PRACTICAL PELVIC

ANATOMY FOR THE

GYNECOLOGIC
SURGEON
• CT
– Spaces
– Levator
– Lines and obturators, aberrants
– Urethral ligaments
– Mb integral theory, mechanism of continence
• Vessels
– HAL
– Vessels and branching of ut art
– Azygous and sulcal veins
• Ant abd wall, pfannenstiel syndrome
• Vulval slanting
• LN
• Pelvic nerves
 PELVIC CT PLANES AND SPACES
• WHY?
– Bl vs
– Exposure of spaces and organs
• Operating in the correct layer – one of the
prerequisites for successful vaginal and pelvic
surgery – is only possible if the surgeon has
exact knowledge of the anatomy of the CT
matrix and of spaces.
NO ONE COULD
SEE WHAT HE
DONOT KNOW
 CT Matrix (firm pelvic CT)
• Main functions:
– Device for conveying blood and
lymphatic vessels
– Organ embedding
• Shape
• Extension
• ATFP
• ATLA
 Frontal CT matrix
• Is a continuation
• Extends along the greater sciatic foramen and
rises to the point of separation of the uterine
artery from the internal iliac artery.
• In a sagittal section, the entire CT matrix has
the shape of sled runner whose point extends
in a sacral direction:
– The horizontal part rests on the levator fascia
– The curved part comes up in a cranial direction to
a frontal plate
• sled (sld) n.
1. A vehicle mounted on runners, used for
carrying people or loads over ice and snow; a
sledge.
2. A light wooden frame on runners, used by
children for coasting over snow or ice.
v. sled·ded, sled·ding, sleds
v.tr. To carry on or convey by a sled.
v.intr.
 Frontal CT matrix “cont’d”
• Also called cardinal ligament of Mackenrodt
• It runs almost transeversely from the uterus to
the pelvic wall = lateral parametrium
• Slowly decreases in mass in caudocranial
direction forming sagittally a wedge.
• Medially, the CT joins the uterine vessels into
the edge of the uterus
• Laterally, it continues upward along the pelvic
sidewall into the firm CT of the hypogastric vs
till ???
 Pillars
• Horizontal CT matrix gives 3 separate layers (CT
sheet):
– Ascending bladder pillar
– Medially directed horizontal vaginal column
– Descending rectal pillar
• Frontal CT matrix gives 3 separate layers:
– Sagittal bladder pillar (vesicouterine ligament = imp.,
it is a misnomer) vascular
– Medially directed frontal cervical column forms the
shell of the cx and contains the ut art.
– Sagittal rectal pillar
 Vesicouterine ligament
• Extension

• Contents
 Rectal pillar
• The upper part of the sagittal rectal column is
called the uterosacral lig:
• It splits at the side of the rectum into two
layers:
– Anterior layer that surrounds the rectum as a fascia
– Posterior layer that attaches to the lateral mass of
the sacrum at level of S2-S4
• A descending rectal column is the contination of
the sagittal one as the rectal pillars w are
located next to the pelvic wall, they continued
with that of the horizontal CT matrix
 Vaginal cervical column
• Lamellae that encircle the organs

• Exercise:
• While U R performing VH, what are the layers
that U will dissect? Contents?
• Between firm CT matrix, the potential spaces
that are filled with loose areolar CT
• Formation of these spaces artificially exposes
the firm columns that contain the major
vessels and organs
• Borders are
– Lateral umbilical ligament? What?
• Contents:
– Fat, loose areolar tis
• Floor: ………
• How to create?
 HOW to create?
• General principles:
• The periphery of the retroperitoneum is
almostly avascular, and thinner.
• Start point is an incision in the parietal
peritoneum over the psoas major at a point
lateral to the infundibulopelvic lig:
– Psoas
– Genitofemoral
– LN
– Great vs
– ureter
 LOOK for azygos veins
• Look for sulcal veins
 Paravesical spaces
• Borders are
– Laterally: ext iliac vs, obturator fossa, fascia of the obturator and lateral
parts of levator ms and its fascia
– Medially: bladder and bladder pillar and the vagina
– Posteriorly: ???
– Anteriorly: superior pubic ramus and obt fascia
– Floor: a layer of endopelvic fascia that separates it from the anterior
component of the pararectal space
– Point of separation of the prevesical space is …..
• Contents:
– Fat, loose areolar tis
• How to create?
– If peritoneum is closed
– If peritoneum is opened (cut round lig)
• Between ext and int iliac ant division
• Accentuate by traction on the UB
Divisions
 Vesicocervical and vesicovaginal spaces
Vesicovaginal Vesicouterine

Ascending bl pillar Laterally Sagittal bl pillar

UB, pubourethral lig Anteriorly UB

Vagina Posteriorly Cervix

Supravaginal septum Superiorly Floor of anterior cul-de-sac

‘vesicouterine fold = plica
vesicouterina)

Cont with urethrovaginal inferiorly Supravaginal septum

space = ¼ till urogenital
 How to create?
• Blunt?
• Sharp?
• ????!!!!!
• Primum, non nocere; what are the
neighborhood anatomy?
 Contents of bladder pillars
Bl pillars = vesicouterine ligament = sagittal pillar:
• Superiorly: the vesical veins (the outlet veins of the vesical
plexus) run to the cardinal lig to drain in the ut veins or to
get to the pelvic wall)
• Between the veins: the superior vesical art (mb a branch of
the ut art.) >>>>
• the inferior vesical art. (a adirect br. of the int iliac art in the
area of the Cardinal lig.) surrounded by veins of the vag.
plexus
• Inferiorly in the floor runs the …… URETER …
• Below the ureter: scanty vs, but venous plexus in the
continuation of the CT
 Rectovaginal space
• Posteriorly: rectum
• Anteriorly: the vagina
• Laterally: rectal pillars
• Superiorly: peritoneum of DP
• Inferiorly: top of perineal body
• What is Denonvilliers fascia?

• The sagittal rectal pillar = the rectouterine lig = rear

parametrium
• Vesicouterine and rectovaginal spaces could
be altered by:
– CS
– EO
– Infection
– FO
– CA
• Soln: creation of the para and para spaces
 Pararectal spaces
Borders:
• Medially: rectal pillars/rectum????????
• Laterally: Large Bl Vs on the pelvic wall (post div
of int iliac), the levator, piriformis.
• Posteriorly: lateral parts of the sacrum
• Anteriorly (inf): the Cardinal lig.
• Superiorly: peritoneum
• Inferiorly: anterior extension below the CT matrix
• Components: anterior and posterior

• Is there medial & lateral pararectal spaces

 How to create?
• Between the HA and the ureter!!!
 How to enter from anterior?
• Stick close to the SSL.
• If U get higher, in the area of the ischial
foramen >>>>>> appendage of the cardinal lig
with genital veins.
Divisions
 Retrorectal space
Borders:
• Laterally:rectal pillars at the height of S2-S4 (the
sparating walls of pararectal spaces
• Posteriorly: the sacrum
• Anteriorly: the rectal fascia
• Superiorly: changes to the retroperitoneal space
• Inferiorly: ends at the levator
• Contents:
• Areolar tis
• Median sacral vs
• Sympathetic n plexus (presacral n)
 How to enter?
• Abdominally: easy
• Perineally: by transecting the ano-coccygeal
ligament
• Difference between vesicouterine ligament,
vesicouterine space, vesicocervical and
vesicovaginal spaces
• While U R performing SSF: what are the
structures lying superior to your dissection
area?
 US lig
(A) Subdivision: total length around 12-13cm:
• (i) a distal (cervical) section of 5-20mm thickness
and generally 2-3cm in vertical length
• (ii) an intermediate section of around 5cm length,
up to 1-2cm wide when placed under tension, and
for the most part 5mm thick (thinning proximally),
running postero-laterally from the level of the
uterine isthmus, curving around the rectum
towards the sacrum
• (iii) a relatively thin proximal section of around 5–
6 cm.
B) Attachments:
• Distally, the USL was attached to the posterior aspect of
the cervix and vaginal dome. This attachment spread to
the lateral aspects of the cervix and vaginal dome where
it was confluent with the attachment of the cardinal
ligament (uterosacral-cardinal ligament complex). The
USL merged caudally with the lateral ligament of the
rectum. Proximally, its diffuse sacral attachment
extended:
• (i) vertically from the sacrococcygeal joint to S3 (with
the sacrouterine fold of peritoneum extending to S2 and
at times S1) and
• (ii) transversely from the pelvic sacral foramina medially
to 5cm lateral to the sacro-iliac joint where it was
attached to fascia overlying piriformis and levator ani.
 ?????????
• The origin of the uterosacral ligament from the genital
tract extends from the cervix to the upper vagina.
• The insertion on the pelvic sidewall occurs to the
sacrospinous ligament and the coccygeus muscle in
82% of all cases, but in only 7% do the uterosacral
ligaments insert on the sacrum.
• This suggests that the uterosacral ligaments exhibits
greater anatomic variability than their name implies,
and this might be an important insight for the
understanding of the pelvic organ support
mechanism.
• the left uterosacral ligament was shorter in its
craniocaudal extent than on the right side.
This may be attributed to the embryologic
development of this region which includes
rotation and attachment of the sigmoid’s
mesentery to the left pelvic side wall.
• The uterosacral ligaments rather connect to
structures which lie ventral or lateral to the
sacral bone than to the bone or its periostium.
(C) Intermediate section: Surgically useful
observations on this relatively unattached
section are
• (i) this section is best seen when under tension
• (ii) even at its closest proximity to the ureter (at
the junction with the cervical section) it is still at
least 2.3-2.7cm from that structure
• (iii) medial traction on the intermediate section
as might occur with midline plication with the
contralateral ligament will also cause its anterior
and superior displacement.
(D) Histology: Stripped of the peritoneum, the USL was seen
as a collection of fatty tissue and dispersed strands of
fibrous tissue investing the vessels and nerves destined for
the cervix and upper vagina.
• Histological sections of the thickest (cervical) section
showed small arteries and veins, numerous nerves
intermingled with thin bands of collagen and elastic fibers
and fatty tissue. Smooth muscle fibres were rarely
observed.
• Collagen fibres decreased in number from the upper
border of the ligament. This differed greatly from the
macroscopic appearance when put under tension.
• In all pelves, fresh or embalmed, the ligament, under
tension, became a dense, well defined structure. In 2
hemipelves, it was however visible as a dense ligamentous
 The ureter
• The rt ureter lies medially OR medially and
infront of the int iliac a and reaches the ov
fossa
• The lt ureter mostly goes along the com iliac a,
then crosses in a sharp angle at the beginning
of the int iliac a and reaches the ov fossa
infront of the int iliac a.
How to locate and distinguish the ureter?

• Ureter in non-adhesion woman:

“U ‘ll NOT see what U don’t know”
• Anatomical site:
Don’t forget the whole course till the UB
1. Peristalsis
2. Small curlicue bl vs in its adventitia
3. Tactile snap
 The pelvic floor
• Levator ani with the investing fascia = ????
• Urogenital diaphragm

• ? Levator hiatus

• The organs one on the other then 90o shift to

be behind each other. The CT matrix follows
this curve.
• Pelvic walls
• The walls of the true pelvis consist predominantly of bone, muscle,
and ligaments, with the sacrum, coccyx, and inferior half of the
pelvic bones forming much of them.
• Two ligaments-the sacrospinous and the sacrotuberous ligaments-
are important architectural elements of the walls because they link
each pelvic bone to the sacrum and coccyx.
• These ligaments also convert two notches on the pelvic bones-the
greater and lesser sciatic notches-into foramina on the lateral pelvic
walls.
• Completing the walls are the obturator internus and piriformis
muscles , which arise in the pelvis and exit through the sciatic
foramina to act on the hip joint
Blood supply of the genital tract
 Common iliacs
• Crossed by:
– Ureter
– Ov vs
– Sympathetic ns
• + on lt side:
– Sigmoid mesocolon
– Inferior mesenteric vs
 Blood supply of the internal genitalia
• The uterine a. almost always branches
together with the residual umbilical art.
• It crosses the ureter 1.5-2 cm lat. to the cx.
NB: ureter mb as near as … & as far as …..
• It gives a small ramus uretricus at the ureteric
crossing, this crosses cranially and caudally
along the ureter
• It gives the vaginal a. bef of after this crossing
• 0.5 cm lat to the ut., the art turns upward
crossing onto the lat margin of the uterus
• It sends off rami uterini to the front and the back
of the uterus anastomosing to the opposite side
• At the angle of the Fallopian tube: it gives 4
terminal branches:
– The fundus ramus: penetrating the m of the fundus
– The round lig. ramus: the weakest of the four
branches>> along the ing canal till anstomosing with a
br of the inf epigastric art. Name???
– The tubal ramus: leads into the mesosalpix and sends
small branches to the tube until it reahes the
infudibulopelvic lig. where it anastomoses with ov art.
– The ovarian ramus: originates below the ov lig, sends
many branches to the ov.
 Just after crossing the ureter
• The cervical vaginal br = descending br.
 The ovarian art.
• It runs across the psoas major, crosses the
ureter at the entrance of the true pelvis
• It has a strong collateral br. connecting the ov
and the tubal rami
 The medial rectal art.
• From the pudendal art.
• It divides within the cardinal lig. into:
• A small br: reaching the rectum through the
descending rectal pillar
• A strong br: extends into the horizontal CT
matrix and the vag pillar to the vag.
• Umbilical >>>>>>> lat ……
• Superior vesical
To revise our int iliac a
 Internal iliac artery
• The internal iliac (hypogastric) artery furnishes most
of the blood supply to the pelvis.
• It arises from the common iliac in front of the sacro-
iliac joint, at the level of the intervertebral disc
between the fifth lumbar vertebra and the sacrum.
• It is usually about 4 cm long.
• The internal iliac artery is crossed in front by the
ureter.
• It is separated from the sacro-iliac joint behind by
the internal iliac vein and the lumbosacral trunk.
• In its upper part, the external iliac vein and psoas
major are lateral to it; in its lower part the obturator
 Posterior Division
• Iliolumbar artery lumbar and iliac branches
psoas major muscle, quadratus lumborum
muscle, iliacus muscle
• Lateral sacral artery superior and inferior
branches anterior sacral foramina
• Superior gluteal artery-greater sciatic foramen
 Anterior Division
• Obturator artery (occasionally from inferior epigastric
artery)-obturator canal
• Inferior gluteal artery-greater sciatic foramen
• Umbilical artery and Superior vesical artery (usually, but
sometimes it branches directly from anterior trunk)
• Uterine artery (female)vaginal branchuterus
• Vaginal artery (female) vagina and the base of the
bladder
• Inferior vesical artery-urinary bladder
• Middle rectal artery-rectum runs in the rectal pillar
• Internal pudendal artery many branches
• a) The iliolumbar artery. The iliac branch sends branches to the iliacus muscle and a large
nutrient branch to the ilium. The lumbar branch ascends to supply the psoas major and the
quadratus lumborum. It sends a spinal branch through the intervertebral foramen between the
fifth lumbar vertebra and the sacrum.
• b) The lateral sacral arteries, usually an upper and a lower, may arise from a common trunk
Both lateral sacral arteries give off spinal branches, which after passing through pelvic sacral
foramina and supplying the contents of the sacral canal, may emerge through dorsal sacral
foramina.
• c) The obturator artery, the origin of which is variable, passes forward and downward on the
obturator fascia to the obturator foramen. The posterior gives off an acetabular branch, which
supplies the fat in the acetabular fossa and the ligament of the head of the femur (medial
epiphysial branches).
•
• d) The superior gluteal artery passes backward, usually between the lumbosacral trunk and the
first sacral nerve, and leaves the pelvis through the greater sciatic foramen, above the piriformis.
• e) The inferior gluteal artery passes backward, between the first and second, or second and
third sacral nerves, and leaves the pelvis through the greater sciatic foramen, below the
piriformis.
• f) The internal pudendal artery is larger in the male than in the female.
• The internal pudendal artery gives off the following branches:
– i) the inferior rectal artery
– ii) the posterior scrotal (or labial) branches,
– iii) the perineal artery
– iv) the artery of the bulb of the penis (or vestibule)
– v) the urethral artery and
– vi) the deep and dorsal arteries of the penis (or clitoris)
 Collateral circulation
The collateral circulation that develops after obstruction
of an internal iliac artery results from anastomoses
1) with branches of the opposite internal iliac,
2) between parietal branches and branches of the
femoral artery in the thigh, and
3) between the superior and middle rectal arteries.
The collateral circulation may be demonstrated by
arteriography.
The collateral channels also supply the lower part of the
abdomen if the abdominal aorta is obstructed, and
the lower limb if the femoral artery is obstructed.
• Collateral Circulation
• The circulation after ligature of the internal iliac
artery is carried on by the anastomoses of:
• the middle rectal artery and the
superior rectal artery
• the iliolumbar artery with the last lumbar artery
• the lateral sacral arteries with the
median sacral artery
• Structure in fetus
• In the fetus, the internal iliac artery is twice as large
as the external iliac, and is the direct continuation
of the common iliac.
• It ascends along the side of the bladder, and runs
upward on the back of the anterior wall of the
abdomen to the umbilicus, converging toward its
fellow of the opposite side.
• Having passed through the umbilical opening, the
two arteries, now termed umbilical, enter the
umbilical cord, where they are coiled around the
umbilical vein, and ultimately ramify in the placenta
.
• At birth, when the placental circulation ceases,
the pelvic portion only of the umbilical artery
remains patent gives rise to the superior vesical
artery (or arteries) of the adult; the remainder
of the vessel is converted into a solid fibrous
cord, the medial umbilical ligament (otherwise
known as the obliterated hypogastric artery)
which extends from the pelvis to the umbilicus.
• Variation
• In two-thirds of a large number of cases, the length of the
internal iliac varied between 2.25 and 3.4 cm.; in the
remaining third it was more frequently longer than shorter,
the maximum length being about 7 cm. the minimum
about 1 cm.
• The lengths of the common iliac and internal iliac arteries
bear an inverse proportion to each other, the internal iliac
artery being long when the common iliac is short, and vice
versa.
• The place of division of the internal iliac artery varies
between the upper margin of the sacrum and the upper
border of the greater sciatic foramen.
• The right and left hypogastric arteries in a series of cases
often differed in length, but neither seemed constantly to
exceed the other.
• The arterial supply to the cervix is primarily
through the cervical branches of the right and
left uterine arteries, which form a rete around
the cervix (coronary artery), creating the
azygos artery in the midline anteriorly and
posteriorly.
• Anastomoses between this artery and the
vaginal artery on both sides afford cruciate
flow on the anterior wall, while on the
posterior wall of the vagina, anastomoses
occur with the right and left middle
hemorrhoidal arteries as they supply the wall
and the rectum.
 Vessels of the vagina
• Int pudendal
• Diffuse anastomoses between the vaginal art,
ut, middle rectal & inferior vesical.
• It arises cephalad and posterior to the uterine
and inf vesical at the lateral extremity of the
CARDINAL >>>>> great clin significance.
• The chief blood supply to the vagina is through the vaginal
branch of the uterine artery.
• After forming the coronary or circular artery of the cervix, it
passes medially, behind the ureter, to send 5 main branches
onto the anterior wall to the midline.
• These branches anastomose with the azygos artery
(originating midline from the coronary artery of the cervix) and
continue downward to supply the anterior vaginal wall and the
lower two-thirds of the urethra.
• The uterine artery eventually anastomoses to the urethral
branch of the clitoral artery.
• The posterior vaginal wall is supplied by branches of the
middle and inferior hemorrhoidal arteries, traversing toward
the midline to join the azygos artery from the coronary artery
of the cervix. These branches then anastomose on the
perineum to the superficial and deep transverse perineal
arteries.
 Venous drainage
• Imp notes:
• Uterovaginal plexus:
• Pass directly around the ureter
– Superficial plexus with the uterine
– The deep plexus
• Internal Iliac Vein The internal iliac (hypogastric) vein
is a short trunk, which unites with the external iliac
to form the common iliac vein. Its tributaries
correspond in general to the branches of the
internal iliac artery, with the exception of the
umbilical and the iliolumbar arteries.
• Each of the viscera within the pelvis is surrounded
by a network of relatively large, thin-walled veins,
which have few valves. These plexuses
communicate freely with each other and give rise to
the visceral tributaries of the internal iliac vein. They
also communicate with the parietal tributaries, and
thereby provide easy pathways for the spread of
• The plexuses are named as follows:
• 1) the rectal venous plexus
• 2) the vesical venous plexus
• 3) the prostatic venous plexus
• 4) the uterine venous plexus
• 5) the vaginal venous plexus
• 6) The sacral venous plexus, located on the pelvic surface of the
sacrum, is not associated with an organ, but it provides a
pathway for blood to pass from the pelvic viscera to the azygos
and vertebral venous systems.
• Material injected into the deep dorsal vein of the clitoris has
been found in the veins of the head, thorax, abdomen, pelvis,
and thighs, and in the vertebral venous system.
• During hysterosalpingography, radiopaque material reached the
veins of the uterus and was detected in the ascending lumbar
veins.
 Medial iliac vein
• Occasionally, the rt obturator may flow to the
ext iliac vein directly.
• In that case: the uterine, vaginal and vesical
veins are drained by the obturator v = a strong
v called medial iliac v
 Aberrant obturator vein
• Drains to the posterior of ext iliac vein near
the canal
 If int iliac v is ligated
• Only: the ut, vag, vesical and int pud v
drainage are stopped
• BUT:
– Obturator iliac ramus >>>>> ext iliac v
– Medial, superior rectals
• Nerves The nerve supply to the pelvis is
derived mainly from the sacral and coccygeal
spinal nerves, and from the pelvic part of the
autonomic system.
• Two anatomical entities of the parametrium were
distinguished: (1) the lateral mesometrium
corresponding to the blade containing vessels and
lymph nodes of the uterus; and (2) the infraureteral
parametrium extending dorsally from cervix and
vagina. The lateral paracervix classically described
under the ureter was never identified. Infraureteral
parametrium appeared as a fibrous tissue extending
in a lateral, dorsal, and caudal direction on both sides
of the rectum and very close to the pelvic plexus.
• Pelvic walls
• The walls of the true pelvis consist predominantly of bone, muscle,
and ligaments, with the sacrum, coccyx, and inferior half of the
pelvic bones forming much of them.
• Two ligaments-the sacrospinous and the sacrotuberous ligaments-
are important architectural elements of the walls because they link
each pelvic bone to the sacrum and coccyx.
• These ligaments also convert two notches on the pelvic bones-the
greater and lesser sciatic notches-into foramina on the lateral pelvic
walls.
• Completing the walls are the obturator internus and piriformis
muscles , which arise in the pelvis and exit through the sciatic
foramina to act on the hip joint
Blood supply of the genital tract
 Common iliacs
• Crossed by:
– Ureter
– Ov vs
– Sympathetic ns
• + on lt side:
– Sigmoid mesocolon
– Inferior mesenteric vs
 Blood supply of the internal genitalia
• The uterine a. almost always branches
together with the residual umbilical art.
• It crosses the ureter 1.5-2 cm lat. to the cx.
NB: ureter mb as near as … & as far as …..
• It gives a small ramus uretricus at the ureteric
crossing, this crosses cranially and caudally
along the ureter
• It gives the vaginal a. bef of after this crossing
• 0.5 cm lat to the ut., the art turns upward
crossing onto the lat margin of the uterus
• It sends off rami uterini to the front and the back
of the uterus anastomosing to the opposite side
• At the angle of the Fallopian tube: it gives 4
terminal branches:
– The fundus ramus: penetrating the m of the fundus
– The round lig. ramus: the weakest of the four
branches>> along the ing canal till anstomosing with a
br of the inf epigastric art. Name???
– The tubal ramus: leads into the mesosalpix and sends
small branches to the tube until it reahes the
infudibulopelvic lig. where it anastomoses with ov art.
– The ovarian ramus: originates below the ov lig, sends
many branches to the ov.
 Just after crossing the ureter
• The cervical vaginal br = descending br.
 The ovarian art.
• It runs across the psoas major, crosses the
ureter at the entrance of the true pelvis
• It has a strong collateral br. connecting the ov
and the tubal rami
 The medial rectal art.
• From the pudendal art.
• It divides within the cardinal lig. into:
• A small br: reaching the rectum through the
descending rectal pillar
• A strong br: extends into the horizontal CT
matrix and the vag pillar to the vag.
• Umbilical >>>>>>> lat ……
• Superior vesical
To revise our int iliac a
 Internal iliac artery
• The internal iliac (hypogastric) artery furnishes most
of the blood supply to the pelvis.
• It arises from the common iliac in front of the sacro-
iliac joint, at the level of the intervertebral disc
between the fifth lumbar vertebra and the sacrum.
• It is usually about 4 cm long.
• The internal iliac artery is crossed in front by the
ureter.
• It is separated from the sacro-iliac joint behind by
the internal iliac vein and the lumbosacral trunk.
• In its upper part, the external iliac vein and psoas
major are lateral to it; in its lower part the obturator
 Posterior Division
• Iliolumbar artery lumbar and iliac branches
psoas major muscle, quadratus lumborum
muscle, iliacus muscle
• Lateral sacral artery superior and inferior
branches anterior sacral foramina
• Superior gluteal artery-greater sciatic foramen
 Anterior Division
• Obturator artery (occasionally from inferior epigastric
artery)-obturator canal
• Inferior gluteal artery-greater sciatic foramen
• Umbilical artery and Superior vesical artery (usually, but
sometimes it branches directly from anterior trunk)
• Uterine artery (female)vaginal branchuterus
• Vaginal artery (female) vagina and the base of the
bladder
• Inferior vesical artery-urinary bladder
• Middle rectal artery-rectum runs in the rectal pillar
• Internal pudendal artery many branches
• a) The iliolumbar artery. The iliac branch sends branches to the iliacus muscle and a large
nutrient branch to the ilium. The lumbar branch ascends to supply the psoas major and the
quadratus lumborum. It sends a spinal branch through the intervertebral foramen between the
fifth lumbar vertebra and the sacrum.
• b) The lateral sacral arteries, usually an upper and a lower, may arise from a common trunk
Both lateral sacral arteries give off spinal branches, which after passing through pelvic sacral
foramina and supplying the contents of the sacral canal, may emerge through dorsal sacral
foramina.
• c) The obturator artery, the origin of which is variable, passes forward and downward on the
obturator fascia to the obturator foramen. The posterior gives off an acetabular branch, which
supplies the fat in the acetabular fossa and the ligament of the head of the femur (medial
epiphysial branches).
•
• d) The superior gluteal artery passes backward, usually between the lumbosacral trunk and the
first sacral nerve, and leaves the pelvis through the greater sciatic foramen, above the piriformis.
• e) The inferior gluteal artery passes backward, between the first and second, or second and
third sacral nerves, and leaves the pelvis through the greater sciatic foramen, below the
piriformis.
• f) The internal pudendal artery is larger in the male than in the female.
• The internal pudendal artery gives off the following branches:
– i) the inferior rectal artery
– ii) the posterior scrotal (or labial) branches,
– iii) the perineal artery
– iv) the artery of the bulb of the penis (or vestibule)
– v) the urethral artery and
– vi) the deep and dorsal arteries of the penis (or clitoris)
 Collateral circulation
The collateral circulation that develops after obstruction
of an internal iliac artery results from anastomoses
1) with branches of the opposite internal iliac,
2) between parietal branches and branches of the
femoral artery in the thigh, and
3) between the superior and middle rectal arteries.
The collateral circulation may be demonstrated by
arteriography.
The collateral channels also supply the lower part of the
abdomen if the abdominal aorta is obstructed, and
the lower limb if the femoral artery is obstructed.
• Collateral Circulation
• The circulation after ligature of the internal iliac
artery is carried on by the anastomoses of:
• the middle rectal artery and the
superior rectal artery
• the iliolumbar artery with the last lumbar artery
• the lateral sacral arteries with the
median sacral artery
• Structure in fetus
• In the fetus, the internal iliac artery is twice as large
as the external iliac, and is the direct continuation
of the common iliac.
• It ascends along the side of the bladder, and runs
upward on the back of the anterior wall of the
abdomen to the umbilicus, converging toward its
fellow of the opposite side.
• Having passed through the umbilical opening, the
two arteries, now termed umbilical, enter the
umbilical cord, where they are coiled around the
umbilical vein, and ultimately ramify in the placenta
.
• At birth, when the placental circulation ceases,
the pelvic portion only of the umbilical artery
remains patent gives rise to the superior vesical
artery (or arteries) of the adult; the remainder
of the vessel is converted into a solid fibrous
cord, the medial umbilical ligament (otherwise
known as the obliterated hypogastric artery)
which extends from the pelvis to the umbilicus.
• Variation
• In two-thirds of a large number of cases, the length of the
internal iliac varied between 2.25 and 3.4 cm.; in the
remaining third it was more frequently longer than shorter,
the maximum length being about 7 cm. the minimum
about 1 cm.
• The lengths of the common iliac and internal iliac arteries
bear an inverse proportion to each other, the internal iliac
artery being long when the common iliac is short, and vice
versa.
• The place of division of the internal iliac artery varies
between the upper margin of the sacrum and the upper
border of the greater sciatic foramen.
• The right and left hypogastric arteries in a series of cases
often differed in length, but neither seemed constantly to
exceed the other.
• The arterial supply to the cervix is primarily
through the cervical branches of the right and
left uterine arteries, which form a rete around
the cervix (coronary artery), creating the
azygos artery in the midline anteriorly and
posteriorly.
• Anastomoses between this artery and the
vaginal artery on both sides afford cruciate
flow on the anterior wall, while on the
posterior wall of the vagina, anastomoses
occur with the right and left middle
hemorrhoidal arteries as they supply the wall
and the rectum.
 Vessels of the vagina
• Int pudendal
• Diffuse anastomoses between the vaginal art,
ut, middle rectal & inferior vesical.
• It arises cephalad and posterior to the uterine
and inf vesical at the lateral extremity of the
CARDINAL >>>>> great clin significance.
• The chief blood supply to the vagina is through the vaginal
branch of the uterine artery.
• After forming the coronary or circular artery of the cervix, it
passes medially, behind the ureter, to send 5 main branches
onto the anterior wall to the midline.
• These branches anastomose with the azygos artery
(originating midline from the coronary artery of the cervix) and
continue downward to supply the anterior vaginal wall and the
lower two-thirds of the urethra.
• The uterine artery eventually anastomoses to the urethral
branch of the clitoral artery.
• The posterior vaginal wall is supplied by branches of the
middle and inferior hemorrhoidal arteries, traversing toward
the midline to join the azygos artery from the coronary artery
of the cervix. These branches then anastomose on the
perineum to the superficial and deep transverse perineal
arteries.
 Venous drainage
• Imp notes:
• Uterovaginal plexus:
• Pass directly around the ureter
– Superficial plexus with the uterine
– The deep plexus
• Internal Iliac Vein The internal iliac (hypogastric) vein
is a short trunk, which unites with the external iliac
to form the common iliac vein. Its tributaries
correspond in general to the branches of the
internal iliac artery, with the exception of the
umbilical and the iliolumbar arteries.
• Each of the viscera within the pelvis is surrounded
by a network of relatively large, thin-walled veins,
which have few valves. These plexuses
communicate freely with each other and give rise to
the visceral tributaries of the internal iliac vein. They
also communicate with the parietal tributaries, and
thereby provide easy pathways for the spread of
• The plexuses are named as follows:
• 1) the rectal venous plexus
• 2) the vesical venous plexus
• 3) the prostatic venous plexus
• 4) the uterine venous plexus
• 5) the vaginal venous plexus
• 6) The sacral venous plexus, located on the pelvic surface of the
sacrum, is not associated with an organ, but it provides a
pathway for blood to pass from the pelvic viscera to the azygos
and vertebral venous systems.
• Material injected into the deep dorsal vein of the clitoris has
been found in the veins of the head, thorax, abdomen, pelvis,
and thighs, and in the vertebral venous system.
• During hysterosalpingography, radiopaque material reached the
veins of the uterus and was detected in the ascending lumbar
veins.
 Medial iliac vein
• Occasionally, the rt obturator may flow to the
ext iliac vein directly.
• In that case: the uterine, vaginal and vesical
veins are drained by the obturator v = a strong
v called medial iliac v
 Aberrant obturator vein
• Drains to the posterior of ext iliac vein near
the canal
 If int iliac v is ligated
• Only: the ut, vag, vesical and int pud v
drainage are stopped
• BUT:
– Obturator iliac ramus >>>>> ext iliac v
– Medial, superior rectals
• Nerves The nerve supply to the pelvis is
derived mainly from the sacral and coccygeal
spinal nerves, and from the pelvic part of the
autonomic system.