Anatomy for the Gynecologic Oncologist

8/6/2019 Anatomy for the Gynecologic Oncologist

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Overview

Abdominal wall anatomy

Upper abdomen organs, vessels,

innervation Pelvic anatomy

Vulvar anatomy


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Abdominal wall anatomy

Best to comprehend the anatomy as it relates to

incision types Midline, Pfannenstiel, Maylard &

Cherney

What dermatomes are affected by a midline

incision? What are affected by a pfannenstiel?

Name all the layers of the abdominal wall above

and below the arcuate line?

Describe the relationship between the incision

type and the inferior epigastric artery?


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Innervation of the abdominal wall


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Musculature


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Rectus sheath


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Rectus sheath


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Course of the epigastric artery


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Veins of the abdominal wall


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Upper abdominal anatomy

Adequate debulking of ovarian carcinomarequires dissection of several key organs

What vessels supply the omentum,spleen, stomach, small bowel, colon andliver?

What are their functions?

How do you manage these organspostoperatively if they are injured orremoved?


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Omentum

Functions as a filter for lymphatic fluid

Lymph fluid flow in a clock-wise patternsecondary to peristalsis of the ascending,

transverse and descending colon Brings lymph fluid to the cisterna chyli, the

thoracic duct and then the left brachiocephalicvein

Right sided lymphatic drainage is directedthrough lymphatic channels of the diaphragm tothe azygos system and then the IVC and SVC


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Omentum


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Stomach

Second organ involved with digestion

Innervated by the vagus nerve

Blood supply from the celiac trunk: left and right

gastric arteries, right and left gastroepiploicarteries and the short gastric arteries

Produces hydrochloric acid and pepsin to digestfood

Produces 1 to 1.5 liters of fluid each day

Injury can be controlled by primary closure Continuous NG suctioning causes a

hyponatremic, hypokalemic metabolic alkalosis


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Stomach


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Spleen

Filter for senescent erythrocytes and circulatingpathogens

Major producer of opsonins (properdin/ tuftsin)

Hilum contains the splenic artery and vein

Extremely vascular

Splenocolic ligament must be mobilized to free thesplenic flexure of the colon

Posterior aspect of this ligament in close proximity to thetail of the pancreas

Splenectomies patients are at risk for pneumonia,

bacteremia, pancreatic injuries and splenic abcesses MUST BE VACCINATED POST OPERATIVELY FOR: Streptococcus pneumoniae

Haemophilus influenzae

Nisseria meningitidis


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Spleen


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Small Bowel

On average 270 to 290 cm in length

Consists of the duodenum ( 20cm), jejunum (100 to110cm) and ileum (150 to 160 cm)

Entire blood supply from the superior mesenteric artery

Both parasympathetic and sympathetic innervation Parasympathetic innervation is from the vagus nerve

which stems from the celiac ganglion

Parasympathetic innervation controls motility andsecretion of enzymes

Sympathetic innervation from three sets of splanchnicnerves oriented around the base of the SMA

Sympathetic innervation responsible for pain sensationand blood vessel motility


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Small Bowel

Majority of nutritional uptake is responsible within thejejunum and ileum

80% to 90% of proteins reabsorbed in the jejunum

95% of lipid reabsorbed within the jejunum and ileum

8 to 10 liters of water are reabsorbed, perhaps only 500ml actually enter the cecum

Fat soluble vitamins are reabsorbed in the terminal ileum(A, D, E and K)

Vitamin B12 also reabsorbed in the terminal ileum KEY POINT: the more small bowel removed expect

problems with digestion, nutrition and diarrhea


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Small Bowel

Enzymes of the small bowel

Gastrin (D) promotes gastric acid and pepsinogen

production

CCK(D) promotes pancreatic enzyme secretion andgall bladder contraction

Secretin (D,J) causes water release, secretion of bile

salts and inhibition of gastrin

Somatostatin (P) universal off switch Gastrin releasing peptide (D,J,I) universal on switch

Motilin (D,J) stimulates upper GI motility


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Small Bowel

Small Bowel Obstruction

Adhesions 60%

Malignancy 20%

Hernias 10%

Crohns disease 5%

Miscellaneous 5%


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Duodenum


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Small Bowel


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Small Bowel


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Colon

6 segments cecum and appendix,

ascending, transverse, descending,

sigmoid and rectum

On average 130 to 150 cm in length

Blood supply from the superior mesenteric

and inferior mesenteric arteries (SMA &

IMA)


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Segments of the colon


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Blood supply to the colon


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Colonic function

Absorption

1000 to 1500ml of ileal effluent crosses the ileocecal

valve

Stool has 100 to 150 ml of water Descending colon mainly responsible

Recycling of nutrients

Nonstarch polysaccharides

Short chain fatty acids Urea

Ascending colon responsible


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Colonic innervation

Parasympathetic innervation from the vagusnerve and the pelvic autonomic center S2-S4

Nerves are centered in plexuses along the

subserosal and muscular components of thecolon: Auerbach and Meissner plexuses

Controls colonic motility

Sympathetic innervation is from the superior and

inferior mesenteric ganglia (found by the SMAand IMA)

Controls pain and vascular tonicity


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Cecal anatomy


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Appendix

No appreciable utility

Associated with carcinoid and primary

appendiceal carcinomas

Must be taken for mucinous ovarian tumors

Appendiceal artery arises from the ileocolic

artery and MUST be ligated

Primary appendiceal tumors often diagnosed bygynecologic oncologists as a right ovarian tumor


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Appendix


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Portal circulation

Not essential for gynecologic malignancies;however must understand the different source ofvenous drainage

Splenic vein, SMV, IMV, gastric veins involved inthe portal system

Portal hypertension can therefore cause,gastroesophageal varices, rectal varices andmedusae caput

Acute bleeding has 25-30% mortality rate

Patients with cirrhosis have a 50% mortality rate


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Portal circulation


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Pelvic Anatomy

The home of the gynecologic oncologist

Focus on blood supply, nerves of thepelvis, musculature and rectal anatomy

Must understand the boundaries of pelviclymph node dissection

Lateral: genitofemoral nerve

Medial: ureter

Inferior: deep iliac circumflex vein

Superior: inferior mesenteric artery

P l i bl d l


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Pelvic blood supply Aorta

Middle sacral artery

Common iliac artery External iliac artery

Inferior epigastric artery

Deep circumflex iliac artery

Posterior division of internal iliac artery Superior gluteal artery

Iliolumbar artery

Lateral sacral

Anterior division of internal iliac artery Obturator artery

Uterine artery

Superior vesical artery

Inferior vesical artery

Umbilical ligament

Middle rectal artery Internal pudendal artery

Inferior rectal artery

Labial arteries

Dorsal artery of the clitoris


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Pelvic blood supply


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Pelvic blood supply


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Common iliac artery


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External iliac artery & vein


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Superior vesical artery


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Obturator space


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Obturator nerve


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Obturator artery


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Obturator venous plexus

Pelvic nerves


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Pelvic nerves Femoral nerve

Nerve roots L2, L3, L4

Provides motor function to the extensor muscles Provides sensation to the thigh

Sciatic nerve Nerve roots L4, L5, S1, S2, S3

Largest nerve in the body

It divides into the tibial and peroneal nerves

Provides motor function to the distal extremity Obturator nerve

Nerve roots L2, L3, L4

Provides motor function to the adductor muscles

Pudendal nerve Nerve roots S2, S3, S4

Provides motor functions to the muscles of the pelvis and external analsphincter

Provides sensation to the vulva and clitoris

Genitofemoral nerve Nerve roots L1, L2

Provides sensation to the thigh and vulva

P l i


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Pelvic nerves

Pelvic nerves


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Pelvic nerves


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Muscles of the pelvis

Psoas L2, L3, L4 flexes thigh

Piriformis S1, S2 rotates thigh laterally

Obturator internus L5, S1, S2 rotates thigh laterally

Levator Ani Pubococcygeus S3, S4 raise pelvic floor

Iliococcygeus

Puborectalis

Coccygeus S4, S5 raise pelvic floor



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M l f th l i


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Bladder

Muscular structure which functions as a reservoir forurine

Can hold 1000 ml however most females have a strongurge to void at 400 ml

Supplied by the superior vesical and inferior vesicalarteries

Innervation is both parasympathetic and sympathetic

Parasympathetic (S2, S3, S4) controls detrusorcontraction while inhibiting the internal sphincter

Sympathetic (T11, T12, L1, L2) transmit sensation

Bladder innervation


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Bladder innervation


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Rectum

Last portion of the colon, rich blood supply, relativelymobile below the peritoneum

Multiple layers which control continence 1st it follows the contour of the sacrum

2nd

the valves of houston produce sharp turns for the feces tonavigate

3rd the puborectalis muscles forms a sling around the rectumcalled the anorectal angle

All these layers close off the lumen with valsalva

The pectinate line marks the transformation fromsquamous epithelium to columnar epithelium

Blood supply stems from both the IMA and the internaliliac arteries (superior, middle, inferior rectal arteries)

Rectum


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Rectum

Rectum


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Rectum


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Vulvar anatomy

Layers of support to the pelvic floor

Blood supply to the vulva Internal pudendal artery

Inferior rectal artery

Labial/ perineal arteries

Dorsal artery of the clitoris External pudendal artery

Nervous supply to the vulva Ilioinguinal nerve

Pudendal nerve Labial/ perineal nerves

Dorsal nerve of the clitoris

Posterior femoral cutaneous nerve

Points of interest with a inguinal lymphadenectomy

Vulva: deep to superficial


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V l d t fi i l


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Vulvar blood supply


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Vulvar blood supply

Vulvar blood supply


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pp y

Vulvar blood supply


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Lymphatic drainage of the vulva


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Lymphatic drainage of the vulva

Innervation of the vulva


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Femoral Triangle


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Femoral Triangle

Borders: Inguinal ligament superiorly, sartoriusmuscle laterally and adductor longus medially

Superficial inguinal lymph nodes above thecribriform fascia (6-8)

Femoral nerve, artery, and vein are found belowthe cribriform fascia

Deep inguinal lymph nodes (2-3)

Cloquets node deepest most superior lymphnode before crossing inguinal ligament andthereby external iliac lymph nodes

Femoral Triangle


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Muscles of the thigh


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Muscles of the thigh

Sartorius

L2, L3 (F) Flexes, abducts and

laterally rotates thigh

Gracilus L2, L3 (O) Flexes, adducts and

medially rotates thigh

Adductor longus L2, L3 (O) Adducts thigh

Femoral and Obturator Nerves


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Anatomy for the Gynecologic Oncologist