderson Cancer Center
Division of Radiation Oncology Houston, Texas
The University of Texas MD Anderson Cancer Center
Houston, Texas Craig A. Messick, MD
Assistant Professor of Surgery
Jose A. Karam, MD Department of Surgical Oncology
Assistant Professor Section of Colon and Rectal Surgery
Department of Urology The University of Texas MD Anderson Cancer Center
The University of Texas MD Anderson Cancer Center Houston, Texas
Houston, Texas
Bassem Mezghani, MD
Anna Kuan-Celarier, MD Department of Surgical Oncology
Resident Institut Claudius Regaud–Institut Universitaire du Cancer
Department of Obstetrics and Gynecology Toulouse, France
Louisiana State University Health Science Center Salah Azaiz Cancer Institute
New Orleans, Louisiana Tunis, Tunisia

Eric Leblanc, MD Lucas Minig, MD, PhD

Head, Department of Gynecologic Oncology Head
Centre Oscar Lambret Department of Gynecology
Lille, France Instituto Valenciano de Oncologia
Valencia, Spain
Fabrice Lécuru, MD, PhD
University Paris Descartes Miziana Mokbel, MD
Sorbonne Paris Cité Assistance Publique–Hôpitaux de Paris
School of Medicine Hôpital Européen Georges-Pompidou
Assistance Publique–Hôpitaux de Paris Gynecological Cancer and Breast Cancer Surgery
Gynecological and Breast Cancer Surgery Paris, France
Paris, France
Camilla Nero, MD
Mario M. Leitao, Jr., MD Division of Gynecologic Oncology
Attending Gynecologic Oncologist Catholic University of the Sacred Heart
Department of Surgery Rome, Italy
Memorial Sloan Kettering Cancer Center
Professor of Obstetrics and Gynecology
Weill Cornell Medical College
New York, New York
viii Contributors

Crystal Nhieu, MD, BS Giovanni Scambia, MD

Resident Division of Gynecologic Oncology
Department of Obstetrics and Gynecology Catholic University of the Sacred Heart
Louisiana State University Health Science Center Rome, Italy
Baton Rouge, Louisiana
Brooke A. Schlappe, MD
Rene Pareja, MD Gynecologic Oncology Fellow
Department of Gynecologic Oncology Department of Surgery
Instituto Nacional de Cancerologia Memorial Sloan Kettering Cancer Center
Bogotá, Colombia New York, New York
Clínica de Oncología Astorga
Medellín, Colombia Yukio Sonoda, MD
Gynecologic Oncologist
Manuel Penalver, MD Department of Surgery
Chairman, Department of Obstetrics and Gynecology Memorial Sloan Kettering Cancer Center
Herbert Wertheim College of Medicine New York, New York
Florida International University
Miami, Florida Edward Tanner, MD
Assistant Professor
George T. Pisimisis, MD Department of Gynecology and Oncology
Department of Thoracic and Cardiovascular Surgery The Johns Hopkins University
Department of Interventional Radiology Baltimore, Maryland
The University of Texas MD Anderson Cancer Center
Houston, Texas Audrey T. Tsunoda, MD, PhD
Surgical Oncologist
Pedro T. Ramirez, MD Department of Surgical Oncology
Professor Erasto Gaertner Hospital
David M. Gershenson Distinguished Professor in Ovarian Curitiba, Brazil
Cancer Research
Director of Minimally Invasive Surgical Research and Stefano Uccella, MD, PhD
Education Consultant
Department of Gynecologic Oncology and Reproductive Department of Obstetrics and Gynecology
Medicine University of Insubria
The University of Texas MD Anderson Cancer Center Varese, Italy
Houston, Texas
Giuseppe Vizzielli, MD
Reitan Ribeiro, MD Division of Gynecologic Oncology
Surgical Oncologist Catholic University of the Sacred Heart
Medical Residency Director Rome, Italy
Department of Surgical Oncology
Erasto Gaertner Hospital Vanna Zanagnolo, MD
Curitiba, Brazil Division of Gynecology
European Institute of Oncology
Emery Salom, MD Milan, Italy
Clerkship Director and Assistant Professor
Florida International University Oliver Zivanovic, MD
College of Medicine Attending Physician
Division of Gynecologic Oncology Department of Surgery
Miami, Florida Memorial Sloan Kettering Cancer Center
New York, New York
Gloria Salvo, MD
Department of Gynecologic Oncology and Reproductive
Medicine
The University of Texas MD Anderson Cancer Center
Houston, Texas

David A. Santos, MD
Assistant Professor of Surgery
Department of Surgical Oncology
The University of Texas MD Anderson Cancer Center
Houston, Texas

The first edition of Principles of Gynecologic Oncology Surgery
capitalizes on the talents of three world-renowned experts in
the field of gynecologic cancer surgery. Drs. Ramirez, Frumo-
vitz, and Abu-Rustum have used the vast expertise of leaders
in the field—in the United States and abroad—to produce one
of the most comprehensive textbooks on the surgical manage-
ment of patients with gynecologic cancer. In the textbook’s
first section, “Anatomy and Principles of Surgery,” the editors
and authors provide their readers with in-depth descriptions of
basic principles of anatomy required for radical upper abdomi-
nal and pelvic surgery. The authors also integrate detailed high-
lights of all the items in the guidelines for the timely issue of
Enhanced Recovery After Surgery (ERAS). The subsequent
sections focus on detailed descriptions of surgical procedures
according to anatomic site of disease, including vulvar, cervi-
cal, uterine, and ovarian cancer. For each disease site, individual
chapters explore intricate surgical procedures, including state of
the art techniques of sentinel lymph node mapping for cervi-
cal and endometrial cancers. In addition, the disease chapters
provide a comprehensive review of surgical techniques. For cer-
vical cancer this includes the entire spectrum of surgical pro-
cedures from conservative fertility-sparing procedures for early
stage disease to radical surgery for more advanced disease, with
a separate section highlighting ultraradical pelvic exenteration
Foreword
for recurrent disease. The ovarian cancer section provides a
comprehensive roadmap for the surgical management of this
disease, including indications for laparoscopic assessment for
cytoreduction through radical upper abdominal procedures and
intestinal surgery for the debulking of advanced ovarian cancer.
In addition to the chapters on surgical management of
gynecologic cancers, one of the major strengths of Principles of
Gynecologic Oncology Surgery is its coverage of surgery on the
gastrointestinal and urinary tracts, as well as the management
of surgical complications associated with these procedures.
Finally, the management of complications associated with radia-
tion therapy, as well as techniques in pelvic reconstruction and
the role of minimally invasive approaches with laparoscopic and
robotic techniques, provides for a well-rounded and compre-
hensive textbook.
Principles of Gynecologic Oncology Surgery is destined to be
an authoritative, high-quality resource in the field for years to
come, whether for a resident, fellows in training, or a well-
established practitioner. This textbook will play a significant
role in developing and sharpening the skills of those dedicated
to the surgical treatment of women with gynecologic cancer.
Richard R. Barakat, MD
ix
Preface
In gynecologic oncology surgery, the surgeon must have a
detailed understanding of the anatomy and basic principles of
radical abdominal and pelvic surgery. In addition, each surgeon
must have a vast fund of knowledge about diagnosing and man-
aging complications related to such complex surgical proce-
dures. In this first edition of Principles of Gynecologic Oncology
Surgery, we aim to provide a comprehensive surgical textbook
that will serve not only experienced surgeons in gynecologic
oncology but also trainees and all those interested in learning
the pertinent details related to various topics of surgery for each
disease site in gynecologic cancers. The guiding principles for
any gynecologic surgeon are (1) to understand the relevant and
updated literature related to a disease site or surgically related
topic, (2) to have a solid understanding of the principles of eval-
uation and management of most surgical scenarios in gyneco-
logic oncology surgery, and (3) to derive treatment based on the
most up-to-date published literature.
This book is intended for all who wish to have a step-by-step
guide to the most commonly performed procedures in gyne-
cologic oncology. Our intent is for students of surgery, both
novice and experienced, to have a classic textbook where they
can go not only to find the most relevant and concise source of
literature on a particular subject but also to seek details on the
specific and key steps of surgical procedures and where they can
learn the ideal approach for each step of the surgery from lead-
ing surgeons throughout the world.
The world of surgery in gynecologic oncology is evolving
at a fast pace. Surgeons today are required to have a mastery
of innumerable approaches to gynecologic cancer surgery and
are expected to become proficient not only in open surgery but
also in minimally invasive surgery, such as laparoscopy and
robotic surgery. New tools are constantly being developed that
demand the surgeon’s time and skill, particularly in the early
learning phases. In addition, surgeons are expected to learn
new approaches in the management of gynecologic cancers,
such as sentinel lymph node mapping, with the understanding
that the quality of the surgery dictates whether a patient will
have a full lymphadenectomy or be spared such a procedure
and potentially avoid its associated adverse effects. This evolu-
tion of surgical education has changed the methods by which
surgeons acquire the necessary skills to perform gynecologic
oncology surgery, and these include surgical simulators, web-
based surgical training, seminars on video series, and live tele-
surgery. These are among some of the most common avenues
for learning today, and therefore surgeons must adapt to this
wave of “nontraditional” learning. In this textbook, we aim to
provide such video-based teaching when applicable. Surgeons
will be able to observe some of the most skilled surgeons in
the world performing procedures of high complexity that will
surely supplement and improve the surgical skills and practice
of each reader.
x
The goal of this textbook is to provide a format designed so that
surgeons will have quick and easy access to relevant information—
a textbook that will present information that is simple to under-
stand and fast to apply. In other words, we hope that surgeons will
use this book as a tool that will allow them to go over the steps
of each procedure just before entering the operating room. We
have compiled chapters that will serve as a roadmap to navigate
the complex anatomy of the abdomen or pelvis, with figures and
illustrations that will provide descriptive strategies to achieve the
best results in the surgery. Video demonstrations, when appli-
cable, will also allow the reader to have immediate access to the
operating room of the skilled surgeons who wrote each chapter
and to learn from them the secrets to the success of their surgi-
cal approach. The success of this textbook rests on the contribu-
tions from each of the internationally renowned chapter authors.
They have all put in a tremendous amount of effort in writing and
editing of the ­chapters. In addition, the entire project would not
have been p ­ ossible without the tremendous amount of work, guid-
ance, patience, and experience of the Elsevier editing team. We are
deeply grateful to all who have contributed to this textbook.
Finally, we are indebted to our mentors who, since early in our
careers, took the time and the effort to teach us their approach
and to provide us with the best “tips and tricks” to make com-
plex surgical procedures more feasible. Their constructive criti-
cism and detailed explanations are the essence of this textbook.
The inspiration they provided is translated in the pages of this
textbook as a testament to the legacy that each of our surgical
mentors instilled in us. Our duty is to see that this textbook
serves as a tool that will enable gynecologic oncology surgeons
throughout the world to provide the best and most comprehen-
sive surgical care to patients with gynecologic cancers. We are
also grateful to our patients who not only endure the burden
of disease but also allow us the privilege, every day, to care for
them. The gynecologic oncology surgeon must remind himself
or herself every day that he or she is gifted with the amazing
responsibility of eradicating cancer, and that to fulfill this hon-
orable task, we must seek each day to expand our fund of knowl-
edge, enhance our surgical skills, and integrate new and novel
approaches and technology. Most of all, though, we must seek
to remain humble in the face of such profound responsibility.
Let us all remember that each time we enter the operating room,
our fate and that of our patient lie not only in the skills of our
hands or the capacity of our tools but more so on our ability to
make sound decisions that will always prioritize, above all, the
well-being of our patients. We hope that this textbook will serve
all who read it to become not only better surgeons and clinicians
but also better doctors.
Pedro T. Ramirez, MD
Michael Frumovitz, MD
Nadeem Abu-Rustum, MD
 SECTION 1 | Anatomy and Principles o“
CHAPTER 1
Introduction to Principles of
Gynecologic Oncology Surgery
PEDRO T. RAMIREZ
The modern era of gynecologic oncology surgery began in
the 20th century with groundbreaking work by pioneering
surgeons who explored novel surgical options for women
with gynecologic malignancies. Gynecologic oncology was
not approved as a subspecialty of obstetrics and gynecology
until 1973, when the American Board of Medical Specialties
approved it as a special qualification. Subsequently, the Society
of Gynecologic Oncology (SGO) was created, and much of the
credit for its foundation must be given to Hervy E. Averette
and John I. Mikuta. The first scientific meeting of the SGO was
held in Key Biscayne, Florida, in 1969.
Over the course of the past century, this specialty has wit-
nessed tremendous advances in surgical technique and indi-
cations. Major innovations have been seen in imaging, cancer
detection, sentinel lymph node mapping, and technology with
the introduction of laparoscopy and robotic surgery. The field
has shifted from very aggressive and deforming procedures to
more precise and conservative approaches. Women with gyne-
cologic cancer have options that would never even have been
considered until just a few years ago. In tumors of the vulva,
patients no longer undergo morbid radical tumor resection
along with extensive groin lymphadenectomy. Extensive work
evaluating the role of local excision combined with sentinel
lymph node alone has led to the current tailored approaches
oifered to patients and thus a decrease in rates of perioperative
complications and long-term side effects, such as debilitating
lymphedema. The management of cervical cancer has evolved
from the times of ultraradical surgery, such as radical hyster-
ectomy, to modified radical surgery, fertility-preserving radical
trachelectomy, or simple conization. Patients with early cervical
cancer should no longer be exposed to extensive lymphadenec-
tomy but, rather, should undergo selective and targeted senti-
nel lymph node mapping. For patients with locally advanced
cervical cancer, the role of pretreatment selective lymph node
dissection has been established as a tool to more definitively
focus on the area of interest for radiation therapy. In patients
with endometrial cancer, laparoscopy or robotic surgery has
provided impressive outcomes, including fewer intraoperative
and postoperative complications, when compared with open
surgery. Sentinel lymph node mapping algorithms have also
mebooksfree
become standard of care in most centers, thus allowing patients
to undergo less morbid procedures with faster recoveries.
More recently, hysteroscopic resection of endometrial tumors
in patients with low-risk disease has allowed young women
interested in future fertility to undergo treatment that spares
the uterus while at the same time treats the cancer. Even in the
setting of advanced ovarian cancer, patients are more appropri-
ately selected for up-front cytoreductive surgery or neoadjuvant
chemotherapy according to the results of increasingly more
accurate imaging modalities and through the direct assessment
of abdominal tumor burden by means of laparoscopic surgery.
Similarly, improvements in perioperative management and
critical care allow surgeons to be much more aggressive when
performing cytoreductive surgery or exenterative procedures
in patients selected to undergo tumor debulking for advanced
ovarian cancer.
Principles of Gynecologic Oncology Surgery is a broad and
comprehensive textbook for all surgeons whose primary prac-
tice involves the care of women with gynecologic cancers. In
each chapter, the reader learns the latest and most clinically rel—
evant updates from the published literature on the topic of focus
of that particular chapter. In addition, each chapter presents
information in a format that is practical in the management of
patients with gynecologic malignancies. For each disease site,
the reader should appreciate standard recommendations in the
initial evaluation, the preoperative workup, the step-by-step
approach to the surgical procedures pertinent to that disease
site, and the postoperative evaluation in the setting of complica-
tions for each of the procedures presented.
A number of chapters address topics that are all-encompass-
ing in the field of gynecologic oncology surgery. These include
chapters on Enhanced Recovery After Surgery, which is a topic
of significant impact in the perioperative care of all surgical
patients but one that is becoming increasingly more important
in all women undergoing gynecologic surgery. In that chapter,
the authors outline the current guidelines to be implemented
in any Enhanced Recovery After Surgery program, with an
emphasis on the importance of compliance with each of these
guidelines and, ultimately, a summary of the outcomes associ-
ated with the implementation of such programs. The textbook
2 Section 1 Anatomy and Principles of Surgery
also provides information on related and relevant surgical top-
ics such as surgery of the intestinal and urinary tract, as well as
reconstructive surgery. In each of these chapters, experts in the
respective fields provide their approach in performing proce-
dures within their area of expertise that are pertinent to gyneco-
logic oncology surgery. Each provides tips and tricks in how to
achieve the best results when performing complex procedures.
Their valuable input allows gynecologic oncology surgeons to
gain insight into the perspective brought by each of these spe-
cialists when consulted.
The work presented in this textbook is a composite repre-
sentation of the outstanding contributions made to the field of
gynecologic oncology by innumerable investigators over many
years. The information presented in each chapter pays tribute
to the endless hours and to the unselfish commitment that such
individuals have made to improve the outcome of women with
gynecologic cancers. Their innovative thinking and courage to
explore beyond the status quo will continue to inspire those in
all corners of the globe who continue to strive to find better
strategies for prevention, diagnosis, management, and surveil-
lance of gynecologic cancers. In this work, the amazing con-
tribution of many patients must also be recognized. Through
the history of this field, these patients have endured the impact
of gynecologic cancers, and through their courage, they helped
advance this field. These are patients who, in light of limited
data at different times through history, accepted new diagnostic
and surgical approaches, who agreed to be among the firsts by
enrolling in promising surgical trials, and who gave of them-
selves so that others in the future could undergo better and
more targeted treatment. With this textbook, tribute is paid to
these patients—the true heroes who have left a lasting mark on
this field.
 CHAPTER 2 mebooksfree
Abdominal and Pelvic Anatomy
LUIS M. CHIVA I JAVIER MAGRINA
Anatomy is to physiology as geography is to history; it describes
the theater of events.
IEAN FRANCOIS FERNEL
All gynecologic oncology surgeons should be familiar with
the anatomy of the abdomen and pelvis to perform all com-
plex and radical procedures required in the surgical manage-
ment of women with gynecologic tumors. There has been an
increasing emphasis on the role of upper abdominal surgery,
particularly in the setting of advanced ovarian cancer. There-
fore it is imperative that surgeons understand the detailed
anatomy of the upper abdomen, in addition to the pelvic anat-
omy. A strong emphasis should be placed on the training of
surgeons embarking on a career in gynecologic oncology to
impart to them the skills and abilities to become proficient
in surgery of the abdomen and pelvis. Gynecologic oncolo-
gists must understand the principles of multiple surgical
disciplines, such as hepatobiliary surgery, urologic surgery,
colorectal and intestinal surgery, and vascular surgery. The
goal of this chapter is to provide surgeons with the anatomic
details of the abdomen and pelvis. The material presented
here aims to describe all structures relevant to the gyneco-
logic oncologist.
Pelvic Anatomy
Pelvic anatomy remains the primary domain of the gyneco-
logic surgeon. As a result, all who perform surgery in the pel-
vis should be thoroughly familiar with its intricate anatomic
landmarks. The pelvic anatomy is complex and requires a great
deal of expertise, given its detailed vascular and nerve structure,
which demands the surgeon’s careful attention to the steps of the
procedures. The consequences of severe complications, such as
severe hemorrhage from vascular lacerations; fistulas of the uri-
nary or gastrointestinal tract from injury to structures such as
ureters, bladder, or bowel; and neuropathic injuries from lacera-
tions or thermal injuries to nerves may all be potentially avoided
by the surgeon’s devoting time to learning the complex anatomy
of the pelvis (Fig. 2.1).
Bony Pelvis
The bones that form the pelvis of the newborn are the ilium,
ischium, pubis, sacrum, and coccyx. The ilium, ischium, and
pubis join together at the age of 16 to 18 years to form a sin-
gle bone, called the pelvic bone. Accordingly, in the adult, the
bones of the pelvis comprise the right and left pelvic bones,
the sacrum, and the coccyx (Fig. 2.2). This bony pelvis is a
firm structure to which all the pelvic ligaments and muscles
are attached.
Ilium
The upper part of the pelvic bone is the ilium. Its superior aspect
enlarges to form a flat wing that provides support for the mus-
cles of the lower abdomen; it is also called the “false pelvis.” The
medial surface of the ilium has two concavities forming the lat-
eral borders of the pelvic channel. The superior and larger of
these two concavities is the greater sciatic notch, and the ischial
spine is its most prominent landmark.
lschium
The ischium is the posterior and inferior part of the pelvic bone.
The ischial spine marks the posterior margin of the bone.
Pubis
The anterior and inferior part of the pelvic bone is the pubis. The
superior and inferior pubic branches are located anteriorly and
articulate in the midline at the pubic symphysis.
Sacrum
The sacrum is composed of five sacral vertebrae that are
fused together. Nerve outlets are positioned anterior and
laterally; the sacral nerves run through them. The coccyx is
attached inferiorly and is the posterior border of the pelvic
outlet (Fig. 2.3).
Orientation of the Bony Pelvis
Typically, surgeons operate with the pelvis in the horizontal
position. However, in the erect woman the pelvis is naturally
oriented so that the anterior superior iliac spine and the front
4 Section 1 Anatomy and Principles of Surgery
A B
Sacrum
Right pelvic Left pelvic
bone bone
Coccyx
FIG. 2.2 The bones of the pelvis comprise the right and left pelvic
bones, the sacrum, and the coccyx.
edge of the pubic symphysis are in the same vertical plane, per-
pendicular to the ground. Therefore the pelvic inlet is tilted
anteriorly, and the urogenital hiatus is parallel to the ground.
This directs the pressure of the pelvic contents and forces them
toward the pelvic bones instead of toward the muscular floor.
Accordingly, in this position, the bony pelvis is oriented so that
forces are distributed to diminish the stress on the pelvic mus-
culature. In summary, most of the load of the abdominal and
pelvic viscera is supported by this bony articulation inferiorly
(Fig. 2.4).
Anatomic Landmarks of the Bony Pelvis
The bones of the pelvis show some significant surgical land-
marks that are important when the surgeon is operating inside
the pelvis, including the ischial spine, coccyx, pubic arch, and
pectineal line (Fig. 2.5).
Ischial Spine
The ischial spine is a sharp protuberance on the inner sur-
face of the ischium that separates the greater from the lesser
sciatic notch. The ischial spine is important clinically and
anatomically because it can be palpated easily via the vagina
and rectum or throughout the retropubic space and serves
as a point of fixation for many structures that are important
for pelvic organ support. The arcus tendineus levator ani
inserts posteriorly on the ischial spine. Also, the ischial spine
represents the lateral attachment site of the sacrospinous
ligament.
FIG. 2.1 (A) Preperitoneal appear-
ance. (B) Retroperitoneal appearance.
The pelvis is a complex anatomic area.
Extraordinary knowledge and exper-
tise are required when radical proce-
dures are performed, especially within
the retroperitoneum.
Coccyx
The coccyx is the terminal portion of the sacrum and consists
of four joined coccygeal vertebrae. It is palpable through the
vagina and the rectum and is a valuable landmark surgically for
many pelvic interventions.
Pubic Arch
The two pubic bones form an arch beneath the pubic symphysis.
The pubic arch serves as the upper and lateral borders of the
urogenital triangle, under which the distal urethra and vagina
exit. The mean pubic arch angle is 70 to 75 degrees; however, a
wide variability can be seen.
Pectineal Line
The edge along the superior, medial surface of the superior
pubic rami is denominated the pectineal line. Anteriorly, this
line is continuous with the pubic crest. Overlying the pectineal
line is the Cooper ligament.
Pelvic Ligaments
Two main ligaments connect the pelvic bones to the sacrum
and coccyx: the sacrotuberous ligament and the sacrospinous
ligament. These ligaments also convert the two indentations on
the pelvic bones in two exit areas on the lateral pelvic walls: the
greater and lesser sciatic foramina (Fig. 2.6).
Sacrospinous Ligament
The sacrospinous ligament is a strong, triangular ligament; the
high point of this ligament attaches to the ischial spine laterally,
and the base joins to the distal sacrum and coccyx medially. This
ligament divides the lateral pelvic outlet into two foramina: the
greater sciatic foramen superiorly and the lesser sciatic foramen
inferiorly. The coccygeus muscle is located on the superior sur-
face of the sacrospinous ligament. The pudendal neurovascular
package crosses behind the ischial spine and lateral aspect of
the sacrospinous ligament as it exits the pelvis and enters the
ischiorectal fossa. The S3 sacral nerve root and the pudendal
nerve run over the superior margin of the sacrospinous liga-
ment. The inferior gluteal artery, a branch of the posterior trunk
of the internal iliac, is located close above the superior border of
the sacrospinous ligament.
Sacrotuberous Ligament
The sacrotuberous ligament is also a triangular ligament. It has
a broad base that extends from the posterior superior iliac spine
 Chapter 2 Abdominal and Pelvic Anatomy 5

Ilium
AIa
Iliac crest
Posterior
superior
iliac spine Anterior superior
iliac spine
Posterior
inferior Anterior inferior
iliac spine iliac spine

Greater sciatic
notch Acetabulum

Ischial body Body of pubis

Ischial spine
Pubis
Ischial
tuberosity
Inferior ramus
of pubis
Ischium
Obturator
Ischial ramus
foramen FIG. 2.3 External view of the right pelvic bone.

Ilium

Iliac fossa
Iliac crest Posterior
superior
iliac spine
Anterior
superior
iliac spine

Body of Auricular
ilium surface

Superior ramus
of pubis

Obturator
Articular surface foramen
of pubis (at pubic
symphysis) Ischium

Inferior ramus Ischial ramus

of pubis FIG. 2.4 Medial view of the right pelvic bone.

along the lateral margin of the sacrum and coccyx. The apex
of the ligament is attached to the medial margin of the ischial
tuberosity. The sacrotuberous ligament forms the lateral-­inferior
border of the lesser sciatic foramen.
Pelvic Muscles
Muscles of the Lateral Pelvis
The obturator internus and piriformis are the muscles of the
pelvic sidewalls.
Obturator Internus Muscle
The obturator internus muscle is found on the superior inner
side of the obturator membrane. The obturator internus muscle
originates from the inferior margin of the superior pubic ramus
and from the pelvic surface of the obturator membrane. Its ten-
don exits the pelvis through the lesser sciatic foramen to insert
onto the greater trochanter of the femur to laterally rotate the
thigh. This muscle is innervated by the obturator internus nerve
(L5–S2).
6 Section 1 Anatomy and Principles of Surgery
Anterior superior iliac spine
Pelvic inlet
Pubic tubercles
Pubic arch
FIG. 2.5 The orientation of the bony pelvis in the erect female. Pubic
tubercles and anterosuperior iliac spines lie in the same vertical plane.
Ischial spine
Pubic arch
Coccyx
Pectineal line
FIG. 2.6 Surgical anatomic landmarks of the bony pelvis.
Piriformis Muscle
The piriformis muscle is part of the pelvic sidewall and is located
posteriorly and lateral to the coccygeus muscle. It extends from
the anterolateral sacrum to pass through the greater sciatic fora-
men and insert on the greater trochanter. Lying on top of the
piriformis is a particularly large neurovascular plexus, the lum-
bosacral plexus.
Muscles of the Pelvic Floor
The skeletal muscles of the pelvic floor include the levator ani
muscles and the coccygeus muscle. Both constitute the levator
ani complex, called the levator platform when it is inserted in
the midline.
Levator Ani Muscle Complex
The levator ani muscle complex is formed by several segments:
the pubococcygeus, puborectalis, and iliococcygeus muscles. The
urogenital hiatus is the space between the levator ani musculature
through which the urethra, vagina, and rectum pass. Muscles of
the pelvic floor, particularly the levator ani muscles, provide sup-
port to the pelvic visceral organs and play an integral role in uri-
nary voiding, evacuation, and sexual function.
Arcus Tendineus Levator Ani
There is a linear thickening of the pelvic fascia covering the
obturator internus muscle called the arcus tendineus levator ani.
This thickened fascia forms a perceptible line from the ischial
spine to the posterior surface of the superior pubic ramus in
both sides. The muscles of the levator ani originate from this
musculofascial attachment.
Puborectalis Muscle
The puborectalis muscle originates on the pubic bone, and its
fibers pass posteriorly, forming a sling around the vagina, rec-
tum, and perineal body. This results in the anorectal angle and
promotes closure of the urogenital hiatus (Figs. 2.7–2.12).
Avascular Spaces
Owing to its embryologic development, the pelvis comprises a
number of avascular spaces and connective tissue planes that
allow the different viscera to function independently. These
spaces are limited by some of the visceral branches of both
hypogastric arteries. Commonly they contain blood vessels and
nerves and are filled with lax areolar tissue, allowing blunt and
easy dissection without rupture of these structures (Fig. 2.13).
The avascular spaces of the female pelvis include two lateral
spaces (paravesical and pararectal) in both sides and four cen-
tral spaces (space of Retzius or prevesical, vesicovaginal, recto-
vaginal, and presacral spaces) (Fig. 2.14).
Retropubic Space (Space of Retzius)
The retropubic space, also called the space of Retzius, is a vir-
tual space between the bladder and the pubic bone. The pubic
bone, the peritoneum, and the muscles of the anterior abdomi-
nal wall limit it. Its lateral borders are the arcus tendineus and
the ischial spines. Within the retropubic space appears the dor-
sal clitoral neurovascular bundle, located in the midline, and
the obturator neurovascular pack, located laterally as it enters
the obturator canal. In some women, an accessory obturator
artery arises from the external iliac artery and runs along the
pubic bone. The space lateral to the bladder neck and urethra
contains some nerves innervating the bladder and urethra, as
well as the venous plexus of Santorini, that results in excessive
bleeding if the proper dissection is not performed. The dissec-
tion of this space must be a blunt dissection close to the pubic
bone, avoiding the clitoral neurovascular bundle. The dissection
is facilitated with a full bladder, which outlines its boundaries
very clearly. The median umbilical ligament or urachus can then
be grasped with downward traction and transected with mono-
polar cautery to enter the retropubic space (Fig. 2.15).
Paravesical Spaces
The paravesical spaces are two lateral spaces that are localized
anterior to the lateral parametria, lateral to the bladder, and
lateral to the space of Retzius. Their margins are the superior
vesical artery and bladder pillars medially; the external iliac ves-
sels, obturator internus, and levator ani muscles laterally; the
pubic bone anteriorly; and the lateral parametrium posteriorly.
The paravesical space needs to be developed at the beginning
for most pelvic radical procedures. Moreover, its dissection is
 Greater sciatic foramen
Anterior superior
iliac spine

Margin of pelvic inlet

Lesser sciatic foramen

Sacrospinous ligament
Pubic tubercle Sacrotuberous ligament

Obturator foramen

Ischiopubic ramus Ischial tuberosity

FIG. 2.7 Sacrospinous and sacrotuberous ligaments delineate both greater and lesser sciatic foramina.

Inferior pubic Pubic symphysis

ligament
Deep dorsal
Inguinal ligament
vein of clitoris
(Poupart)
Transverse Fascia of deep
perineal perineal muscles
ligament Obturator canal
Urethra
Vagina Obturator fascia
(over obturator
Rectum internus muscle)
Iliococcygeus
muscle (part of Puborectalis and
levator ani muscle) pubococcygeus
muscles (part of
Levator late levator ani muscle)
(median raphe) of
levator ani muscle Tendinous arch of
levator ani muscle
Coccyx
Ischial spine
Anterior
sacrococcygeal
ligament (Ischio-)
coccygeus muscle
Sacral promontory
Piriformis muscle
FIG. 2.8 Muscles of the wall and floor of the pelvis.

Obturator muscle Urethra

Vagina Arcus tendineus

Arcus tendineus
levator ani Left
levator ani
obturator m.

Levator Coccygeus m.
muscle Left
Rectum Piriformis m. levator ani m.
Bladder
neck

FIG. 2.9 Pelvic floor after supralevator anterior exenteration. FIG. 2.10 Pelvic floor after a total supralevator exenteration. Lateral
view from the right side of the patient.
8 Section 1 Anatomy and Principles of Surgery

Left levator ani Cooper ligament

Bladder neck

Right obturator m. Visceral branches of

Arcus tendineus the hypogastric arteries
levator ani
Middle
Rectal stump rectal a.

Left coccygeus m. Uterine a.

Promontorium sacrum Superior

vesical a.

FIG. 2.11 Pelvic floor after a total supralevator exenteration. Central

view.
FIG. 2.14 Schema showing the lateral avascular spaces limited by
the main visceral branches of the hypogastric artery. The superior vesi-
cal artery is the key to dissecting the lateral pelvic spaces. The middle
rectal artery shown here is not present in all patients.

Parametrial insertion indispensable to identify the anterior aspect of the lateral para-
Uterosacral metria or cardinal ligament. After transection of the round
insertion ligament, the surgeon develops this space softly between the
superior vesical artery medially and the external iliac vessels
laterally and medially displaces the lateral aspect of the bladder.
Levator muscle Pararectal Space
Urogenital The pararectal spaces are bilaterally located posterior to the
Sacrococcygeal hiatus lateral parametria or cardinal ligaments. The cardinal ligament
ligament defines the borders of the pararectal space anteriorly; the space
is defined medially by the rectum, posteriorly by the sacrum,
Pubic and laterally by the internal iliac artery or pelvic sidewall. The
symphysis
Coccyx pararectal space must always be developed at the time of radical
hysterectomy and pelvic exenteration. Opening the broad liga-
ment parallel and lateral to the infundibulopelvic ligament per-
FIG. 2.12 Pelvic floor after a total infralevator exenteration. Lateral mits access to this space. The displacement of the uterus medially
view from the right. helps to expose the pararectal space. The ureter must be identi-
fied, and it usually remains attached to the peritoneum of the
posterior leaf of the broad ligament. Then the space between the
ureter and the internal iliac artery is developed with meticulous
blunt dissection, avoiding bleeding of small vessels in this area
that could delay the dissection (Figs. 2.16 and 2.17).
Left obturator m.
Vesicovaginal Space
Fat of ischioanal The vesicovaginal space is located in the midline. Its limits are
fossa
the bladder anteriorly, the bladder pillars laterally, and the vagina
Left levator ani m. posteriorly. The bladder pillars are composed of connective tis-
partially removed
IORT sue and vessels, particularly small veins from the vesical plexus,
blanket and some cervical branches and contain the parametrial portion
of the ureters. This plane is essential for the performance of any
type of hysterectomy. To dissect the space, the surgeon should
Left coccygeus m. make a sharp incision in the midline between the bladder pil-
lars; this incision will reveal a loose areolar avascular layer when
in the proper plane. Misplacing the correct anatomic plane can
result either in bleeding or in a bladder injury (Fig. 2.18).

FIG. 2.13 Pelvic floor after a total infralevator exenteration and remov-
Rectovaginal Space
al of levator ani complex. Application of intraoperative high–dose-rate The rectovaginal space separates the posterior vaginal wall
brachytherapy. IORT, Intraoperative radiotherapy. from the rectum. It starts at the pelvic cul-de-sac and extends
 Chapter 2 Abdominal and Pelvic Anatomy 9

Prevesical space
(of Retzius)
Pubovesical
ligament
Vesical fascia
Bladder
Cervical fascia Vesicovaginal
space
Vesicouterine Paravesical
ligament space
Cervix
Uterosacral Retrovaginal
ligament space
Carinal
ligament
Rectal fascia Rectum
Pararectal FIG. 2.15 The pelvic spaces as well as
Posterior sheath space uterine ligaments are demonstrated in this
of the rectal
Retrorectal drawing. (Modified from Peham H, Amreich
septum
space J. Operative Gynecology. Philadelphia: JB
Sacrum Lippincott Company; 1934.)

Right paravesical
space

Retzius space Right cardinal

ligament

Bladder

Right ureter
Right pararectal
space

FIG. 2.18 View during a radical hysterectomy of lateral pelvic spaces

demonstrated on the right side of the pelvis. Anteriorly is the para-
vesical space, and posteriorly the pararectal space. In between both
spaces, the lateral parametrium is seen.
FIG. 2.16 The retropubic space, also called the space of Retzius,
has been dissected. It is limited by the pubic bone, the peritoneum,
and the muscles of the anterior abdominal wall. Its lateral borders are
the arcus tendineus and the ischial spines.

to the perineal body. It contains lax areolar tissue that can eas-
ily be dissected. Its lateral margins are the rectal pillars, which
are part of the cardinal-uterosacral ligament complex connect-
ing the rectum to the sacrum. Frequently, the surgeon may
need to enter the rectovaginal space during a hysterectomy
when the patient has unrecognizable anatomic features owing
to an obliterated cul-de-sac from endometriosis or malig-
nant disease. In that case, both ureters should be identified in
advance, followed by identification of the rectum, to prevent
Right pararectal any injury (Fig. 2.19).
space
Presacral Space
Right ureter The presacral or retrorectal space is found between the rectum
Right paravesical
space anteriorly and the sacrum posteriorly. This space is entered by
dividing the peritoneum at the base of the mesentery of the
Right cardinal sigmoid colon or through the pararectal spaces. Inferiorly this
ligament space terminates at the level of the levator muscles and laterally
FIG. 2.17 The lateral parametrium is demonstrated by traction on continues as the pararectal fossae. The middle sacral artery and
the uterus. The paravesical space is located anterior to the right par- a plexus of veins are attached superficial to the anterior longitu-
ametrium, and the pararectal space is located posterior to the right dinal ligament of the sacrum. The endopelvic fascia in this space
parametrium.
10 Section 1 Anatomy and Principles of Surgery
Vagina
Right uterine
artery
Right ureter
Bladder
Right
hypogastric a.
FIG. 2.19 Vesicovaginal space. The cut edge of the vesicouterine
peritoneum is seen in the lower part of the uterus. The ureter has been
dissected out of the parametrial tunnel. The relationship of the ureter to
the bladder, cervix, and upper vagina is demonstrated here.
Uterus
Posterior vagina
Left ureter
Right ureter
Rectum
FIG. 2.20 The rectovaginal space is dissected, demonstrating the
ureters at each side.
envelops the visceral nerves of the superior hypogastric plexus
and lymphatic vessels. The lateral boundaries of the presacral
space are formed by the common iliac arteries, both ureters, and
the sigmoidal branches of the inferior mesenteric artery (IMA)
crossing on the left side.
The correct plane of dissection is between the rectum and
the presacral fascia. Adequate development of this plane allows
a radical extirpation en bloc of the rectum with the entire meso-
rectum, critical in rectal cancer; a mistaken dissection from the
natural plane, invading the presacral fascia, may lead to injury
of presacral veins, leading to significant bleeding (Fig. 2.20).
Uterine Support Structures
The structures that connect the cervix and vagina to the
pelvic sidewall and sacrum are known as the cardinal and
uterosacral ligaments, respectively or in conjunction, uterine
parametria.
Parametria
The cardinal-uterosacral ligament complex suspends the
uterus and upper vagina in their normal position. It serves to
Left common
iliac
Mesorectum
Presacral space
FIG. 2.21 The presacral space has been dissected to the lower
pelvis.
maintain vaginal length and keep the upper vaginal axis nearly
horizontal in an erect woman so that the pelvic floor supports
it. Absence of this support contributes to prolapse of the uterus
and/or vaginal cuff. The cardinal ligaments are condensations
of connective tissue that are several centimeters in width and
run from the cervix and upper vagina to the pelvic sidewall.
The uterine vessels run for much of their course within the
cardinal ligaments.
The uterosacral ligaments are bands of connective tissue that
are attached with the cardinal ligaments at their point of inser-
tion in the cervix and upper vagina. The uterosacral ligaments
pass posteriorly and inferiorly to attach to the ischial spine and
sacrum.
The parametrium can be artificially divided into three bands
of connective tissue: the posterior parametrium or uterosacral
ligament, the cardinal ligament or lateral parametrium, and the
cervicovesical ligament or anterior parametrium. The uterosac-
ral ligaments are bands of connective tissue joining the cardinal
ligaments at their point of insertion in the cervix. The uterosac-
ral ligaments pass posteriorly and inferiorly to reach the ischial
spine and sacrum. This ligament lies in close contact with the
ureter before crossing the uterine artery within the lateral para-
metrium. The hypogastric nerve runs 1 to 2 cm inferior to the
ureter and along the lateral aspect of the uterosacral ligament.
The lateral parametrium contains the uterine artery and veins
(superficial and deep) and some variable number of parame-
trial lymph nodes; in its deepest portion—close to the pelvic
floor—appear the parasympathetic nerves (splanchnic nerves)
coming from roots S2 to S4. Finally, the anterior parametrium,
also known as the bladder pillar, includes the ureteric tunnel
containing the ureter after crossing under the uterine artery
(Figs. 2.21–2.23).
Round Ligaments
The round ligaments are expansions of the uterine muscula-
ture. They originate at the uterine fundus anteriorly and infe-
riorly to the fallopian tubes, run retroperitoneally through the
broad ligament, and then enter the inguinal canal, terminating
in the labia majora.
Broad Ligament
The broad ligament covers the lateral uterine corpus and upper
cervix. The limits of the broad ligament are as follows: superiorly,

Paravesical
space
Inferior
hypogastric
plexus
Sacrouterine
space
Splanchnic
nerves
Hypogastric
nerve
Pararectal
space
Prerectal
space
FIG. 2.22 The pelvic parametria are demonstrated. The anterior par-
ametrium is also known as the bladder pillar or vesicouterine ligament.
The lateral parametrium is also known as the parametrial web. The
uterosacral ligament is also denominated as a rectal pillar. The pelvic
spaces are dissected. The pelvic splanchnic nerves are parasympa-
thetic nerves coursing in the lower aspect of the lateral parametrium.
The efferent nerves of the inferior hypogastric plexus course along the
lower aspect of the anterior parametrium.
Uterus
Cardinal ligaments
FIG. 2.23 The lateral parametria are held by Kocher clamps after
resection in a radical hysterectomy.
the round ligaments; posteriorly, the infundibulopelvic liga-
ments; and inferiorly, the cardinal and uterosacral ligaments. It
consists of anterior and posterior leaves that separate to enclose
viscera and blood vessels. Structures included within the broad
ligament are considered retroperitoneal. Dissection between
these sheets is necessary to provide retroperitoneal exposure of
these structures. Various zones of the broad ligament are named
for nearby structures such as the mesosalpinx (located near the
fallopian tubes) and the mesovarium (located near the ovary).
The broad ligament is composed of visceral and parietal perito-
neum that contains smooth muscle and connective tissue.
Pelvic Vasculature
Arterial Supply
The aorta provides the blood supply to the pelvic structures. The
aorta bifurcates at approximately the level of L4 to L5 into the
right and left common iliac arteries. The common iliac arteries
Chapter 2 Abdominal and Pelvic Anatomy 11
Cardinal ligaments
FIG. 2.24 The lateral parametria are shown in a radical hysterectomy
specimen.
divide into the external iliac and internal iliac arteries; the inter-
nal iliac artery is also referred to as the hypogastric artery and
provides most of the vascularization to the pelvic viscera and
pelvic side wall and the gluteal muscles. The left common iliac
vein travels anterior to the sacrum and medial to the aortic
bifurcation and joins the right common iliac vein to form the
vena cava under the right common iliac artery. The external
iliac artery is located medial to the psoas muscle; it continues
its course caudally to ultimately give off the femoral artery after
crossing underneath the inguinal ligament. In the pelvis, the
external iliac artery has few branches; these include the infe-
rior epigastric artery and a variable superior vesical artery. The
external iliac vein is much larger and lies posterior and medial
to the artery. The external iliac vein also passes below the ingui-
nal ligament before reaching the thigh.
The inferior epigastric vessels supply the rectus abdominis
muscles. The inferior epigastric artery originates from the exter-
nal iliac artery and travels through the transversalis fascia into a
space between the rectus muscle and posterior sheath. In their
course from the lateral position of the external iliac vessels, the
inferior epigastric artery and vein run obliquely toward a more
medial location as they approach the umbilicus. The superfi-
cial epigastric vessels originate from the femoral artery, perfuse
the anterior abdominal wall, and branch extensively as they
approach the umbilicus.
The hypogastric artery branches into anterior and posterior
divisions. The posterior division runs toward the large sciatic
notch, dividing into the lateral sacral, iliolumbar, and superior
gluteal arteries. The anterior division of the internal iliac artery
branches into the obliterated umbilical, uterine, superior vesical,
obturator, vaginal, and inferior gluteal and internal pudendal
arteries. The internal iliac vein lies medial to the internal iliac
artery; the other veins travel with their corresponding arteries
(Figs. 2.24–2.26).
To reach the perineum, the internal pudendal artery
courses through the greater sciatic foramen, around the
sacrospinous ligament, and back in through the lesser sci-
atic foramen. In this way the pudendal artery ends up below
the pelvic diaphragm. Its branches supply the anal sphincter,
the pelvic diaphragm, and the external genital structures in
the female.
The internal iliac artery is a retroperitoneal struc-
ture; for any of its branches to be identified and accessed,
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