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SURGICAL ANATOMY

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The complexities of radical extirpative surgery for locally advanced and recurrent pelvic cancer and the associated procedures necessary for successful functional and cosmetic reconstruction require a thorough understanding of anatomy that extends from the upper abdomen to the thigh. This chapter is not intended as an exhaustive anatomic discourse but rather as a summary of the relevant anatomic considerations important to the various operative procedures detailed in the chapters that follow.

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Pelvis

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1. Pelvic viscera
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The true pelvis is bounded by the pelvic floor inferiorly and the pelvic brim superiorly and is defined by an imaginary line connecting the sacral promontory, the upper margin of the pubic symphysis, and the arcuate and pectineal lines (Figure 2-1). The pelvis contains the urinary bladder, rectosigmoid colon, uterus, adnexa, and a portion of the vagina, and important vasculature and lymphatic structures. The uterus is a centrally located organ between the bladder anteriorly and the rectosigmoid colon posteriorly. The muscular upper portion of the uterus is the fundus, while the tapered more fibrous component is the cervix, which directly communicates with the vagina. The fallopian tubes arise from the lateral, superior portion of the uterine corpus anterior to the utero-ovarian ligaments. The utero-ovarian ligaments suspend the ovaries and contain anastomoses between the uterine and ovarian vessels. The adnexa are classically lateral to the uterus; however, they may be found between the uterus and the rectosigmoid colon along the pelvic sidewall.

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Fig. 2-1.

Pelvis lateral view, right paramedian section.

Graphic Jump Location
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The only portion of the uterus not covered with serosa is the anterior cervix, which is covered by the bladder. The posterior portion of the bladder not only covers the anterior cervix, but it also overlies the proximal vagina. The anterior portion of the bladder lies against the pubic symphysis and abdominal wall, and the lateral and inferior portions lie against the obturator internus and levator ani muscles, respectively. The ureters are smooth muscle, retroperitoneal structures that drain urine from the kidney and enter the pelvis at the level of the bifurcation of the common iliac artery, medial to the infundibulopelvic ligament. They cross the common iliac vessels anteriorly and course laterally, under the infundibulopelvic ligaments while descending into the pelvis, running posterior to the ovary and deep to the broad ligament before traversing through the cardinal ligament and under the uterine artery approximately 2 cm lateral to the cervix. The ureters then curve anteromedially to enter the back of the bladder at the vesicoureteric junction.

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The sigmoid colon is a short “S” curving of the descending colon just before the rectum. It is normally approximately 40 cm in length and is distinguished from the descending colon and rectum because it features a traditional mesentery and is not retroperitoneal. The sigmoid mesocolon ...

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