Overview by Moi University student

1. SURGICAL ANATOMY
IN OBSTETRICS &
GYNAECOLOGY
PRESENTED BY:
APILLOGOWE ( MED 4)
MODATOR: DR. WAMALWA

2. “IT IS NOT BAD TO PRAY
BEFORE A SURGERY BUT
REMEMBER THAT IF YOU MAKE
AN ANATOMICAL FAULT, EVEN
GOD WILL NOT BE HAPPY WITH
YOU”

3. Objectives/ Outline
•Part 1: Anatomy of the anterior
abdominal wall
•Part 2: Anatomy of the reproductive
system- external genitalia and internal
genitalia

4. Part 1:Anterior abdominal wall
• Theanterior abdominal wall extends from the costal
margins and xiphoid process superiorly to theiliac crests,
pubis and pubic symphysisinferiorly.
• It overlaps and is connected to both the posterior
abdominal wall and paravertebraltissues.
• It forms acontinuous but flexible sheet of tissue across
the anterior and lateral aspects of the abdomen.
• Theanterior abdominal wall is made up of skin,
superficial fascia, deep fascia, muscles, extraperitoneal
fascia, and parietal peritoneum.

5. LANDMARKS
1. Xiphoid process.
2. Costal margin.
3. Tip of the ninthcostal
cartilage.
4. Tendinous intersections.
5. Umbilicus.
6. Iliac crest.
7. Anterior superioriliac
spine.
8. Linea semilunaris.
9. Linea alba.
10. Inguinal ligament.
11. Pubic tubercule.
12. Pubic crest.
13. Pubic symphysis.

6. ABDOMINAL PLANES
•Vertical planes:
• Themidline, which passesthrough the xiphisternal
process and the pubic symphysis
• There are two paramedian planes which are
projected from the midclavicular line (also called the
lateral or the mammary line).
• This line passesthrough the midpoint of theclavicle,
just lateral to the tip of the ninth costal cartilage,
and passes through apoint mid way between the
anterior superior iliac spine and the symphysis
pubis.

7. •Horizontalplanes
• Thetranspyloricplane- level of L1
• Thetranstubercular plane- level of L5
• Thexiphisternal plane -level of the ninth thoracic
vertebra
• Thesubcostalplane-levelofL3/10th costalcartilage
• Thesupracristalplane- joins the highest point of the iliac
crest on each side( L4)
• Theinterspinousplane joins the centres of the
anterior superior spines of the iliaccrests.
• Theplane of the pubiccrestlies at the level of
the inferior end of the sacrum or part of the coccyx.

8. Abdominal regions
• Theabdomen canbe divided into nine arbitrary regionsby
the subcostal and transtubercular planes and the two
midclavicular planes projected onto the surface of the body
• Thenine regions thus formed are:
• epigastrium;
• right and left hypochondrium;
• central or umbilical;
• right and left lumbar;
• hypogastrium or suprapubic;
• right and left iliacfossa.

10. SKIN OF ANTERIOR
ABDOMINAL WALL
• Loosely attached to the underlying structures except at theumbilicus,
where it is tethered to thescartissue.
• Thenatural lines of cleavagein the skin are constant and run
downward and forward almost horizontally around thetrunk.
• Theumbilicus is ascarrepresenting the site of attachment of the
umbilical cord in the fetus; it is situated in the linea alba and is a
common site of infections.
• If possible, all surgical incisions should be made in the lines of cleavage
where the bundles of collagen fibers in the dermis run in parallel rows.
An incision along acleavageline will heal asanarrow scar,whereas
one that crossesthe lines will heal aswide orheaped-up scars

11. Variations of abdominal skin
LINEANIGRA STRIAGRAVIDARUM

12. INCISIONS OF ABDOMINAL
SKIN IN GYNAECOLOGY
VERTICAL
INCISION
PFANNENSTIEL
INCISION
LOWERMIDLINE
VERTICALINCISIONSUBUMBILICALINCISION
FORLAPAROSCOPY

13. Superficial Fascia
• Thesuperficial fascia is divided into
asuperficial fatty layer (fascia of
Camper) and adeep membranous
layer (Scarpa'sfascia).
• Thefatty layer is continuous with
the superficial fat over the rest of
the body and may be extremely
thick (3 in. [8 cm] or more in obese
patients).
• Themembranous layer is thin and
fades out laterally and abovewhere
it becomes continuous with the
superficial fascia of the back and
the thorax,respectively.
SUP
CI
FAS
ERF
I AL
CIA
FATTY
LAYER
MEMB
R
ANOUS
LAYER

14. Muscles of the ant’ abdominal wall
• The muscles of the anterior abdominal wall consist of three broad
thin sheets that are aponeurotic in front; from exterior to interior
they are :
• Theexternal oblique
• Theinternal oblique
• Thetransversus abdominis
• On either side of the midline anteriorly is, in addition, awide
vertical muscle, the rectus abdominis.
• Asthe aponeuroses of the three sheets passforward, theyenclose
the rectus abdominis toform the rectus sheath.
• The lower part of the rectus sheath contains a small muscle called
the pyramidalis.

15. Mus
c
l
e
s
o
f
t
h
• The muscles of the anterior abdominal wall consist of three broad
thin sheets that are aponeurotic in front; from exterior to interior
they are :
• Theexternal oblique
• Theinternal oblique
• Thetransversus abdominis
• On either side of the midline anteriorly is, in addition, awide
vertical muscle, the rectus abdominis.
• Asthe aponeuroses of the three sheets passforward, theyenclose
the rectus abdominis toform the rectus sheath.
• The lower part of the rectus sheath contains a small muscle called
the pyramidalis.

17. Inguinal
canal
• Atriangular-shaped defect in the external oblique
aponeurosis lies immediately above and medial to thepubic
tubercle. Thisis known asthe superficialinguinalring.
• Between the anterior superior iliac spine and the pubic
tubercle, the lower border of the aponeurosis is folded
backward on itself, forming the inguinalligament.

18. Conjoint tendon
• The conjoint tendon is formed from the lower fibres of internal
oblique and the lower part of the aponeurosis of transversus
abdominis.
• It is attached to the pubic crest and pectineal line.
• It descends behind the superficial inguinal ring and acts to
strengthen the medial portion of the posterior wall of the
inguinal canal.
• Theattachment tothe pectineal line is frequently absent.
• Medially, the upper fibres of the tendon fuse with the anterior
wall of the rectus sheath, and laterally some fibres may blend
with the interfoveolarligament.

19. Fascia Transversalis
• Thefascia transversalis is athin layer of fascia that lines
the transversus abdominis muscle and is continuouswith
asimilar layer lining the diaphragm and the iliacus
muscle .
• Thefemoral sheath forthe femoral vesselsin the lower
limbs is formed from the fascia transversalis and the
fascia iliaca that covers the iliacus muscle.

20. • RECTUS SHEATH
• Description the rectus sheath is considered at three levels:
• Above the costal margin, the anterior wall is formed by the
aponeurosis of the external oblique. Theposterior wall is formedby
the thoracic wall—that is, the fifth, sixth, and seventh costal
cartilages and the intercostalspaces.
• Between the costal margin and the level of the anterior superior iliac
spine, the aponeurosis of the internal oblique splits to enclose the
rectus muscle; the external oblique aponeurosis is directed in frontof
the muscle, and the transversus aponeurosis is directed behind the
muscle.
• Between the level of the anterosuperior iliac spine and the pubis, the
aponeuroses of all three muscles form the anterior wall. The
posterior wall is absent, and the rectus muscle lies in contact with the
fasciatransversalis.

21. Linea alba
• Thetendinous raphe extending from thexiphoid process to
the symphysis pubis and pubiccrest.
• It lies between the two recti and is formed by the interlacing
and decussating aponeurotic fibres of external oblique,internal
oblique and transversusabdominis.
• Below the umbilicus, the lineaalba narrows progressively as
the rectus muscles lie closer together.
• Above the umbilicus, the linea alba is correspondinglybroader
Superficial fibres are attached to the symphysis pubis, and its
deeper fibres form atriangular lamella that is attached behind
rectus abdominis to the posterior surface of the pubic crest
on each side.
• Crossed from side to side by afew minute vessels.

22. Deep Fascia (FASCIA OFSCARPA)
• Thedeep fascia in the anterior abdominal wall ismerely
athin layer of connective tissue covering themuscles; it
lies immediately deep to the membranous layer of
superficial fascia.
• In the female, it is continued into the labia majora and
from there to the fascia of Colles.

23. Extraperitoneal Fat
•
T
c
he extraperitoneal fat is athin layer of connective tissuethat
ontains avariable amount of fat and lies between thefascia
transversalis and the parietalperitoneum.
SKIN
EXTRAPERITONEALFAT
PARIETALPERITONEUM

24. Parietal Peritoneum
• The walls of the abdomen are lined with parietal
peritoneum.
• Thisis athin serous membrane and is continuous below
with the parietal peritoneum lining the pelvis .

25. NERVE SUPPLY
• Thenerves of the anterior abdominal wallare:
• Theanterior rami of the lower sixthoracicnerves–
include the lower five intercostal nerves and the
subcostal nerves
• Thefirst lumbar nerve - represented by the
iliohypogastric and ilioinguinal nerves, branches ofthe
lumbar plexus.
• Theypassforward in the interval between theinternal
oblique and the transversusmuscles.
• They supply the skin of the anterior abdominal wall, the
muscles, and the parietal peritoneum.

26. DERMATOMES
Thedermatome of
• T7 : in the epigastrium
over the xiphoidprocess,
• T10: umbilicus
• L1 : just abovethe
inguinal ligament andthe
symphysis pubis.
XIPHOIDPROCESS
UMBILICUS
PUBICSYMP HYSIS

27. BLOOD SUPPLY
• Theskin near the midline is
supplied by branches of the
superior and the inferior
epigastric arteries.
• Theskin of the flanks is
supplied by branches of the
intercostal, the lumbar, andthe
deep circumflex iliacarteries
• the skin in the inguinalregion
is supplied by the superficial
epigastric, the superficial
circumflex iliac, and the
superficial external pudendal
arteries, branches of the
femoral artery.

28. VEINS
• Superficial Veins
• Thesuperficial veins form anetwork that radiates outfrom the
umbilicus.
• Above- drainedinto the axillary vein via the lateral thoracic vein.
• Below- into the femoral vein viathe superficial epigastric and great
saphenous veins.
• Afew small veins, the paraumbilical veins, connect the network
through the umbilicus and along the ligamentum teres to the portal
vein. Thisforms an important portal- systemic venous
anastomosis.
• Thedeep veins-the superior epigastric, inferior epigastric, and deep circumflex
iliac veins, follow the arteries of the samenameand drain into the internal
thoracicand external iliac veins.
• Theposterior intercostal veinsdrain into the azygos veins, and the lumbar veins
drain into the inferior vena cava.

29. Lymphatic Drainage
• Lymphaticsin the regionabove
the umbilicus
Axillary lymph nodes which canbe
palpated justbeneath the lower
border of thepectoralis major
muscle
• Lymphaticsin the regionbelow
the umbilicus
Superficial inguinal nodes. Their
efferent vesselsprimarily enter the
external iliac nodes and, ultimately,
the lumbar (aortic)nodes.
• Thedeeplymphvesselsfollow the
arteries and drain into the internal
thoracic, external iliac, posterior
mediastinal, and para-aortic (lumbar)
nodes.

30. PART 2: ANATOMY OF THE
REPRODUCTIVE SYSTEM

31. ExternalGenitalia

32. External Genital Organs

33. Vulva
UGLecture, SGSMC& KEMHospital,
Mumbai
Blood supply:
Arterial:
Internal Pudendal A. (chiefly)
Branches of Femoral A .also
Venous:
Internal pudendal vein
Long Saphenous vein

34. UGLecture, SGSMC& KEMHospital,
Mumbai
Vulva
Nerve Supply:
• Ilioinguinal nerve
• Genital branch of Genitofemoral nerve (L1,L2)
• Pudendal branches from Posterior Cut Nerve of Thigh (S123)
• Labial and Perineal branches of Pudendal nerve (S234)
Lymphatics
• Superficial Inguinal nodes
• Gland of Cloquet
• External and Internal Iliac lymph node

35. UGLecture, SGSMC& KEMHospital,
Mumbai
Vulva
Development:
• External genitalia: cranial aspect of ectodermal cloacal fossa
• Clitoris: Genital Tubercle
• Labia minora : Genital folds
• Labia majora: Labio-scrotal swelling
• Vestibule: Urogenital Sinus

36. UGLecture, SGSMC& KEMHospital,
Mumbai
Internal GenitalOrgans

37. UGLecture, SGSMC& KEMHospital,
Mumbai
Vagina
• Fibro-musculo-membranous sheath communicating the uterine cavity
with exterior atvulva
Organ of copulation and forms birth canal duringparturition•
• Directed upward and backwards forming angle of 45 degrees(with
horizontal in erectposture)
• Long axis of vagina lies parallel to the plain of pelvic inlet and
perpendicular to theuterus
Walls: Four (ant-7cm,Post-9
cmand2lateral)
Fornices: Four (posterior isdeepest)
•
•
• Layers: Four (Mucous, sub-mucous, muscular, fibrous)

38. UGLecture, SGSMC& KEMHospital,
Mumbai
Vagina
Anteriorly-Base of the bladder, urethra
Posteriorly- From up downwards: Pouch of Douglas, anterior rectal wall separated
by rectovaginal septum and the anal canal separated by the perineal body
Lateral walls- Base of broad ligament in which the ureter and the uterine artery
lie approximately 2 cm away, middle-third is blended with the levator ani and the
lower-third is related withthe bulbocavernosus muscles, vestibular bulbs, and
Bartholin’s glands

39. UGLecture, SGSMC& KEMHospital,
Mumbai
Internal Genital Organs;crosssection

40. Vagina
• Secretions:Acidic (Dodderlein’s bacilli- pHvaries with
estrogenic activity, average 4.5)
• Blood supply:
 VaginalA.- branch of ant. dvsn of internal iliac or
in common with uterine
 Cervicovaginal branch of the UterineA.
 Internal PudendalA.
 Middle RectalA.
• Veins:
–
–
Internal Iliac vn.
Internal Pudendalvn.

41. • Lymphatics:
– Internal Iliac group
– Superficial Inguinalgroup
• Nerve:
– Sympathetic and Parasym:PelvicPlexus
– Somatic: Pudendal nerve
UGLecture, SGSMC& KEMHospital,
Mumbai
Vagina

42. UGLecture, SGSMC& KEMHospital,
Mumbai
• Development: All 3 germlayers
• Upper 4/5th:
•
•
Mucosa: Endoderm of canalised sinovaginal bulb
Musculature: Mesoderm of 2 fused MullerianDucts
• Lower 1/5th: Endoderm of urogenitalsinus
• External genital orifice: Genital fold ofEctoderm
Vagina

43. Hollow pyriform muscular organ situated inpelvis between
the bladder in front and the rectum behind
• Position:Anteversion, Anteflexion, usuallydextro-rotated,
sothat the cervix is levorotated ( towards the leftureter)
• 8 x5 cms; 50-80 gms
• Parts:
UGLecture, SGSMC& KEMHospital,
Mumbai
Uterus

44. UGLecture, SGSMC& KEMHospital,
Mumbai

45. UGLecture, SGSMC& KEMHospital,
Mumbai
Uterus-Relations
Anteriorly-Body forms posterior wall of the uterovesical pouch( above
the int. os); separated from the base of the bladder by areolar tissue(
below the int. os)
Posteriorly- covered by peritoneum and forms
the anterior wall of the pouch of Douglas containing
coils of intestine.
Laterally: The double folds of peritoneum of the
broad ligament are attached laterally between which
the uterine artery ascends up; At the level of the internal os, about
1.5cm away, the uterine artery crosses from above and in front of the
ureter, soon before the ureter enters the ureteric tunnel

46. UGLecture, SGSMC& KEMHospital,
Mumbai
Relationsof the Uterus

47. UGLecture, SGSMC& KEMHospital,
Mumbai
Uterus

48. Supportsof UterusSupportsof Uterus

49. UGLecture, SGSMC& KEMHospital,
Mumbai

50. UGLecture, SGSMC& KEMHospital,
Mumbai
BloodSuppplyof Uterus

51. UGLecture, SGSMC& KEMHospital,
Mumbai

52. UGLecture, SGSMC& KEMHospital,
Mumbai
• Vein: Internal IliacVein
• Lymphatics:
– Uterus:
• Fundus and upper part: Pre-aortic andLateral
Aortic
• Cornu: Superficial Inguinal glands
• Lower part: ExternalIliac
– Cervix:
• External Iliac , Obturator andParacervical
• Int. Iliac
• Sacral group

53. UGLecture, SGSMC& KEMHospital,
Mumbai
•Nerves:
•Sympathetic: T5 to L1
•Parasympathetic: S234 ends in Ganglia of
Frankenhauser
•Somatic: T10 to L8
•Cervix is insensitive to touch, heat
•Development: Fused vertical part of two Mullerian
Ducts

54. UGLecture, SGSMC& KEMHospital,
Mumbai
Fallopian Tubes
•Paired structures, 10cms long, in the upper free margin
of broad ligament
•Three layers

55. UGLecture, SGSMC& KEMHospital,
Mumbai
•Blood supply: Uterine A. and Ovarian A.
•Venous drainage- Pampiniform plexus into Ovarian vein
•Tube is very sensitive to handling
•Development: corresponding Mullerian duct at 6-12
weeks

56. UGLecture, SGSMC& KEMHospital,
Mumbai
Ovary
•Paired sex gland concerned with germ cells , their storage
and release and steroidogenesis
•2 ends: Tubal and Uterine
•2 surfaces: medial and lateral
•Lies in ovarian fossa on the lateral pelvic wall
•Attached to pelvic wall by infundibulopelvic ligament and
to uterus by ovarian ligament
•Consists of cortex and medulla

57. UGLecture, SGSMC& KEMHospital,
Mumbai
Mesovarium /anterior border—A fold of peritoneum from the posterior leaf of
the broad ligament is attached to the anterior border through which the
ovarian vessels and nerves enter the hilum of the gland.
Posterior border is free and is related with tubal ampulla. It is separated by the
peritoneum from the ureter and the internal iliac artery
Medial surface –related to fimbrial part of the tube.
Lateral surface -in contact with the ovarian fossa on the lateral pelvic wall.
The ovarian fossa is related superiorly to the external iliac vein, posteriorly to
ureter and internal iliac vessels and laterally to the peritoneum separating
the obturator vessels and nerves

58. UGLecture, SGSMC& KEMHospital,
Mumbai

59. UGLecture, SGSMC& KEMHospital,
Mumbai
•Arterial supply: Ovarian A.
•Venous drainage:
•Right: into IVC
•Left: into Left renal vein at right angle
•Lymphatics: Para-aortic LN
•Development: Genital ridge

60. UGLecture, SGSMC& KEMHospital,
Mumbai
Pelvic Floor
•Muscular partition separating the pelvic cavity from
anatomical perineum-Levator Ani+Coccygeous+Piriformis

61. UGLecture, SGSMC& KEMHospital,
Mumbai
Pelvic Floor

62. UGLecture, SGSMC& KEMHospital,
Mumbai
Perineal Body
•Pyramidal shaped tissue where the pelvic floor, the
perineal muscles and the fascia meet
•In between vagina and anal canal
•Measures 4 x 4 cms

63. `
UGLecture, SGSMC& KEMHospital,
•Structures:
• Muscles:
•Superficial and Deep Transverse
Perinei paired
•Bulbospongeosus
•Levator Ani
•Sphincter Ani
•Fascia:
•Superficial
• Deep (Colle’s fascia)

64. `
UGLecture, SGSMC& KEMHospital,

65. UGLecture, SGSMC& KEMHospital,
Mumbai
Ureter
•Measures 13 cms in length
•Clinically important because of crossing of the ureter
over important structures
•Forms posterior boundary of ovarian fossa
•Lies over the pelvic floor at the level of ischial spine
•Crossed by Uterine A. anteriorly at the base of broad
ligament
•Lies close to the supra vaginal part of the cervix

66. UGLecture, SGSMC& KEMHospital,
Mumbai

67. REFERENCE
DC Dutta’s Textbook of Obstetrics, 7th Edition
Gynecology by Ten teachers, 20th Edition

68. UGLecture, SGSMC& KEMHospital,
Mumbai