Anatomy Of Reconstructive Pelvic Surgery

Objective:To observe and define the anatomy of the uterosacral ligament,sacrospinous ligament with regard to adjacent anatomy, describe the distances of the major bony,vascular,neurologic to the path of the infracoccygeal sacropexy trocar , supply foundmation of the anatomy of reconstructive pelvic surgery for pelvic organ prolapse.Methods:Fifteen female cadavers and twenty hemisected pelves were dissected to better define the uterosacral ligament ,sacrospinous ligament with regard to adjacent anatomy,describe the distances of the major bony,vascular,neurologic to the path of the infracoccygeal sacropexy trocar.1 Define the uterosacral ligament and identify adjacent anatomy,describe the distance of the ureter to uterosacral ligament. Observing the origin ,course,branch and distribution of anterior gluteal vessels and describe the relationship of inferior gluteal vessels and uterosacral ligament.2 Define the sacrospinous ligament and identify adjacent anatomy,Observing the origin ,course,branch and distribution of inferior gluteal nerve ,inferior gluteal vessels, pudendal nerve, internal pudendal vessels , describe the distance between the ischial spine and the most distal part of the inferior gluteal nerve ,inferior gluteal vessels, pudendal nerve, internal pudendal vessels.3 Modeling clinical operation of posterior intravaginal ingplasty, Infracoccygeal sacropexy trocars were inserted bilaterally into five female cadavers.Dissection was performed and the maximal length of the vagina, ischiorectal fossa,and pararectal spaces were measured bilaterally. Mean distances to important anatomic structures were made from fixed points along the trocar's path.Results: 1 The uterosacral ligament was attached broadly to the first, second, and third sacral vertebrae, and variably to the fourth sacral vertebraethe .The uterosacral ligament was divided into three equal segments: the cervical portion, intermediate portion, and sacral portion. The distance from ureter to uterosacral ligament was (0.8±0.5)cm,(2.4±0.8)cm,(4.0±0.7)cm,in the cervical, intermediate, and sacral portions of the uterosacral ligament, respectively.2 Pelvic of the ureter was divided into three equal segments , the distance was (4.6±0.9)cm ,(1.7±0.5)cm, (2.4±0.6)cm ,respectively .The distance from the ischial spine to the ureter was (4.8±2.0)cm.3 The length was (4.3±0.7)cm. The width of sacrospinous ligament at its middle point,origin and insertion was(2.3±0.4) cm, (1.2±0.2) cm, (3.5±0.4) cm, respectively. The distance between the ischial spine and the inferior gluteal neurovascular bundle was(1.7±0.3) cm.The distance between the ischial spine and the most distal part of the inferior gluteal nerve ,inferior gluteal vessels, pudendal nerve, internal pudendal vessels was(1.4±0.4) cm, (0.9±0.2) cm, (0.3±0.1) cm, (0.4±0.1) cm ,respectively .4 The path of the trocar began dorsal and lateral to the anus, passed through the ischiorectal fossa,iliococcygeus muscle,into the pararectal space, and into the posteriolateral vagina. Along this course,The distance to the pudendal vessels at the exit of Alcock's canal was (2.7±0.6)cm,and rectum was (0.6±0.3)cm,.The closest inferior rectal vessel was (0.2±0.1)cm,.In the pararectal space,The distance of the ischial spine was (2.5±0.9)cm.In trocar passages,the inferior rectal branches of the pudendal artery and the rectum were within l cm or less of the trocar.The distance of trocar entry into the vagina was only (4.7±0.4) cm proximal to the hymenal ring compared with a mean total vaginal length of (8.6±0.7) cm.Conclusion:1 the optimal site for fixation is the intermediate portion of the uterosacral ligament.2 If the suture is placed to the lower portion and of medial of the sacrospinous ligament,close to the sacrum ,the risk of complication will be minimal. 3 The anatomic study suggests that the rectum and the inferior rectal branches of the pudendal neurovascular bundle may be at risk of injury during infracoccygeal sacropexy trocar placement.Posterior IVS is a minimally invasive,efective and safety surgery for reconstruction of pelvic floor.