Inferior Gluteal Artery

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VaginismusInferior Mesenteric Circumflex Iliac

Figure 6

1 External pudendal artery

2 Superficial epigastric artery

3 Superficial circumflex iliac artery

4 Inferior epigastric artery

5 Deep circumflex iliac artery

6 Internal iliac artery

7 External iliac artery

8 Inferior mesenteric artery

9 Gonadal artery

10 Superior mesenteric artery

11 Splenic artery

12 Coliac trunk

13 Left gastric artery

14 Internal jugular vein

15 Subclavian vein

16 Cephalic vein

17 SVC

18 Hepatic artery

19 Gastroduodenal artery

20 Renal artery

21 L2

22 L3

23 L4

24 Inferior rectal artery

25 Obturator artery

26 Internal pudendal artery

27 Uterine artery

Lateral Sacral Artery

Figure 7

1 Middle rectal artery

2 Internal pudendal artery

3 Inferior gluteal artery

4 Superior gluteal artery

5 Lateral sacral artery

6 Iliolumbar artery

7 Aorta

8 Common iliac artery

9 Internal iliac artery

10 External iliac artery

11 Uterine artery

12 Circumflex liliac artery

13 Obturator artery

14 Inferior epigastric artery

15 Superior vesical extended arm. During vaginal procedures, an assistant unfamiliar with the course of the femoral nerve might rest an arm on the patient's medial anterior thigh and compress the femoral nerve. This nerve may also be injured by an abdominal retractor placed too deeply over the psoas muscle. Finally, some of the

Abdominal Retractors

Figure 8

1 Articularis genus nerve

2 Vastus intermedius nerve

3 Gracialis nerve

4 Adductor magnus nerve

5 Vastus lateralis nerve

6 Adductor longus nerve

7 Adductor brevis nerve

8 Pectineus nerve

9 Obturator externus nerve

10 Sartorius nerve

11 Rectus femoris nerve

12 Obturator nerve near fossa

13 Obturator nerve

14 Femoral nerve

15 Scalene muscle

16 Schial pleus

17 Iliohypogstric nerve

18 Ilioinuin al nerve

19 Lateral cutaneous fenoral

20 Genitofeoial nerve

21 Sciatic nerve

22 Bdendal nerve smaller nerves, such as the genital femoral nerve, may be transected during the removal of suspicious lymph nodes.

Femoral nerve injury results in decreased hip flexion and leg extension due to the loss of the iliacus, rectus femoris, vastus lateralis, intermedius and medialis, and sartorius muscle function. Injury to the obturator nerve results in loss of leg adduction and pronation from loss of the adductor brevis, longus and magnus, as well as obturator externus and gracilis muscle innervation. The sciatic nerve is not usually injured during surgical procedures but can be compromised by cervical cancer spread to the lateral pelvic wall, causing significant pain. Pain, secondary to cancer or postoperative, can be controlled in the pelvis by regional anesthetic blockade of the dorsal nerve roots of T10, T11, and T12 to the uterus tubes and ovary, and S2, S3 and S4 to the remaining genital structures (see Chapter 22).

Muscles

Many of the cutaneous landmarks used in planning gynecologic surgery are made up of the borders of the superficial muscles (Figures 9 and 10). In some of the reconstructive procedures discussed in this book, the muscles are the primary focus of the procedure. For the most part, however, they are structures to be retracted or transected. Nevertheless, they are helpful in identifying related anatomical structures, and therefore should be familiar to the operating surgeon.

One useful relationship is that between the rectus abdominis muscle and the epigastric vessels. When performing laparoscopy, it is best to place the lateral trocars completely lateral to these muscles to be sure of avoiding the epigastric vessels. This also makes operating easier by keeping the instruments as far apart as possible. It is this relationship with the 1epigastrics that makes the rectus an ideal vascular pedicle flap for reconstructive procedures. The gracilis muscle is also a suitable pedicle flap, but because it is more variable, the rectus is preferred for perineal reconstruction.

The muscles of the abdominal cavity are infrequently involved in either the disease process or the operative procedure in gynecologic oncology. However, they do serve as borders for lymph node dissections. For instance, the middle of the psoas muscle marks the lateral extent of the pelvic lymphadenectomy and the internal obturator muscle does the same for the obturator space lymphadenectomy. The muscles of the proximal lower extremity are similarly used as landmarks in the inguinofemoral dissection (see Figures 3-5, Chapter 15). During a scalene node biopsy, the dissection is carried to the surface of the scalenus anterior muscle between the sternocleidomastoid and the trapezius muscles (Figures 9, 10).

Bony and cutaneous landmarks

Bony and cutaneous landmarks are sometimes overlooked by junior operating surgeons in their eagerness to enter the abdomen (see Figure 9). However, more experienced surgical oncologists will recognize their value in planning successful gynecologic oncology procedures. For instance, gaining central venous access always begins with determination of the location of the distal third of the clavicle or the heads of the sternocleidomastoid muscle. Vascular access may also be achieved through a cephalic vein cut-down. This vein is identified by the cutaneous border of the deltoid and pectoralis major muscles. These same landmarks are also useful in initiating a scalene node biopsy. An inguinal node dissection may be performed through different incisions as long as the operator recognizes the relationship of the nodes to the inguinal ligament. Tube thoracostomy and thoracentesis require recognition of the location of the inferior scapula at the seventh and eighth ribs. Finally, although the soft tissue dimensions of the patient are important, the truly

Adductor Longus

1 Adductor longus groove

2 Sartorius muscle groove

3 Inguinal ligament

4 Anterior superior iliac spine

5 Level of L4/L5 vertebral bodies

Sternal head Clavicular head sternocleidomastoid muscle

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