A hysterosalpingogram determines patency of the uterine ostia and uterine tubes. Radiographic contrast is injected into the uterine cavity through the vagina and cervix. If the fallopian tubes are patent, dye fills spills into the abdominal cavity. Blockages are then ruled out as the cause of a patient's infertility. Indicate your understanding of the uterus, uterine tubes, and ovary as to structure, orientation, relationships (anterior, posterior, superior, inferior, medial, lateral), ligamentous support, peritoneal associations, innervation (preganglionic, postganglionic, and visceral afferent pathways), vasculature, and lymphatics. (12 pts)

Uterus

• Structure
  • Pear shaped hollow organ - 8cm long, 5cm wide
  • myometrium and endometrium
  • cervix, body, fundus
  • external os, cerivical canal, internal os, uterine cavity
• Orientation
  • anteflexed and anteverted (lengthens posterior fornix vagina)
• Support
  • intraperitoneal organ
  • Broad lig. - visceral lig (peritoneum)
    • lateral uterus to parietal peritoneum of lateral pelvic wall
  • fibrous ligs derived from endopelvic fascia
    • utereosacral, pubouteral, and lateral cervical (Cardinal) ligs.
  • round lig to lateral anterior pelvic brim - anterior lamina broad lig.
  • ovarian lig to posterior abdominal wall via suspensory lig. ovary
• Relationships
  • anterior: bladder, vesicouterine pouch
  • posterior: rectum, rectouterine pouch
  • superior: false pelvis, abdominal cavity
  • inferior: vagina, posterior fornix, rectouterine pouch
  • lateral: broad lig, pelvic wall, ovary, uterine tube
• vasculature and lymphatics,
  • uterine a. at the cervix and ovarian a. at the fundus
    • ovarian v. to ivc on right and left renal v. on left
    • uterine venous complex into internal iliac vv.
  • fundus drains lymph to upper lumbar nodes along ovarian vessels
  • superior body near round ligament drains lymph to superficial inguinal nodes
  • cervix drains lymph toward internal iliac nodes
• innervation
  • sympathetic by way of inferior hypogastric plexus to uterovaginal plexus along uterine a.
    • preganglionic in IMLCC lower thoracic and upper lumbar
    • postganglionic in microscopic ganglia of aortic and hypogastric plexuses
  • parasympathetic: pelvic splanchnic if present
  • sensory pain follow sympathetic pathways (eg. hypogastric nerves)

Uterine Tube

• Structure
  • shaped as a salpinx and about 10 cm long
  • connects uterine cavity to the peritoneal cavity
  • isthmus, ampulla, infundibulum, fimbriae
• Orientation
  • courses laterally from fundus of uterus toward pelvic wall
  • intraperitoneal in superior free edge of broad lig.
  • cradles ovary as a posterior relation
• Support
  • mesosalpinx - visceral lig (peritoneum) part of broad lig.
    • continuous with mesovarium
  • ovarian lig to posterior abdominal wall via suspensory lig. ovary
• Relations
  • anterior: bladder, vesicouterine pouch
  • posterior: broad lig., rectum, rectouterine pouch, ovary
  • superior: false pelvis, abdominal cavity
  • inferior: broad lig., rectouterine pouch
  • lateral: broad lig, pelvic wall, ovary, ovarian fossa, uterine tube
  • medial: fundus and body of uterus
• vasculature and lymphatics,
  • tubal a., uterine a. at the cervix and ovarian a. at the fundus
  • uterine venous complex to internal iliac vv
  • drains lymph to upper lumbar nodes along ovarian vessels
  • drains lymph to superficial inguinal nodes
  • drains lymph toward internal iliac nodes
• innervation
  • sympathetic by way of inferior hypogastric plexus to uterovaginal plexus along uterine a.
    • preganglionic in IMLCC lower thoracic and upper lumbar
    • postganglionic in microscopic ganglia of aortic and hypogastric plexuses
  • sympathetic by way of ovarian plexus
  • parasympathetic: unknown if present
  • sensory pain follow sympathetic pathways

Ovary

• structure and support
  • The ovary is roughly cylindrical about 3 cm long and 1 cm in diameter. The visceral peritoneum covering the ovary gives way to a specialized germinal epithelial cell layer. The egg is able to penetrate this layer and enter the peritoneal cavity.
  • The ovary is suspended from the posterior lamina of the broad ligament by the mesovarium -- a peritoneal ligament. Supporting the superior pole of the ovary to the pelvic brim is the suspensory ligament of the ovary. Supporting the inferior pole of the ovary to the lateral uterus is the ovarian ligament.
  • relationships
    • superior to the ovary is the pelvic brim and suspensory ligament
    • inferior to the ovary is the uterine wall and the ovarian ligament
    • anterior to the ovary is the broad ligament, uterine tube, and fimbria of uterine tube
    • posterior to the ovary is the rectum and pelvic floor
    • medial to the ovary is the pararectal fossa, rectouterine pouch, fundus of the uterus
    • lateral to the ovary is the ovarian fossa (internal iliac a. and ureter), psoas major muscle, and obturator n.
  • innervation (motor and sensory)
    • Parasympathetic preganglionic cell bodies are located in the central gray of the spinal cord (IMLCC) at levels S2-4. Preganglionic fibers enter the inferior hypogastric plexus by way of the pelvic splanchnic nerves. The inferior hypogastric plexus contributes a uterine plexus and then to the ovarian plexus. Postganglionic parasympathetic cell bodies are located in intrinsic ganglia of the ovary. The above pathway assumes that the uterovaginal plexus reaches the ovary. This is not known for certain. Parasympathetic pregangionic contributions from the vagus n. may also follow the ovarian plexus.
    • Sympathetic preganglionic cell bodies are located in the interomedial lateral cell column at cord levels T10 (and perhaps T11-12). Preganglionic fibers follow the lesser and least splanchnic nerves to aortic ganglia near (and including) the superior mesenteric ganglion and the aorticorenal ganglion. Postganglionic fibers from these ganglia enter the aortic plexus and extend along the ovarian artery as the ovarian plexus. Visceral afferent pathways follow the sympathetic pathways up to the T10 spinal level. Additional visceral pathways follow parasympathetic pathways back to the S3-4 spinal levels.
  • blood supply and lymphatics
    • The arterial supply is mostly from the ovarian arteries. These are paired arteries arising from the anterolateral surface of the aorta near the level of the third lumbar vertebra. The ovarian veins arise from the IVC on the right and the left renal vein on the left. Additional blood supply is by ascending branches of the uterine vessels (ovarian br.) that anastomose with the ovarian vascular supply. Lymph drainage is primarily along the embryological decent of the ovary. This includes upper lumbar nodes in the vicinity of the renal arteries. Much of the vascular supply reaches the ovary through the suspensory ligament.

• Prolaps of Uterus
  • Weakening of the ligamentus support of the uterus leads to prolapse
    • most noteably, the lateral cervical ligs and important

Indirect inguinal hernias result from a patent processus vaginalis. Abdominal viscera may move through the processus vaginalis into the scrotum. Review the anatomy of the spermatic cord. Include contents, coverings, fascial boundaries, innervation, vasculature, lymphatics, and relationships. Discuss the pathway and location of an indirect inguinal hernia that has descended into the scrotum. (12 pts)

General Comments

• The spermatic cord is the pedicle of testis. Beginning at the deep ring, the spermatic cord transmits the contents of the deep ring from the abdominopelvic cavity to the scrotum.
• The pathway from the deep ring to the scrotum marks the "descent" of the testis.
• A peritonealized surface of the testis causes a trailing diverticulum know as the processes vaginalis.
• Applied to the anterior aspect of the testis is the visceral layer of tunica vaginalis.
• The deep ring marks the beginning of the inguinal canal and is located: at the midinguinal point; lateral to the inferior epigastric artery; and slightly more than 1 cm superior to the inguinal ligament.
• At the deep ring the spermatic cord receives the internal spermatic fascia derived from transversalis fascia. Within the inguinal canal the internal oblique contributes the cremasteric fascia.
• The cord exits the inguinal canal by way of the superficial ring.
• The superficial ring, a defect in the external oblique aponeurosis, contributes the external spermatic fascia.
• The testis, at the distal extent of the cord, ultimately resides within the scrotum. It is tethered to the most inferior aspect of the scrotum by the scrotal ligament.
• The external spermatic fascia (deep fascia) is opposed to dartos fascia (superficial fascia).

Internal Spermatic Fascia. Structures that pass through the deep ring were retroperitoneal and reside within the internal spermatic fascia derived from transversalis fascia.

• processes vaginalis - a trailing diverticulum of peritoneum that accompanies the testis during the "descent."
• Distally, within the scrotum, the processes vaginalis opens into the tunica vaginalis
• Extraperitonial connective tissue
• Testicular artery - paired branches from lumbar aorta near renal arteries
• Testicular vein - proximally the testicular vein consists of 3-4 veins
• Distally the testicular surrounds the testicular artery forming the pampinifrom plexus veins numbering 10 to 12 veins
• Left testicular vein drains into left renal vein and the right testicular vein drains into the IVC near the renal artery
• Testicular lymphatics - provide drainage to upper lumbar nodes, to lumbar lymph ducts, to cysterna chyli
• Testicular autonomic plexus - sympathetic preganglionic cell bodies in IMLCC T10(11-12)
  • Symmpathetic postganglionic cell bodies in superior mesenteric ganglion
  • Parasympathetic preganglionic fibers derived from the vagus nerve
• Afferent "pain" fibers following sympathetic pathways to spinal levels T10(11-12)
• Vas deferens - under sympathetic control, the walls (2-3 mm thick) of the vas deferens contract to discharge spermatozoa
• Within the cord the Vas deferens lies posterior to the testicular artery
• Distally, the Vas deferens forms the tail of the epididymis at the posterior inferior pole of testis
• Further distally the tail gives way to the body and then to the head of the epididymis at the posterior superior pole
• Deferential artery - branch of the internal iliac artery vascularizes the vas deferens and anastomoses with the testicular artery
• Deferential autonomic plexus - derived from the superior/inferior hypogastric autonomic plexus to prostatic plexus
  • Parasympathetic preganglionic fibers possibly derived from pelvic splanchnics (S2-4)
  • Afferent "pain" fibers following sympathetic pathways to spinal levels T10(11-12)
• Deferential lymphatics - drainage to internal iliac nodes, to lumbar lymph ducts, to cysterna chyli
• Genital branch of genitofemoral nerve - mediates efferent component of cremasteric reflex
• Cremesteric artery - branch of inferior epigastric artery vascularizes the tunics

The cremesteric fascia is superficial to the internal spermatic fascia and deep to the external spermatic fascia

• Derived from internal oblique muscle, the cremesteric fascia contributes to the cord within the inguinal canal
• Genital branch of the genitofemoral nerve - provides somatic motor supply
• Cremesteric artery - branches provide vascularization to the cremesteric fascia

The external spermatic fascia is superficial to the cremesteric fascia and is the outer most tunic

• Derived from the external oblique, the external spermatic fascia extends to the cord beyond the superficial ring
• Within the scrotum the external spermatic fascia is deep to dartos tunic

Path of indirect inguinal hernia

• An indirect hernia follows the embryologic "descent" of the testis indirectly out the superficial ring by way of the deep ring.
• A patent processes vaginalis allows herniated material to pass through the deep ring lateral to the inferior epigastric artery
• Herniated material passes through the inguinal canal and out the superficial ring - superior and medial to pubic tubercle
• Distally, the hernia is arrested by the tunica vaginalis
• In the case of herniated intestine, visceral peritoneum is directly opposed to visceral and parietal tunica vaginalis
• Palpation of the hernia occurs at the anterior aspect of the testis within the scrotum
• The long and curvaceous path of an indirect hernia make strangulation a distinct possibility

Peptic ulcer disease may erode the posterior wall of the stomach and spill stomach contents into the lesser sac. Define the boundaries (including spaces and/or recesses) of the lesser sac. Account for dull pain followed by sharp pain when the posterior stomach wall perforates. Discuss the pathway of spilled stomach contents that pass from the lesser sac into the greater sac, and the location of these contents with respect to body position. (12 pts)

General comments

• The lesser sac is a diverticulum in the superior region of the peritoneal cavity. Communication with the greater sac is via the epiploic foramen. For the most part, the lesser sac is posterior to the stomach and liver, anterior to the pancreas and diaphragm, superior to the duodenum, pancreas, and transverse mesocolon, inferior to the liver and diaphragm, left of the caudate, and right to the gastroleino and leinorenal ligs.

Superior recess - posterior to liver, begins at epiploic foramen

• anterior - caudate lobe of liver and lesser omentum
• posterior - diaphragm
• superior - diaphragm
• inferior - lesser recess
• right - liver, ligamentum venosum
• left - splenic recess

Inferior recess - inferior ot the right gastropancreatic fold (common hepatic a.)

• anterior - hepatoduodenal ligament, duodenum, gastrocolic ligament
• posterior - pancreas, tail of pancreas enters leinorenal ligament
• superior - superior recess
• inferior - transverse mesocolon
• right - liver
• left - gastroleino ligament

Splenic recess - left of gastroepiploic fold (left gastric a.)

• anterior - stomach, gastrocolic ligament (greater omentum)
• posterior - aorta, left suprarenal gland, upper pole left kidney, splenic a., diaphragm
• superior - liver and diaphragm
• inferior - inferior recess
• right - caudate lobe, superior recess
• left - gastroleino and leinorenal ligaments

Epiploic foramen - communication between lesser and greater sacs

• anterior - hepatoduodenal ligament
• posterior - inferior vena cava
• superior - caudate lobe liver
• inferior - duodenum
• right - opening into hepatorenal recess and right paracolic gutter
• left - lower recess of lesser sac

Pathway of Materials?

• Person rolls to the right - contents of lesser sac enter the greater sac via the epiploic foramen
• Person returns to supine - contents enter the hepatorenal recess
• Person stands - contents follow the right paracolic gutter to the pelvic basin and the rectouterine or rectvesical pouch
• General discussion of abdominopelvic gutters

Somatic afferent innervation

• parietal peritoneum of the posterior wall innervated by thoracoabdominal nerves

Why sharp pain?

• Irritation of the parietal peritoneum of the posterior wall activates somatic afferent activity in the thoracoabdominal nerves (intercostals, subscostals, iliohypogastric, ilioinguinal) and possibly phrenic nerve.

Vascular supply of the Walls - vascular supply is by regional aa and vv (optional)

• posterior - splenic av
• anterior - common hepatic, right gastric, left gastric, aa
• inferior - right and left gastroepiploic aa vv, supra- and retroduodenal aa vv
• superior - inferior phrenic av
• left - short gastric aa vv
• right - right and left gastric aa vv

Lymphatic drainage of the Walls - follows vascular supply (optional)

• paraaortic nodes to lumbar trunks to cysterna chyli
• diaphragmatic border involves mediastinal and axillary nodes (anterior wall vasculature)

Autonomic Innervation to the Walls (optional)

• sympathetic preganglonics - mostly from greater and lesser splanchnic nerves (cell bodies in imlcc of T5-11)
• sympathetic postganglionics - mostly from celiac plexus (cell bodies in celiac ganglion)
• parasympathetic preganglionics - from vagus nerve (cell bodies in dorsal motor nucleus of vagus nerve)
• parasympathetic postganglionics - intrinsic ganglia

Visceral afferent innervation from the Walls (optional)

• "pain" follows sympathetic pathways to spinal levels T5-11