Topographic anatomy of the pelvic organs. Pelvic diaphragm. Topographic anatomy and operative surgery of the pelvis and perineum Topography of the uterus in the small pelvis

The uterus and its appendages

Uterus , uterus, is a derivative of the Müllerian canals, which are laid in the early embryonic period. From these canals, the fallopian tubes develop in the upper part, and in the lower part, as a result of their fusion, the uterus and vagina are formed. In those cases when the fusion of the Mullerian canals does not occur, certain forms of malformations occur. Thus, the mechanism of development of the fallopian tubes, uterus and vagina explains to us the often occurring anomalies in the development of these organs.

The malformations of the female genital organs are quite diverse, and basically by origin they can be of two types: in some cases, as was said, the Müllerian ducts in their lower sections do not merge at all or merge very low, in other cases one of the Müllerian ducts does not develop completely resulting in unilateral development of the uterus.

In the first case, there is a varying degree of bifurcation of the uterus and vagina. Thus, if the uterus and vagina are completely divided into two halves with the formation, as it were, of two uteruses, we have a doubled uterus, uterus didelphys, if we observe a bifurcation of only the bottom area - a bicornuate uterus, uterus blcornisif inside the uterus is divided by a septum into two cavities, such a uterus is designated as uterus blloculari's. With a weak degree of bifurcation of the fundus of the uterus, when an interception, or gutter, is formed in the sagittal direction in the region of the bottom, such a uterus receives the name uterus arcuatus.

With the underdevelopment of one of the Müllerian ducts, another type of duct arises - one-horned, uterus unicornis.Such a uterus is characterized by weakness of the muscles and often the presence of an underdeveloped adnexal horn. If pregnancy occurs in the accessory horn, severe, sometimes fatal bleeding is possible with its subsequent rupture.

The uterus is located in the small pelvis. Located between the bladder and the rectum, the uterus under normal conditions is a very mobile organ. It significantly changes its location depending on the filling of the organs adjacent to it. So, when filling the ampoule of the rectum, the uterus moves significantly anteriorly, while filling the bladder, on the contrary, it is pushed back. With the simultaneous filling of both of these organs, the uterus rises upward, as if it is forced out of the cavity of the small pelvis.

The shape of the uterus approaches the pear-shaped, but somewhat compressed in the anteroposterior direction. Its narrowed part has a cylindrical shape and is directed downwards, where it protrudes into the initial part of the vaginal canal. The expanded part of the uterus is directed mainly upward, where, depending on the individual characteristics and the filling of the pelvic organs, it occupies a different position.

The uterus is divided into three sections:

1.Bottom, fundus uteri,

2.Body, corpus uteri,

3.Shake, cervix uteri.

The cervix, in turn, is divided into supra-vaginal and vaginal portions, portlo suprava-ginalis and portlo vaginalis.Under the bottom of the uterus refers to the expanded upper section, located above the discharge of the fallopian tubes. The body of the uterus includes its middle section, located between the confluence of the fallopian tubes and the narrowed interception of the uterus, Isthmus uteri, followed by the cervix. Nearly 2/z the length of the cervix should be attributed to the supravaginal portion. Only a small part of the cervix protrudes into the vagina in the form of a circular protrusion. The free end of the vaginal part of the cervix has two lips - the front, labium anterius, and back, labium posterius.

In addition, two surfaces are distinguished in the uterus: the anterior cystic, facies veslcalis, and back - intestinal, facies intestinalis, and two side edges - margines laterales, dexter and sinister.

The size of the uterus under normal conditions in a nulliparous woman - nullipara: about 7-8 length cm,width - 4 cmat a thickness of 2.5 cm.All indicated sizes of the uterus in multiparous, multipara: more by 1 - 1.5 cm.Average uterus weight 50 G,in multiparous - 100 G.

The walls of the uterus are represented by the following three layers: a mucous membrane, a muscular one, and a layer of serous cover that does not completely cover the uterus.

mucous membrane, endometrium, without the formation of a submucosal layer is tightly fixed to the muscular membrane. It contains two kinds of glands: uterine glands, glandulae uterinae, and cervical glands, glandulae cervicales. From the cervical glands, mucous cysts can develop, called ovula Nabothi .

The mucous membrane of the uterus has a folded character, and with age, smoothing of the folds is observed. More intensively developed longitudinally branched folds within the neck are called branched folds, plicae palmatae.

Muscular membrane, myometrium- the most powerful layer of the uterus, consisting of smooth muscle fibers. In the body of the uterus, bundles of muscle fibers are located mainly in three layers: the outer and inner with a longitudinal arrangement of the muscles and the middle - annular. Within the neck there is one annular layer with an admixture of a significant amount of elastic fibers, due to which the neck has a very high density and elasticity (V. A. Tonkov).

Three layers of uterine muscles:

) stratum muscularis submucosum- the least pronounced layer with the longitudinal direction of the fibers.

) stratum muscularis vasculare- the most powerful middle layer of muscles with a huge number of blood vessels and with an annular direction of the fibers.

) stratum muscularis subserosum- a slightly pronounced outer layer with a longitudinal direction of muscle fibers.

Serous membrane of the uterus, perimetrium, or its peritoneal cover does not completely line the uterus.

relation to the peritoneum.

The anterior surface of the uterus is lined with peritoneum only in its upper half; the posterior surface is completely lined with the peritoneum, with the serosa posteriorly lining the supravaginal part of the cervix, the posterior fornix, and one upper quarter of the posterior vaginal wall.

Thus, most of the serous membrane of the uterus is located on its posterior surface.

The lateral edges of the uterus are completely devoid of peritoneal cover, since the anterior and posterior layers of the peritoneum, which form the so-called wide uterine ligaments on the sides, are at some distance from each other, due to which paths devoid of peritoneum are formed on the sides of the uterus. The peritoneum in the area of ​​the bottom and body is tightly attached to the uterus; within the neck it is fixed more loosely. This may explain the so-called anterior and posterior parametritis, in which the infection is localized between the anterior and posterior surface of the uterus and the sheets of peritoneum covering it.

The uterine cavity is divided into two spaces: the uterine cavity proper , cavum uteri, and neck canal canalis cervicis . The border between them is the internal uterine os, orificium uteri internum , and outside - the isthmus of the uterus, isthmus uteri, separating the body of the uterus from the cervix.

On the frontal sectionthe uterine cavity has a triangular shape. The top of the triangle is represented by the internal uterine os, the base is the bottom of the uterus, and the upper corners of the triangle are the openings of the fallopian tubes.

On the sagittal sectionthe uterine cavity is pulverized. This cavity is small nulliparaits capacity is 3-4 mlliquids, at multipara - 5-6 ml.

The cervical canal has a spindle shape and is enclosed between the external and internal uterine os.

The uterine cavity communicates with two openings with the fallopian tubes and one with the vagina. Together with the internal uterine os, the following four openings can be described in the uterus:

1. Orificium uteri externum- external uterine os. At nulliparait has an oval shape; at multipararepresents a stretched gap in the transverse direction, delimiting the anterior lip of the vaginal portion of the neck from the back. The external uterine os can be examined with the eye by inserting a gynecological speculum into the vagina.

2. Orificium uteri internum- internal uterine os - the most narrowed part of the uterine canal, delimits the cervical canal from the uterine cavity.

3 and 4. The uterine openings of the fallopian tubes.They are located in the area of ​​​​the corners of the uterus and in diameter reach about 1 mm.

Ligament apparatus of the uterus.

The ligamentous apparatus of the uterus is represented by a number of ligaments. It should be emphasized that the muscular-fascial pelvic floor is of greater importance in strengthening the uterus and the ligaments are less important. Therefore, the apparatus fixing the uterus should be attributed primarily pelvic diaphragm, and then a system of reinforcing ligaments. Wherein pelvic diaphragmapplies to "support"apparatus, ligaments - to the "suspending".According to modern views, therefore, the supporting apparatus, consisting of a strong muscular-fascial tissue, is a true strengthening apparatus of the uterus, the ligamentous apparatus, on the contrary, has only an auxiliary value: the ligaments only limit the mobility of the uterus in one direction or another.

The ligaments of the uterus include:

I. big. latum uteri (dextrum et sinistrum) - wide uterine ligament(right and left)is a paired duplication in the frontal plane in the small pelvis. In the process of development, the uterus, gradually increasing, raises the peritoneum upwards, as if “dressing” it and giving away its doubled sheets, which are called the wide uterine ligaments. Approaching the side walls of the small pelvis, the wide ligament of the uterus directly passes into the parietal peritoneum.

Stretched broad ligamenthas a quadrangular shape. Its medial edge is fixed to margo lateralisuteri with the formation of a narrow interperitoneal path. The lateral edge is fixed to the side wall pelvis minorin the area of articulatio sacroiliaca.The top edge is free; in its thickness passes the tube of the uterus. The lower edge is located at the bottom of the small pelvis. Both leaves here diverge anteriorly and posteriorly and turn into a parietal peritoneum.

Along the lower edges of the wide uterine ligaments, away from the uterus, compacted connective tissue strands diverge - the so-called cardinal ligaments.

Wide uterine ligaments are not smooth throughout. In their thickness are the fallopian tubes, ovaries, own ligaments of the ovaries and round uterine ligaments. All these formations protrude the peritoneum of the wide uterine ligament with the development for each of them, as it were, of the mesentery.

In the wide uterine ligament, there are:

1. Mesometrium - own mesentery of the uterus, which occupies most of the wide uterine ligament (approximately its lower 2/3). In its duplication lies a significant amount of fatty tissue, gradually increasing downwards. Inflammation of this fiber is called lateral parametritis, parametritis lateralis.

2. Mesosalpinx - mesentery of the fallopian tube, occupies the upper ⅓ of the wide uterine ligament. This is a transparent duplication of the peritoneum, which does not contain fatty tissue between sheets.

3. Mcsovarium - the mesentery of the ovary and its own ligament of the ovary is formed by stretching the posterior sheet of the broad ligament posteriorly. It is the border between the overlying sheets of mesosalpinx and the duplication of mesometrium located below. It is also a transparent duplication that does not contain fatty tissue.

4. Mesodesma - braid - a peritoneal strip, under which there is a round uterine ligament, somewhat raising the peritoneum.

Unlike the mesentery of the small intestine, the wide uterine ligament is a paired mesentery; its duplication is located to the right and left of the uterus.

II. Cardinal ligaments of the uterus, ligamenta cardljialla uteri, are essentially the base of the broad uterine ligaments.

The lower edge of the wide uterine ligaments, thickening due to the development of fibrous elements and smooth muscle fibers, forms dense cords diverging away from the cervix of the uterus, which are called the cardinal ligaments of the uterus. These ligaments prevent lateral displacements of the uterus and are, as it were, an axis around which physiological movements of the body and the bottom of the uterus are carried out anteriorly and posteriorly. These ligaments depart at the level oriflclum uteri internumand fix the uterus on both sides. It can be concluded, therefore, that these ligaments prevent the occurrence lateropositlo (dextra or sinistra).

III. Round uterine ligament, llg. rotundum uteri, is an analogue, as well as llg. ovarii proprium, hunter's strand of men, gubernaculum hunteri. It departs from the lateral surface of the body, more precisely, from the angle of the uterus anterior to the beginning tuba uterina, heading forward and outward and enters into anulus ingulnalis Internus. On the way, the bundle crosses n. and vasa obturatorla, llg. umbilicale laterale, vena iliaca externaand vasa eplgastrlca Inferlora.

into the inguinal canal lig. teres utericomes along with a. spermatica externaand n.spermaticus externus.The basis of the round uterine ligament is fibrous tissue. From uterus to anulus ingulnalis internusthe ligament has a significant admixture of smooth muscle fibers, in the inguinal canal it consists of fibrous tissue, smooth muscles, a derivative of the muscular elements of the uterus itself, and striated fibers due to the attachment of muscle bundles from the internal oblique and transverse muscles, and upon exiting the inguinal canal - within labia majorafrom only one fibrous tissue, the bundles of which fan-shaped diverge in the upper 2/3big lips.

Upon exiting the external inguinal ring, the round uterine ligament is surrounded by branched fatty lobules, forming bunch of Imlach.

In some cases, the round uterine ligament drags a section of the peritoneum into the inguinal canal, like the processus vaginalis peritonaei of men. This area of ​​the peritoneum is called nuccadiverticulum, diverticulum Nuckii , which often serves as a site for the development of Nukka cysts filled with serous fluid. In cases where a large amount of such fluid accumulates, real dropsies of these diverticula develop, which are called hydrocele femlinum.

Functionally, the round ligaments have some value in preventing the uterus from tilting backwards.

IV. Sacro-label ligaments, lig. sacrouterine, are muscular-fibrous bundles, somewhat stretching on both sides in the form of a fold of the peritoneum. The muscle elements of this ligament are called m. rectouterinus s. secrouterinus. This paired muscle in the form of a rounded stem on each side stretches from the posterior surface of the cervix, starting approximately at the middle of its length, goes back and is woven into the muscle elements of the rectum; part of the fibers goes further and is fixed to the sacral bone at the level of the II-III sacral vertebra. Hence the name m. rectouterinus s. sacrouterinus. Together with the bundles of fibrous tissue surrounding these muscles and the peritoneum covering them, the described formations are called sacro-uterine ligaments, lig. sacrouterine. These ligaments, together with their muscles, to a certain extent prevent the anterior deviation of the uterus and are essentially antagonistic to the round uterine ligaments.

V. Own ligament of the ovary, lig. ovarii proprium, stretches from the lateral surface of the body of the uterus to the ovary. This ligament is more important for the ovary than for the uterus and therefore will be discussed in more detail when describing the topography of the ovaries.

The position of the uterus in both physiological and pathological conditions varies to a very large extent. The following options are available here.

1. Antepositio uteri- the entire uterus is moved somewhat anteriorly.

2. retropositio uteri- the entire uterus is moved somewhat posteriorly.

3. Lateropositio uteri (dextra or sinistra)- the entire uterus is moved from the midline to the right or left.

If there is an angle between the cervix and the body of the uterus, the following options are also possible.

4. Anteflexio uteri- the angle between the body and the neck is open anteriorly, therefore, the body of the uterus is tilted forward.

5. retroflexlo uteri - the angle between the body and the cervix is ​​open backwards, therefore, the body of the uterus is tilted backwards.

6. Lateroflexio uteri (dextra or sinistra)- the angle between the body and the neck is open to the right or left, therefore, the body of the uterus has a corresponding slope to the right or left.

If the axis of the uterus deviates in one direction or another from the axis of the small pelvis, the following options are possible.

7. Anteversio uteri- the entire uterus is tilted anteriorly.

8. Retroversio uteri- the entire uterus is tilted backwards.

9. Lateroversio uteri- the entire uterus is tilted to the right or to the left.

The normal position of the uterus is a mildly pronounced state anteversioand anteflexio uteri.

Parametrium, parametrium, is a space in the form of a slit-like cavity in the thickness of the sheets of mesometrium. This space, clinically very important, has the following boundaries:

in front - anterior leaf of mesometrium;

behind - the back sheet of mesometrium;

from the inside - the lateral edge of the uterus;

outside - the lateral edge of the broad ligament;

above - mesovarium (resp. ovary u lig. ovarii proprium)

below - freely communicates with the adjacent tissue of neighboring areas, since the sheets of mesometrium gradually diverge downwards.

Thus, with parametritis, the infection, due to the described anatomical conditions, can communicate with four spaces of the small pelvis through the gap open downwards - with spatlum paravesical, spatium parauterinum, spatium paravaginale and spatium pararectal.

Syntopy of the uterus.

Anterior to the uterus, between it and the bladder, is the vesicouterine cavity, excavatio vesicouterina. It extends down to about half of the uterus. Behind the uterus is a deeper recto-uterine cavity, excavatio rectouterina, which reaches the proximal part of the vagina. This recess serves very often as a receptacle for all kinds of pathological effusions.

At ectopic pregnancythis is where the blood released after a stroke accumulates.

At pelvioperitonitispus or other exudate flowing down due to gravity is also localized here.

Since the excavatio rectouterina extends down to the upper part of the vagina, the pus accumulated here is very close to the posterior vaginal fornix. This is used to open such purulent accumulations by piercing the back wall of the vagina in the region of the posterior fornix with a scalpel and diverting pus through the vagina.

If an ectopic pregnancy is suspected, a puncture of the excavatio rectouterina is performed through the posterior fornix to detect the blood that has poured out here after a stroke.

Below the excavatlo vesicouierina, the uterus is attached to the bladder with the help of connective tissue. This may explain spontaneous breakthroughs of pus directly into the bladder through its back wall with the so-called anterior parametritis. In these cases, an infection originating from the uterus infiltrates the tissue between the uterus and the bladder, causes parametritis anterior, and can later perforate the wall of the bladder and penetrate into it. On the sides of the body of the uterus in the parametric spaces, a large amount of fatty tissue, blood vessels, nerves and lymphatic pathways are concentrated. The infection penetrating here by the lymphogenous route or per continuitatem from the uterus affected by the inflammatory process causes parametritis lateralis (dextra or sinistra).

Since the parametric space freely communicates through the lower edge of the uterine ligament with the surrounding pelvic tissue, diffuse phlegmon of the pelvis may occur with the penetration of infection into spatium parauterinum, spatium paravesicaleand spatium pararectale.In these cases, often the uterus, bladder and rectum are directly immured in the general infiltrate ( K. K. Skrobansky). Squeezing adjacent adjacent organs, the infiltrate disrupts their blood circulation, which can lead to perforation of the walls of the rectum or bladder and to a breakthrough of pus into these organs.

Following the path of least resistance, pelvic tissue pus can erupt:

1) through foramen ischiadicum majus or minus- in the gluteal region;

2) through canalls obturatoriusto the system of adductor muscles;

3) through canalis inguinalisin the subgroin area;

4) through lumbar triangles of Petit and Grunfeldunder the skin of the lumbar region.

In rare cases, parametric ulcers open into the abdominal cavity, more precisely in the excavatio rectouterina.

Very important in the syntopy of the pelvic organs is the relationship of the ureters to the uterus and uterine artery.

The ureters penetrate into the small pelvis, spreading through the iliac vessels, and the left ureter crosses a. iliaca communis, and the right a. iliaca externa.

Below the ureters cross from the inside n. and vasa obturatoriaand at the level of the middle of the cervix at a distance of 1-2 cmfrom it intersect with a. uterina.It must be remembered that the artery passes in front of the ureter. This decussation is very important during the operation of the total extirpation of the uterus according to Wertheim, as it is sometimes captured in the clamp along with the uterine artery and the ureter, which in this case can be accidentally cut.

From above, loops of small intestines and an S-shaped intestine are adjacent to the uterus.

Behind in excavatio rectouterinaloops of small intestines are also located.

Lies in front excavatio vesicouterina.

From the sides in the parametrial spaces lie, touching the body and cervix, powerful venous plexuses, plexus venosl uterovaginales, and at the level of the middle of the neck is the already described intersection of the ureter with the uterine artery.

The order of location of the organs extending from each corner of the uterus and diverging to the sides of it:

somewhat anteriorly directed - lig. teres uteri and her mesodesma;

away from the rib of the uterus - tuba uterina and its mesosalpinx;

somewhat posteriorly - lig. ovarii proprium and its mesovarium.

Blood supply.

Arterial supplyuterus is carried out by a pair of uterine arteries, a. uterina which is a branch of the internal iliac artery a. iliaca interna . Moving away from it, the uterine artery makes an arc, penetrates into the base of the wide uterine ligament and along the rib of the uterus in the parametric space, wriggling strongly, ascends to the bottom, where it anastomoses with its ovarian branch with the ovarian artery , a. ovarica coming directly from the aorta.

At a distance of 1-2 cmfrom the cervix, usually at the level of its internal pharynx, the uterine artery crosses with the ureter, while located in front of it. In this area, the artery lies horizontally, and the ureter - vertically.

The artery varies greatly in its position, which explains the frequent injury of the ureter during the operation of extended extirpation of the uterus. according to Wertheim. Therefore, ligation of the artery during this operation requires special care.

The uterine artery often gives a different number of branches and has different types of branching, which is very important to know when performing an operation on this organ. Anatomical manuals usually describe a descending - vaginal branch, ramus vaginalis, running down the sides of the vagina, ovarian branch, ramus ovaricus,going through the fallopian tube to the ovary and tubal branch ramus tubarlusaccompanying the pipe and branching in it.

Venous outflowfrom the uterus is carried out in three directions, originating from a powerful venous plexus, located mainly on the sides of the uterus, the vagina. The interweaving is called plexus venosus uterovaginalis.

From the bottom of the uterus, venous outflow occurs mainly through the system v. ovaricaedirectly into the inferior vena cava,

On the left - in the left renal vein. In the same system of veins, blood flows from the ovaries and fallopian tubes.

From the body of the uterus and the supravaginal part of the cervix, venous blood flows through the system vv. uterinaethat fall into vv. illacae internae.

From the vaginal part of the cervix and from the vagina, blood flows directly into v. Iliaca interna.

The described three directions of outflow of venous blood are largely conditional, since it is, of course, impossible to draw the exact border of the "blood division" between the individual parts of the uterus.

It must also be remembered that plexus venosus uterovaginaliswidely anastomoses anteriorly with plexus vesicalisand plexus pudendusand behind with plexus rectalis.

Innervation.

Parasympathetic and sympathetic nerves.

Parasympathetic fibers are sent to the uterus as part of n. pelvicus s, erigens, s. slpanchnicus sacralis. The nucleus of this nerve, nucleus parasympathicits, is located in the lateral horn of the spinal cord III and IV of the sacral segments. Impulses emanate from this nucleus and travel to the rectum, bladder, and uterus, resulting in the emptying of these organs.

Sympathetic fibers that inhibit the emptying of these organs are part of n. iliacus internus.

The works that came out of the laboratory of B. I. Lavrentiev and A. N. Mislavsky found that the cervix and body of the uterus have different innervation:

body- predominantly sympathetic,

neck- predominantly parasympathetic.

This has been proven by the following experiments:

when cutting n. pelvicus, degeneration of the nerve fibers of the cervix and vagina soon followed.

when cutting n. iliacus internus degenerated postganglionic fibers within the body of the uterus.

In the region of the body of the uterus, there is a parietal nerve plexus with a small content of ganglionic elements. Within the neck, on the contrary, the number of individual nodules is very significant and forms their entire clusters ( Naiditsch). These cervical clusters of ganglia, located on the sides of the neck, are known as ganglion cervicale.

Lymph flow.

carried out in various directions.

Schematically: 1) body and fundus of the uterus and oviducts

) from the cervix and from most of the vagina.

Having formed a network of lymphatic vessels on the surface of the muscle layer, plexus lymphaticus uterinus.,main lymphatic collectors vasa lymphatica- directed from the body and the bottom of the uterus and oviducts:

1) along the way v. spermatica interna- in the peri-aortic lymph nodes;

2) along the way lig. rotundum uteri - in l-di inguinales(from the area of ​​the bottom of the uterus);

3) along the way v. uterina- in 1-di iliaci inferioresand further - 1-dus interiliacus.

From the cervix and vagina, lymph is directed:

1) along the way v. iliaca interna- in 1-di iliaci inferiores.

2) along the way v. iliaca externa- in 1-di iliaci inferiores. and further into

The bone base of the pelvis is formed by two pelvic bones, the sacrum and the coccyx. The pelvic cavity is the receptacle for loops of the small and part of the large intestine, as well as the genitourinary system. The upper external landmarks of the pelvis are the pubic and iliac bones, the sacrum. The lower part is limited by the coccyx, ischial tubercles. The exit from the pelvis is closed by the muscles and fasciae of the perineum, which form the diaphragm of the pelvis.

In the region of the pelvic floor, formed by fascia and muscles, the pelvic diaphragm and the urogenital diaphragm are isolated. The diaphragm of the pelvis is formed mainly by the muscle that lifts the anus. Its muscle fibers, connecting with the bundles of the opposite side, cover the wall of the lower part of the rectum and intertwine with the muscle fibers of the external sphincter of the anus.

The urogenital diaphragm is a deep transverse perineal muscle that fills the angle between the inferior rami of the pubic and ischial bones. Below the diaphragm is the perineum.

Separate the large and small pelvis. The boundary between them is the boundary line. The pelvic cavity is divided into three sections (floors): peritoneal, subperitoneal and subcutaneous.

In women, the peritoneum, when moving from the posterior surface of the bladder to the anterior surface of the uterus, forms a shallow vesicouterine depression. In front, the cervix and vagina are located subperitoneally. Covering the bottom, body and cervix from behind, the peritoneum descends to the posterior fornix of the vagina and passes to the rectum, forming a deep recto-uterine cavity.

Duplications of the peritoneum, directed away from the uterus to the side walls of the pelvis, are called the wide ligament of the uterus. Between the leaves of the broad ligament of the uterus are the fallopian tube, the proper ligament of the ovary, the round ligament of the uterus and the ovarian artery and vein that go to the ovary and lie in the ligament that supports the ovary. At the base of the ligament lie the ureter, uterine artery, venous plexus, and uterovaginal nerve plexus. In addition to the wide ligaments, the uterus in its position is strengthened by round ligaments, recto-uterine and sacro-uterine ligaments and muscles of the urogenital diaphragm, to which the vagina is fixed.

The ovaries are located behind the broad ligament of the uterus closer to the side walls of the pelvis. With the help of ligaments, the ovaries are connected to the corners of the uterus, and with the help of suspensory ligaments, they are fixed to the side walls of the pelvis.

The subperitoneal pelvis is located between the peritoneum and the parietal fascia, it contains parts of organs that do not have a peritoneal cover, the final parts of the ureters, the vas deferens, seminal vesicles, the prostate, in women - the cervix and part of the vagina, blood vessels, nerves, lymph nodes and their surrounding loose fatty tissue.

In the subperitoneal part of the small pelvis, two spurs of the fascia pass in the sagittal plane; in front they are attached at the medial edge of the internal opening of the obturator canal, then, following from front to back, they merge with the fascia of the bladder, rectum and are attached to the anterior surface of the sacrum, closer to the sacroiliac joint. In each of the spurs there are visceral branches of vessels and nerves going to the pelvic organs.

In the frontal plane, as noted, between the bladder, prostate and rectum in men, between the rectum and vagina in women, there is a peritoneal-perineal aponeurosis, which, having reached the sagittal spurs, merges with them and reaches the anterior surface of the sacrum. Thus, the following parietal cellular spaces can be distinguished; prevesical, retrovesical, retrorectal and two lateral.

The retropubic cellular space is located between the pubic symphysis and the visceral fascia of the bladder. It is divided into preperitoneal (anterior) and prevesical spaces.

The prevesical space is relatively closed, triangular in shape, bounded anteriorly by the pubic symphysis and posteriorly by the prevesical fascia, laterally fixed by obliterated umbilical arteries. The prevesical space of the pelvis along the femoral canal communicates with the tissue of the anterior surface of the thigh, and along the course of the cystic vessels - with the lateral cellular space of the pelvis. Through the prevesical space, an extraperitoneal access to the bladder is carried out when a suprapubic fistula is applied.

The retrovesical cellular space is located between the posterior wall of the bladder, covered with a visceral sheet of the prevesical fascia, and the peritoneal-perineal aponeurosis. From the sides, this space is limited by the already described sagittal fascial spurs. The bottom is the urogenital diaphragm of the pelvis. In men, the prostate gland is located here, which has a strong fascial capsule, the end parts of the ureters, the vas deferens with their ampoules, seminal vesicles, loose fiber and the prostate venous plexus.

Purulent streaks from the retrovesical cellular space can spread into the cellular space of the bladder, into the region of the inguinal canal along the vas deferens, into the retroperitoneal cellular space along the ureters, into the urethra, and into the rectum.

The lateral cellular space of the pelvis (right and left) is located between the parietal and visceral fascia of the pelvis. The lower boundary of this space is the parietal fascia, which covers the levator ani muscle from above. Behind there is a message with the retrointestinal parietal space. From below, the lateral cellular spaces can communicate with the ischiorectal tissue if there are gaps in the thickness of the muscle that lifts the anus, or through the gap between this muscle and the internal obturator.

Thus, the lateral cellular spaces communicate with the visceral cellular spaces of all pelvic organs.

The posterior rectal cellular space is located between the rectum with its fascial capsule in front and the sacrum in the back. This cellular space is delimited from the lateral spaces of the pelvis by sagittal spurs running in the direction of the sacroiliac joint. Its lower border is formed by the coccygeal muscle.

In the fatty tissue behind the rectal space, the upper rectal artery is located at the top, then the median and branches of the lateral sacral arteries, the sacral sympathetic trunk, branches from the parasympathetic centers of the sacral spinal cord, sacral lymph nodes.

The spread of purulent streaks from the retrorectal space is possible in the retroperitoneal cellular space, lateral parietal cellular spaces of the pelvis, visceral cellular space of the rectum (between the intestinal wall and its fascia).

Operative access to the posterior rectal cellular space of the pelvis is carried out through an arcuate or median incision between the coccyx and the anus, or the coccyx and sacrum are resected no higher than the third sacral vertebra.

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The pelvic diaphragm consists of a muscle that lifts the anus, the fibers of which extend arcuately from the posterior surface of the lower branches of the pubic bones, and on the sides - from the tendon arch (formed by a thickening of the fascia of the obturator internus muscle) towards the coccyx, and from three paired muscles: pubic- coccygeal, iliococcygeal and ischiococcygeal. The end section of the rectum passes through the pelvic diaphragm. The pelvic diaphragm is covered on both sides with fascial sheets.

Pelvic Diaphragm:
1 - muscle that lifts the anus; 2 - coccygeal muscle; 3 - piriformis muscle; 4 - pubic articulation; 5 - urethra; 6 - vagina; 7 - rectum; 8 - obturator fossa

The urethra, passing through the urogenital diaphragm, goes around the pubic fusion from below and behind, firmly fixing to it. Behind the urethra is soldered by means of a dense connective tissue septum with the anterior wall of the vagina.

Pelvic organs

Uterus- a hollow smooth muscle organ, resembling a pear flattened in the anteroposterior direction, from 7 to 11 cm long. Its width at the level of the fallopian tubes is 4-5 cm, the anterior-posterior size is 3-4 cm.

The uterus and its appendages:
1 - the body of the uterus; 2 - cervix; 3 - bladder; 4 - round ligament of the uterus; 5 - fallopian tube; 6 - uterine artery; 7 - ureter; 8 - ovary; 9 - vagina; 10 - rectum

The cervix often has a cylindrical shape, its average length is 3 cm. The supravaginal (approximately 2/3 of its length) and the vaginal parts of the cervix are distinguished.

The body cavity of the uterus is a flat triangular slit, the top of which is directed downwards. In the lower part, the uterine cavity passes into the cervical canal, which has a fusiform shape due to constrictions in the area of ​​​​the external and internal pharynx.

The walls of the uterus consist of 3 layers:
a. Mucous membrane.
b. muscle layer.
in. Peritoneum with subperitoneal connective tissue.

From below, the vagina adjoins the cervix, forming an anteriorly open angle with the axis of the uterus, slightly exceeding 90 °.

The vagina is a tubular organ, the walls of which consist of 3 layers: outer (connective tissue), middle (smooth muscle) and inner (vaginal mucosa). The total thickness of the vaginal wall does not exceed 3-4 mm.

The position of the vagina is fixed mainly due to the urogenital diaphragm, as well as connective tissue partitions between the walls of the vagina and neighboring organs. The anterior wall of the vagina is intimately soldered to the urethra.

The middle third of the vagina at the level of the pelvic floor from the sides comes into contact with the muscles that lift the anus. Above the pelvic floor, in front, the wall of the vagina adjoins the bladder and is connected to it by means of loose connective tissue that forms the vesico-vaginal septum.

The back wall of the vagina lies on the rectum, from which it is separated by a weakly expressed peritoneal-perineal aponeurosis. In the upper section, corresponding to the posterior fornix, the posterior wall of the vagina is covered with peritoneum for 1-2 cm. From the sides, above the pelvic diaphragm, the vagina is fixed by cardinal ligaments.

In the region of the upper corners, the uterus is connected to the appendages, which include the fallopian tubes and ovaries.

The fallopian tube is a paired tubular organ that connects the uterine cavity with the abdominal cavity in the region of the upper uterine angle.

There are 4 sections in the fallopian tube:
a. The uterine part of the tube (interstitial section) is located in the thickness of the uterine wall and opens into its cavity. The length of the interstitial section ranges from 1 to 3 cm. The diameter of the lumen does not exceed 1 mm.
b. Isthmic department - part of the tube 3-4 cm long, located at the outlet of the tube from the wall of the uterus. In this department, the wall of the fallopian tube has the greatest thickness.
in. The ampullar part of the fallopian tube is a gradually expanding convoluted part of the tube about 8 cm long.
The funnel of the fallopian tube is its final, widest section, ending with numerous fimbriae (fimbria) that border the abdominal opening of the fallopian tube. The length of the fimbriae varies from 1 to 5 cm.

The longest fimbria is usually located along the outer edge of the ovary and is fixed to it (the so-called ovarian fimbria).

The walls of the fallopian tubes consist of 4 layers:
a. The outer layer is the serosa.
b. Subserous connective tissue membrane, usually expressed only in the isthmus and ampullar regions.
in. The muscular membrane, which in turn consists of 3 layers of smooth muscles: external (longitudinal), middle (circular) and internal (longitudinal).
g. The inner layer of the fallopian tube - the mucous membrane. It forms numerous longitudinal folds in the lumen of the fallopian tube, the height of which increases towards the distal section.

The fallopian tubes depart from the corners of the uterus horizontally at a right angle. Further, the ampullar sections of the fallopian tubes from the lateral side of the arc wrap around the ovaries in such a way that the final sections of the fallopian tubes are adjacent to the medial surface of the ovaries. Throughout the fallopian tubes are located in the duplication of the peritoneum of the upper edge of the broad ligaments of the uterus.

Along the lower edge of the fallopian tubes of the uterus, the peritoneum forms the mesentery of the fallopian tubes (mesoovarium). In the mesoovarium along the fallopian tubes, vessels formed by the fusion of the terminal branches of the uterine and ovarian arteries pass and give off numerous branches to the fallopian tubes. At the same time, the intraorganic vessels of the interstitial and isthmic sections are located mainly in the transverse direction, and in the ampullar sections their direction approaches oblique.

In addition to the vascular network, the mesoovarium also contains an ovarian appendage (parovarium), located parallel to the fallopian tube in the form of a tubule with perpendicular branches extending from it in the direction of the ovary gate.

In the pelvis and on the lower limb between the muscles, a number of channels, pits and furrows are localized, through which the vessels and nerves pass.

In the pelvic region, forr is distinguished. ischiadica majus et minus. The large sciatic foramen is formed by the greater sciatic notch and the sacrospinous ligament, the small foramen is limited by the lesser sciatic notch, lig. sacrospinale et lig. sacrotuberale. The piriformis muscle leaves the pelvis through the large sciatic foramen, which does not completely fill this hole. Therefore, there are gaps above and below the muscle: forr. supra-et infrapiriforme. Through them, arteries, veins and nerves exit the pelvic cavity to its posterior surface for innervation and blood supply to the gluteal muscles and skin. From the small pelvis, the obturator canal (canalis obturatorius) 2-2.5 cm long passes to the thigh. Its walls are limited by the obturator groove of the pubic bone, internal and external obturator muscles. Through the canal, the obturator nerve and blood vessels penetrate the medial part of the thigh, innervating and supplying blood to the medial muscles of the pelvis.

In the cavity of the large pelvis there is an iliac fossa, which occupies the inner surface of the wing of the ilium. The fossa is partially filled with the iliac muscle; in most cases, the caecum with the vermiform appendix is ​​located in it on the right in most cases. Below, the cavity of the large pelvis communicates with the anterior surface of the thigh through a wide opening, bounded in front by the inguinal ligament stretched between the spina iliaca anterior superior and tuberculum pubicum, and behind the pelvic bone. This hole is divided by lig. iliopectineum into two parts: lacuna musculorum - laterally and lacuna vasorum - medially. Arteries, veins, and lymphatics pass through the lacuna vasorum. A femoral canal may form in this space.

femoral canal. Normally, the femoral canal does not exist; only in the case of the exit of the internal organs or the greater omentum from the abdominal cavity in the regio subinguinalis does the femoral canal appear, having an internal and external opening, with a constant topography. Therefore, in a course of normal anatomy, attention is paid only to the way in which the internal organs can penetrate from the abdominal cavity to the anterior surface of the thigh.

The place where the internal organs from the side of the abdominal cavity penetrate the canal is called the femoral ring (anulus femoralis); it is limited in front lig. inguinale, behind - f. pectinea, laterally - femoral vein, medially - lig. lacunare (Fig. 203), representing a ligament stretched between the inguinal ligament and the pubic bone. The femoral canal is 2-2.5 cm long and is located between the inguinal ligament, the femoral vein, and the fascia covering the pectineus muscle (Fig. 204). The hiatus saphenus becomes the external opening of the femoral canal (see below), which limits the margo falciformis with two legs: cornu superius et inferius. V passes through the hiatus saphenus. saphena magna.

203. The inner surface of the anterior wall of the abdomen and pelvis (according to V. P. Vorobyov).
1 - m. transverse abdominis; 2-f. transversa; 3-f. iliaca; 4 - m. iliacus; 4 - m. fliacus; 5 - m. psoas major; 6-a. femoralis; 7-v. femoralis; 8 - m. obturatorius internus; 9-lig. lacunar; 10 - anulus femoralis; 11-lig. interfoveolare; 12 - ductus deferens, passing through the inguinal canal; 13 - m. rectus abodominis.

204. Right inguinal region. Location of the femoral canal.
1-lig. inguinale: 2 - lig. iliopectineum; 3-a. femoralis; 4-v. femoralis; 5 - anulus femoralis; 6-lig. lacunar; 7 - funiculus spermaticus; 8 - m. iliopsoas; 10-n. femoralis.

The vascular lacuna (lacuna vasorum) continues to the anterior surface of the thigh, where it passes into the iliopectineal groove (sulcus iliopectineus), which continues into the anterior femoral groove (sulcus femoralis anterior). The first - the iliac-comb groove - is limited to m. pectineus and m. iliopsoas, the second - m. adductor longus et magnus and m. vastus medialis. In the lower third of the thigh, the anterior femoral groove passes into the adductor canal (canalis adductorius) 6-7 cm long, communicating the anterior surface of the thigh with the popliteal fossa. The upper opening of the channel is limited: in front - a thickened fascial plate (lamina vastoadductoria), stretched between m. adductor longus and m. vastus medialis, laterally - m. vastus medialis, medially - m. adductor magnus. The lower opening of the adducting canal (hiatus tendineus) is limited by the tendon ring in the lower part of m. adductor magnus. The femoral artery passes through the canal into the popliteal fossa, and the popliteal vein passes from the fossa to the thigh. Through the upper opening, along with the vessels, n enters. saphenus, which deviates forward in the canal and leaves it through a narrow gap that opens near the medial condyle. Therefore, the canalis adductorius has an upper and two lower openings. If you remove f. lata and f. subinguinalis, then the femoral triangle (trigonum femorale) will be visible, bounded from above by lig. inguinale, laterally m. sartorius, medially - m. adductor longus.

On the back surface of the knee area there is a deep popliteal fossa filled with a large lump of adipose tissue. The popliteal fossa is limited from above by m. biceps femoris and m. semimembranosus, below - two heads of the gastrocnemius muscle. The popliteal fossa below communicates with the ankle-popliteal canal (canalis cruropopliteus). The anterior wall of the canal is limited by the popliteal muscle, behind - by the tendon arch, from which m. soleus. The channel passes between m. tibialis posterior and m. soleus, has upper and lower openings. The upper hole opens into the popliteal fossa, and the lower one is at the level of the beginning of the tendon m. soleus. Vessels and nerves for the posterior, lateral and anterior muscles of the leg pass through the canal.

The canalis musculoperoneus inferior runs along the middle third of the fibula, limited behind mm. flexor hallucis longus and tibialis posterior, and in front - fibula. This canal communicates with canalis cruropopliteus and contains a. peronea. In the upper third of the lower leg there is canalis musculoperoneus superior, through which passes n. peroneus superficialis. It is located between the fibula and m. peroneus longus.

On the plantar side of the foot, the medial groove (sulcus plantaris medialis) is limited by m. flexor digitorum brevis and m. abductor hallucis; the lateral furrow passes between m. flexor digitorum brevis and m. abductor hallucis.

Each groove contains a plantar artery, vein, and nerve.

In the female pelvis, the blood supply, innervation and covering of the peritoneum of the rectum is the same as in the male. Anterior to the rectum are the uterus and vagina. Behind the rectum lies the sacrum. The lymphatic vessels of the rectum are connected with the lymphatic system of the uterus and vagina (in the hypogastric and sacral lymph nodes) (Fig. 16.4).

Bladder in women, as in men, lies behind the pubic symphysis. Behind the bladder are the uterus and vagina. Loops of the small intestine are adjacent to the upper, covered with peritoneum, part of the bladder. On the sides of the bladder are the muscles that lift the anus. The bottom of the bladder lies on the urogenital diaphragm. The blood supply and innervation of the bladder in women occurs in the same way as in men. The lymphatic vessels of the bladder in women, like the lymphatic vessels of the rectum, form connections with the lymphatic vessels of the uterus and vagina in the lymph nodes of the broad ligament of the uterus and iliac lymph nodes.

As in the male pelvis, the right and left ureters at the level of the borderline cross the external iliac and common iliac arteries, respectively. They are adjacent to the side walls of the pelvis. At the point of departure from the internal iliac arteries of the uterine arteries, the ureters intersect with the latter. Below in the cervical region, they once again intersect with the uterine arteries, and then adjoin the wall of the vagina, after which they flow into the bladder.

Rice. 16.4. Topography of the organs of the female pelvis (from: Kovanov V.V., ed., 1987): I - fallopian tube; 2 - ovary; 3 - uterus; 4 - rectum; 5 - posterior fornix of the vagina; 6 - anterior fornix of the vagina; 7 - entrance to the vagina; 8 - urethra; 9 - clitoris; 10 - pubic articulation; II - bladder

Uterus in the pelvis of women, it occupies a position between the bladder and the rectum and is tilted forward (anteversio), while the body and cervix, separated by the isthmus, form an angle open anteriorly (anteflexio). Loops of the small intestine are adjacent to the bottom of the uterus. The uterus has two sections: the body and the cervix. The part of the body located above the confluence of the fallopian tubes into the uterus is called the fundus. The peritoneum, covering the uterus in front and behind, converges on the sides of the uterus, forming broad ligaments of the uterus. At the base of the broad ligament of the uterus are the uterine arteries. Next to them lie the main ligaments of the uterus. In the free edge of the broad ligaments of the uterus lie the fallopian tubes. Also, the ovaries are fixed to the wide ligaments of the uterus. On the sides, the broad ligaments pass into the peritoneum, covering the walls of the pelvis. There are also round ligaments of the uterus running from the angle of the uterus to the internal opening of the inguinal canal. The uterus is supplied with blood by two uterine arteries from the system of internal iliac arteries, as well as by the ovarian arteries - branches of the abdominal aorta. Venous outflow is carried out through the uterine veins into the internal iliac veins. The uterus is innervated from the hypogastric plexus. The outflow of lymph is carried out from the cervix to the lymph nodes lying along the iliac arteries and the sacral lymph nodes, from the body of the uterus to the peri-aortic lymph nodes.

The uterine appendages include the ovaries and fallopian tubes.

The fallopian tubes lie between the leaves of the broad ligaments of the uterus along their upper edge. In the fallopian tube, an interstitial part is distinguished, located in the thickness of the uterine wall, an isthmus (narrowed part of the tube), which passes into an expanded section - an ampulla. At the free end, the fallopian tube has a funnel with fimbriae, which is adjacent to the ovary.

ovaries with the help of the mesentery, they are connected with the posterior sheets of the broad ligament of the uterus. The ovaries have uterine and tubal ends. The uterine end is connected to the uterus by its own ligament of the ovary. The tubular end is attached to the lateral wall of the pelvis by means of the suspensory ligament of the ovary. At the same time, the ovaries themselves are located in the ovarian fossae - depressions in the side wall of the pelvis. These recesses are located in the area of ​​​​dividing the common iliac arteries into internal and external. Nearby are the uterine arteries and ureters, which should be taken into account during operations on the uterine appendages.

Vagina located in the female pelvis between the bladder and rectum. At the top, the vagina passes into the cervix, and at the bottom

opens with an opening between the labia minora. The anterior wall of the vagina is closely connected with the posterior wall of the bladder and urethra. Therefore, with ruptures of the vagina, vesicovaginal fistulas can form. The back wall of the vagina is in contact with the rectum. The vagina is isolated vaults - recesses between the cervix and the walls of the vagina. At the same time, the posterior fornix borders on the Douglas space, which allows access to the recto-uterine cavity through the posterior fornix of the vagina.