FEMALE PROCEDURE
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This is the procedure for the female, for male donor instructions select male instructions

PROCEDURE

1. PRE-WORK (before lab) review the pelvic bony landmarks.
    (Figure401) (Netter334) (Netter337)

Lumbar and sacral vertebra - observe how sharply posterior the sacrum is oriented relative to the lumbar vertebra and that the sacrum consists of multiple vertebrae fused together with remnants of intervertebral disks often visible.

Coccyx - The coccyx is the final segment of the vertebral column articulated to the end of the sacrum.

Sacral promontory - The most anterosuperior ridge of the sacrum is sharply angled and marks the border of the pelvic inlet.

Pubic symphysis - Anteriorly, observe the pubic symphysis at the midline.

Pelvic inlet (or pelvic brim) - The pelvic inlet is an imaginary planar line/sheet between the sacral promontory and the upper margin of the pubic symphysis. Laterally, while not visible with the organs in place, the line passes along the inferior edge of the iliac fossa. 

The pelvic inlet defines the boundary of the lesser pelvis (also called the 'true pelvis') inferior to the inlet. The greater pelvis (also called 'false pelvis') consists of the area above the pelvic inlet enclosed by the superior edges of the ilia bone. Primarily this area holds the ileum and sigmoid colon. 

2. Using moist paper towels clean any excess fluid or debris from the surface of the peritoneum in the pelvic cavity.

3. Observe the pelvic organs and their position relative to the pelvic bony architecture.
    (Figure413) (Netter344) (Netter346) (Netter345)
    (Photo4055)

Urinary bladder - Immediately posterior to the pubic symphysis is the bisected urinary bladder. Typically, fluid content has emptied and the bladder is in a completely relaxed state flattened against the anterior wall.  The superior and lateral edges of the bladder are practically invisible due to this flattening.

Rectum - Anterior to the sacrum/coccyx will be the rectum. Depending on where your viscera removal cut was made there may be a small length of colon still connected to the rectum. The rectum 'start' approximately the level of the sacral promontory (reference sources vary in the anatomic definition of the start of the rectum, thus it is approximate).

Vagina - Situated between the bladder and the rectum is the muscular tube of the vagina. This is a subperitoneal organ and thus too inferior to palpate as you follow the peritoneum surface.

Uterus - Superior to the vagina is the uterus visible just posterior to the bladder position. The wall of the uterus is significantly thicker than that of the vagina, and typically sits in a sharply anteverted angle relative to the vagina. The anteverted and antiflexed position 'tilts' the fundus of the uterus towards the bladder superior surface.

In 20% of individuals the uterus is retroflexed to some degree, thus some donors will have a uterus that may have greater or lesser antervertion tilt.

Many women will have had a hysterectomy (~30-50% of women above the age of 60). Thus, you may find all or part of the uterus absent in some individuals. Where possible, surgeons will leave at least one ovary to control hormonal balance in the patient.

Ovary - Just lateral to the uterus, attached to the posterior side of the mesentery connecting the uterus to the lateral wall, is the ovary. Typically this is an oval shaped irregular surfaced solid structure. In the elderly it is approximately 2-3cm in size ranging to 3-5cm in younger individuals. 

4. Trace the peritoneum from the anterior wall across to the posterior wall of the abdomen as it 'drapes' over the pelvic organs forming several spaces/grooves.
    (Figure413) (Netter344) (Netter346) (Photo4055)

Begin by sliding fingers down the inner wall of the anterior abdominal wall and across onto the superior surface of the bladder. Due to collapse of the bladder, the demarcation between anterior abdominal wall and bladder lacks a distinct groove.

Supravesical fossa - In the living, contents of the bladder result in the superior surface being more horizontal or bulged. The reflection of the peritoneum off the anterior abdominal wall onto the surface of the bladder forms the small supravesical fossa (space) anterosuperior to the bladder.

Vesicouterine fossa (or pouch) - Follow the peritoneum across the bladder where it dips inferiorly before reflecting superiorly up onto the uterus. The space formed by this inferior to superior reflection of peritoneum from the bladder to the uterus is the  vesicouterine fossa.

Rectouterine fossa (or pouch) - Follow the peritoneum surface over the uterus where it turns inferiorly to follow the posterior side of the uterus before reflecting superiorly up onto the rectum. The space formed by the inferior to superior reflection of peritoneum from the uterus to rectum is the rectouterine pouch (also called the pouch of Douglas in older literature).

If your donor has had a hysterectomy, in the absence of the uterus the demarcation between the vesicouterine and rectouterine pouches is not present and the peritoneum continues across where the uterus was posteriorly to the rectum.

Broad ligament - Use your fingers to trace the peritoneum on the anterior side of the uterus and the peritoneum on the posterior side extending laterally out to the lateral side of the pelvic wall. These two sheets come close together lateral to the uterus, fusing to form a double layer structure called the broad ligament of the uterus (examined in more detail below). The ovary is attached to the posterior surface of the board ligament.

5. Place fingers on the posterior surface of the bladder and slide your fingers laterally to each side of the bladder, in the donor the bladder is fully collapsed and the exact lateral extend difficult to determine.
    (Figure413) (Netter344) (Netter346)

Paravesical fossa - In the living the bladder is expanded posteriorly as well as superiorly, resulting in a groove along each lateral side of the bladder. This is referred to as 'para' meaning 'beside'.

6. Place your fingers on the anterior surface of the rectum and slide your fingers laterally to each side of the rectum and the sigmoid colon.
    (Figure413) (Netter344) (Netter346)

Pararectal fossa - The peritoneum sheet reflects off the rectum onto the posterior wall of the sacrum forming the grooves of the pararectal fossa. This will vary in distinctness depending on the distension state of the rectum.

7. Identify the broad ligament of the uterus spanning from the left and right sides of the uterus across to the pelvic wall.
    (Figure414) (Netter355) (Netter357)
    (Photo4055) (Photo4056)

The broad ligament is a double layer of peritoneum that extends from the lateral sides of the uterus over to the lateral pelvic wall. The broad ligament consists of several regions that contain structures sandwiched between the two sheets of peritoneum. 

Mesosalpinx (the mesentery of the uterine tube) - This is the superior edge of the broad ligament that covers and supports the uterine tubes.

Mesovarium (the mesentery of the ovaries) - The ovaries hang partly away from the posterior side of the broad ligament, attached to the broad ligament by a small extension of posterior peritoneum called the mesovarium. The mesovarium extends over the ovaries in an incompletely cover.

Mesometrium (the mesentery of the uterus) - This is the region below the attachment of the mesovarium and includes all of the peritoneum that continues over the uterus. 

This arrangement of two sheets of peritoneum with structures running in the fascia between the sheets is identical in concept to the 'ligaments' that contained vessels/ducts you examined previously in the abdominal viscera section.

The pelvic organs have several supportive 'ligaments' which are really just thickenings of the fascia spanning from the lateral walls and avascular loose fascia 'spaces' located between each of the organs in anterior to posterior axis. The most important supports are the cardinal ligament running at the base of the broad ligament laterally spanning from the uterus to the pelvic wall and the uterosacral ligaments spanning from the uterus to the sacrum.

Cardinal (Transverse Cervical) Ligament: The fascia just inferior to base of the broad ligament is slightly thicker called the cardinal (or transverse cervical) ligament. While not yet visible, this region also contains the uterine artery supplying blood to the uterus.

The cardinal ligament forms a lateral support to the uterus helping to prevent prolapse and is important in pelvic surgery as the uterine artery courses within the ligament.

8. On your donor, observe the uterosacral ligaments, which span from the uterus to each side of the rectum forming an attachment to the sacrum.
    (Figure413) (Netter344) (Netter346)

These ligaments are covered (draped) by peritoneum and appear as 'arches' of the peritoneum to each side of the rectum.

The uterosacral ligament attaches to the cervical region of the uterus and provides stability to the uterus position in the pelvic cavity helping to prevent uterine prolapse.

SWAP POINT #1: At this point, swap with your pre-identified table (Laboratory Swap Map). containing a donor of the opposite sex and go through the steps on the appropriate instruction set until you reach the swap point in those instructions. Then return to your donor to continue steps below.

9. Examine the anterior side of the broad ligament of the uterus for the impression of the round ligament of the uterus.
    (Figure414) (Netter355) (Photo4056)

The round ligament traverses inside the broad ligament (sandwiched between the peritoneum sheets) and is typically visible through the peritoneum or discernable by palpating.

The round ligament of the uterus is a rod of dense connective tissue attaching at the junction between the uterus and the uterine tube, and extending out to pass through the deep inguinal ring. 

The round ligament of the uterus continues through the inguinal canal and superficial inguinal ring. Upon exiting the superficial ring the fibers of the ligament spread to anchor into the tissue of the labia majora.

10. Move to the deep inguinal ring and strip away peritoneum exposing the round ligament of the uterus.
    (Figure413a) (Netter344) (Netter346)

Remove peritoneum working from lateral to medial to follow the ligament across to the connection of the round ligament until it reaches the pelvic brim (i.e. to where it is sandwiched in the broad ligament).

The function of the round ligament is to support the anteverted position of the uterus. During pregnancy and in the elderly, the round ligaments are more stretched.

11. Find the superior free edge of the board ligament which holds the uterine tube. 
    (Figure414) (Netter355) (Photo4056)

The uterine tube is connected to the uterus proximally and the diameter of the uterine tube expands at the distal end forming the infundibulum.

Delicate finger-like projections of tissue, the fimbriae, extend from the infundibulum to embrace the ovary. However, the ovary is not directly connected to the fimbriae.

12. Sandwich the broad ligament between your fingers in the region between the ovary and uterus to feel the stiffer cord like structure of the proper ligament of the ovary.
    (Figure414) (Netter355) (Photo4056)

Reflecting the uterine tubes anteriorly and holding the ovary can extend this ligament making it easier to visualize.

The proper ligament of the ovary is a fibromuscular tissue that connects the inferior pole of the ovary to the junction between the uterus and the uterine tube.

13. Observe on the superior pole of the ovary (opposite to the connection of the proper ligament of the ovary), a fold of peritoneum extending laterally out to the pelvic wall.
    (Figure414) (Netter355) (Netter382) (Photo4056)

This peritoneal fold is the suspensory ligament of the ovary, which contains the ovarian (gonadal) blood vessels, nerves, and lymphatic vessels.

Recall, in females the specific term for the generic gonadal artery is the ovarian artery.

14. Return to the aorta where you had identified the ovarian arteries in the previous labs and follow the ovarian artery inferiorly all the way along to the ovary via the suspensory ligament of the ovary.
    (Netter346) (Netter382) (Photo4056)

The ovarian artery provides branches to the uterine tubes, and commonly, but not always, continues across to the superior part of the uterus.

15. Return to the ureters, identified in the previous sessions and follow them to the edge of the pelvic inlet where you had previously dissected.
     (Netter346) (Netter382)

The ureter passes posterior to (under) the gonadal vessels.

The ureter is a critical structure for gynecological surgery. Ureteral injury is a serious complication associated with high post-surgery morbidity. The ureter has distinct anatomic associations with reproductive organ structures that help the gynecological surgeon determine where they are.

16. Return to the infra-renal section of the aorta and follow the aorta inferiorly to the bifurcation into the left and right common iliac arteries approximately L4.
     (Netter382) (Netter266)

This segment of the aorta inferior to the renal arteries and superior the bifurcation is the most likely area for aneurysms to develop. 

Numerous mesh like arrangements of nerve fibers of the superior hypogastric plexus will be spread out over the aorta and inferior vena cava in this region that were observed in the previous lab.

The superior hypogastric plexus receives mainly lumbar splanchnic nerves (sympathetic) that emerged from the sympathetic chain in the lumbar region.  The inferior hypogastric plexus deeper in the pelvis receives sacral splanchnic (sympathetic) from the continuation of the sympathetic chain in the pelvic region and pelvic splanchnic (parasympathetic) nerves emerging from S2-4.

17. Follow the inferior vena cava from the renal arteries to the bifurcation into the left and right common iliac veins.
     (Netter382) (Netter266)

18. Remove peritoneum from the common iliac artery and vein on both sides following those vessels to their branch into the internal and external iliac vessels.
     (Netter382) (Netter266)

Ensure you have identified the gonadal vessels and ureter so as to avoid damaging those as you expose the iliac vasculature.

The ureter usually passes anteriorly over the iliac vessels approximately at the bifurcation of the external and internal branches.

The common and external iliac vessels course along the pelvic brim. The internal iliac vessels will 'dive' inferoposterior into the pelvis. Only expose peritoneum sufficiently to observe the branch as we will not be dissecting all the internal iliac vessel branches.

19. Continue to follow the external iliac artery lateral and inferior to where it passes posterior to the inguinal ligament.
     (Netter382) (Netter266)

You may be able to observe the branching of the inferior epigastric vessels which occurs just prior to the external iliac vessels passing under the inguinal ligament.

As the vessel passes under the inguinal ligament the name changes to the common femoral vessels. Following these further will be part of the "Skin, Bones and Musculature" course in MS2 so stop your dissection as the vessels reach the inguinal ligament.

20. Examine the female external genitalia organization.
    (Figure432) (Netter358) (Photo4022)

Mons pubis - This is formed by a fat pad in the superficial fascia anterior to the pubic symphysis. Mons pubis adipose is sensitive to hormones (primarily estrogen), enlarging post puberty and commonly diminishing in size post menopause.

Labia majora - These are longitudinal folds of skin extending posteriorly from the pubic mons. Each labia majora has an exterior pigmented skin surface and an interior smooth skin surface.

The round ligament of the uterus, which exited through the superficial inguinal ring, separates into multiple fibers which anchor into the mons pubis and labia majora.

Labia minora - Retract the labia majora laterally to observe two folds/flaps of skin lateral to the vaginal opening. These extend posteriorly and obliquely.

Clitoris - The clitoris is formed from erectile tissue (continuations of the crus of the clitoris and bulb of the vestibule). The visible portion is present anterior to the vaginal opening, with the the labia minora of one side passing anterior to the clitoris fusing with the labia minora of the other side.

Vulvar vestibule - This is the region demarcated between the labia minora. The urethra and vagina open into this space.

Vaginal opening - The midline opening into the muscular canal of the vagina. 

External urethral orifice - This orifice is present approximately 2.5cm posterior to the clitoris and immediately anterior to the vaginal opening.

21. Return to the deep inguinal ring and observe the round ligament found in the previous lab, noting that as the round ligament emerges from the superficial inguinal ring it is usually separated into dozens of indistinct small fibers that anchoring into the fascia of the labia majora.
    (Netter359)

Note, the membranous superficial fascia of the abdomen (Scarpa's fascia) is continuous with the membranous superficial fascia of the superficial perineal pouch (Colles' fascia). This is the same layer with a name change denoting the different region. 

Laterally the membranous superficial fascia (Colles') firmly attaches along the margins of the pubic rami, extends within the labia majora to attach to the crus of the clitoris, and continues posteriorly to join the inferior fascia of the urogenital diaphragm. Thus, membranous superficial fascia (Colles') forms a fully enclosed compartment, the superficial perineal pouch.

The enclosed superficial perineal pouch is clinically important as bleeding or infections that enter the space will extend up the abdominal wall between the fascia layers, but cannot extend onto the thighs or anal triangle.

The fatty superficial fascia of the abdomen (Camper's) is also continuous inferiorly between the skin and membranous superficial fascia (Colles') as the adipose tissue of the mons pubis and labia majora.

SWAP POINT #2: At this point, swap with your pre-identified table (Laboratory Swap Map) containing a donor of the opposite sex and go through the steps on the appropriate instruction set until you reach the swap point in those instructions. Then return to your donor to conclude the lab.

CHECKLIST

Return to the main pelvis page HERE for the combined male/female checklist