C H Nezhat1, F Nezhat, A I Brill, C Nezhat. 1. Department of Gynecology and Obstetrics, Stanford University School of Medicine, Palo Alto, California, USA.
Abstract
OBJECTIVE: To describe certain anatomic relationships in the pelvis and abdominal wall at laparoscopy and the effect of body mass index (BMI) on those parameters. METHODS: In 103 patients we determined the following: distances from the midline to each medial umbilical ligament and the respective inferior epigastric vessels; distances between each ureter and the ipsilateral uterosacral and the infundibulopelvic ligament; relative visibility of the ureters, umbilical and uterosacral ligaments, and the sacral promontory; and the presence and location of congenital bowel attachments to the pelvic walls. RESULTS: The right ureter ran significantly closer to the infundibulopelvic and uterosacral ligaments than the left ureter. The right inferior epigastric vessels and umbilical ligament coursed more laterally than did those on the left. Both sets of inferior epigastric vessels, and the left umbilical ligament and ureter were significantly more difficult to identify in overweight women. In 69% of the subjects, the uterosacral ligaments were found to be thick or moderately thick. In two thirds, the sacral promontory was more than 75% visualized. Congenital bowel attachments were observed in 74.8% of subjects on the left pelvic sidewall, and 48.5% on the right. CONCLUSION: Left and right pelvic anatomy are not necessarily mirror images laparoscopically. The course of the inferior epigastric vessels can be more difficult to identify in overweight patients. Despite marked obesity or congenital bowel attachments to the pelvic side walls, both ureters can usually be identified. The proximity of the ureter to the uterosacral and infundibulopelvic ligaments reaffirms the need to identify them before dissection.
OBJECTIVE: To describe certain anatomic relationships in the pelvis and abdominal wall at laparoscopy and the effect of body mass index (BMI) on those parameters. METHODS: In 103 patients we determined the following: distances from the midline to each medial umbilical ligament and the respective inferior epigastric vessels; distances between each ureter and the ipsilateral uterosacral and the infundibulopelvic ligament; relative visibility of the ureters, umbilical and uterosacral ligaments, and the sacral promontory; and the presence and location of congenital bowel attachments to the pelvic walls. RESULTS: The right ureter ran significantly closer to the infundibulopelvic and uterosacral ligaments than the left ureter. The right inferior epigastric vessels and umbilical ligament coursed more laterally than did those on the left. Both sets of inferior epigastric vessels, and the left umbilical ligament and ureter were significantly more difficult to identify in overweight women. In 69% of the subjects, the uterosacral ligaments were found to be thick or moderately thick. In two thirds, the sacral promontory was more than 75% visualized. Congenital bowel attachments were observed in 74.8% of subjects on the left pelvic sidewall, and 48.5% on the right. CONCLUSION: Left and right pelvic anatomy are not necessarily mirror images laparoscopically. The course of the inferior epigastric vessels can be more difficult to identify in overweight patients. Despite marked obesity or congenital bowel attachments to the pelvic side walls, both ureters can usually be identified. The proximity of the ureter to the uterosacral and infundibulopelvic ligaments reaffirms the need to identify them before dissection.