Topographic anatomy of the pelvic organs. Topographic anatomy of the female pelvis in general. Topographic anatomy of the small pelvis

Lecture for doctors "Surgical anatomy of the small pelvis". The lecture is conducted by Bolshakov, I.N.

BORDERS AND FLOOR PELVIS

The pelvis is a part of the human body, which is limited by the pelvic bones (iliac, pubic and ischial), sacrum, coccyx, ligaments. The pubic bones are connected to each other by means of a pubic fusion. The ilium with the sacrum form inactive semi-joints. The sacrum is connected to the coccyx through the sacrococcygeal fusion. Two ligaments start from the sacrum on each side: sacro-spinous (lig. Sacrospinale; attached to the ischial spine) and sacro-tuberous (lig. sacrotuberale; attached to the ischial tuberosity). They transform the greater and lesser sciatic notches into the greater and lesser sciatic foramen.

The border line (linea terminalis) divides the pelvis into large and small.

The large pelvis is formed by the spine and the wings of the ilium. It contains the organs of the abdominal cavity: the caecum with the appendix, the sigmoid colon, loops of the small intestine.

The small pelvis is a cylindrical cavity and has an upper and lower opening. The upper aperture of the pelvis is represented by the boundary line. The lower aperture of the pelvis is limited behind by the coccyx, on the sides - by the ischial tubercles, in front - by the pubic fusion and the lower branches of the pubic bones. The inner surface of the pelvis is lined with parietal muscles: iliopsoas (m. iliopsoas), pear-shaped (m. piriformis), obturator internus (m. obturatorius internus). The piriformis muscle performs a large sciatic foramen. Above and below the muscle there are slit-like spaces - supra- and piriform openings (foramina supra - et infrapiriformes), through which blood vessels and nerves exit: the superior gluteal artery, accompanied by veins and the nerve of the same name through the supra-piriform opening; the lower gluteal vessels, the lower gluteal, sciatic nerves, the posterior cutaneous nerve of the thigh, the internal genital vessels and the pudendal nerve - through the subpiriform opening.

The bottom of the small pelvis is formed by the muscles of the perineum. They make up the pelvic diaphragm (diaphragma pelvis) and the urogenital diaphragm (diaphragma urogenitale). The pelvic diaphragm is represented by the muscle that lifts the anus, the coccygeal muscle and the upper and lower fascia of the pelvic diaphragm covering them. The urogenital diaphragm is located between the lower branches of the pubic and ischial bones and is formed by the deep transverse muscle of the perineum and the sphincter of the urethra with the upper and lower leaves of the fascia of the urogenital diaphragm covering them.

The pelvic cavity is divided into three floors: peritoneal, subperitoneal and subcutaneous (Fig. 16.1).

The peritoneal floor of the pelvis (cavum pelvis peritoneale) is the upper part of the pelvic cavity, enclosed between the parietal peritoneum of the small pelvis; is the lower abdomen. Here

Rice. 16.1. Floors of the pelvic cavity

(from: Ostroverkhov G.E., Bomash Yu.M., Lubotsky D.N., 2005):

1 - peritoneal floor, 2 - subperitoneal floor, 3 - subcutaneous floor

contain peritoneal organs or parts of the pelvic organs. In men, part of the rectum and part of the bladder are located in the abdominal floor of the pelvis. In women, the same parts of the bladder and rectum as in men, most of the uterus, fallopian tubes, ovaries, broad ligaments of the uterus, and the upper part of the vagina are placed in this floor of the pelvis. The peritoneum covers the bladder from above, partly from the sides and in front. When moving from the anterior abdominal wall to the bladder, the peritoneum forms a transverse cystic fold (plica vesicalis transversa). Behind the bladder in men, the peritoneum covers the inner edges of the ampullae of the vas deferens, the tops of the seminal vesicles and passes to the rectum, forming a rectovesical depression (excavatio rectovesicalis), bounded on the sides by rectovesical folds of the peritoneum (plicae rectovesicales). In women, when moving from the bladder to the uterus and from the uterus to the rectum, the peritoneum forms an anterior - vesico-uterine cavity (excavatio vesicouterina) and a posterior - recto-uterine cavity, or Douglas space (excavatio rectouterina), which is the lowest place abdominal cavity. It is limited laterally by the recto-uterine folds (plicae rectouterinae) running from the uterus to the rectum and sacrum. In the recesses of the pelvis, inflammatory exudates, blood (in case of injuries of the abdominal cavity and pelvis, ruptured tubes during ectopic pregnancy), gastric contents (perforation of a stomach ulcer), urine (injuries of the bladder) can accumulate. The accumulated contents of the Douglas recess can be identified and removed by puncture of the posterior vaginal fornix.

The subperitoneal floor of the pelvis (cavum pelvis subperitoneale) is a section of the pelvic cavity, enclosed between the parietal peritoneum of the pelvis and the sheet of the pelvic fascia, which covers the levator ani muscle from above. In the subperitoneal floor of the small pelvis in men there are extraperitoneal sections of the bladder and rectum, the prostate gland, seminal vesicles, pelvic sections of the vas deferens with their ampoules, pelvic sections of the ureters, and in women - the same sections of the ureters, bladder and rectum , as well as the cervix and the initial section of the vagina. The organs of the small pelvis occupy a median position and do not come into direct contact with the walls of the pelvis, from which they are separated by fiber. In addition to organs in this part of the pelvis, there are blood vessels, nerves and lymph nodes of the pelvis: internal iliac arteries

with parietal and visceral branches, parietal veins and venous plexuses of the pelvic organs (plexus venosus rectalis, plexus venosus vesicalis, plexus venosus prostaticus, plexus venosus uterinus, plexus venosus vaginalis), sacral plexus with nerves arising from it, sacral sympathetic trunk, lymphatic nodes lying along the iliac arteries and on the anterior concave surface of the sacrum.

The pelvic fascia, which covers its walls and viscera, is a continuation of the intra-abdominal fascia and is divided into parietal and visceral sheets (Fig. 16.2). The parietal sheet of the pelvic fascia (fascia pelvis parietalis) covers the parietal muscles of the pelvic cavity and the muscles that form the bottom of the small pelvis. The visceral sheet of the pelvic fascia (fascia pelvis visceralis) covers the organs located on the middle floor of the small pelvis. This sheet forms fascial capsules for the pelvic organs (for example,

Rice. 16.2. Fascia and cellular spaces of the pelvis:

1 - perirectal cellular space, 2 - periuterine cellular space, 3 - prevesical cellular space, 4 - lateral cellular space, 5 - parietal sheet of intrapelvic fascia, 6 - visceral sheet of intrapelvic fascia, 7 - abdominoperineal aponeurosis

Pirogov-Retzia for the prostate gland and Amyuss for the rectum), separated from the organs by a layer of loose fiber, in which the blood and lymphatic vessels, nerves of the pelvic organs are located. The capsules are separated by a septum located in the frontal plane (Denonville-Salishchev aponeurosis; septum rectovesicale in men and septum rectovaginale in women), which is a duplication of the primary peritoneum. Anterior to the septum are the bladder, prostate gland, seminal vesicles and parts of the vas deferens in men, the bladder and uterus in women. Behind the septum is the rectum.

The cellular spaces allocated in the pelvic cavity include both the fiber located between the pelvic organs and its walls, and the fiber located between the organs and the fascial cases surrounding them. The main cellular spaces of the pelvis, located in its middle floor, are the prevesical, paravesical, parauterine (in women), pararectal, retrorectal, right and left lateral spaces.

The prevesical cellular space (spatium prevesicale; Retzius space) is a cellular space bounded in front by the pubic symphysis and branches of the pubic bones, and behind by the visceral sheet of the pelvic fascia covering the bladder. In the prevesical space, with fractures of the pelvic bones, hematomas develop, and with damage to the bladder, urinary infiltration. From the sides, the prevesical space passes into the perivesical space (spatium paravesicale) - the cellular space of the small pelvis around the bladder, bounded in front by the prevesical, and behind by the retrovesical fascia. The parauterine space (parametrium) is a cellular space of the small pelvis, located around the cervix and between the sheets of its broad ligaments. The uterine arteries and the ureters crossing them, the ovarian vessels, the uterine venous and nervous plexuses pass in the periuterine space. Ulcers that form in the periuterine space, along the round ligament of the uterus, spread in the direction of the inguinal canal and to the anterior abdominal wall, as well as towards the iliac fossa and into the retroperitoneal tissue, in addition, an abscess can break through into the adjacent cellular spaces of the pelvis, cavities of the pelvic organs, gluteal region, on the thigh. Pararectal space (spatium pararectale) - a cellular space bounded by a fascial case of the straight line

intestines. The posterior rectal space (spatium retrorectale) is a cellular space located between the rectum, surrounded by the visceral fascia, and the anterior surface of the sacrum, covered by the pelvic fascia. The tissue behind the rectal space contains the median and lateral sacral arteries with their accompanying veins, sacral lymph nodes, pelvic divisions of the sympathetic trunk, and sacral nerve plexus. The spread of purulent streaks from the retrorectal space is possible in the retroperitoneal cellular space, the lateral spaces of the pelvis, and the perirectal space. Lateral space (spatium laterale) - a paired cellular space of the small pelvis, located between the parietal sheet of the pelvic fascia, covering the side wall of the pelvis, and the visceral sheet, covering the pelvic organs. The cellular tissue of the lateral spaces contains the ureters, the vas deferens (in men), the internal iliac arteries and veins with their branches and tributaries, the nerves of the sacral plexus, and the inferior hypogastric nerve plexus. The spread of purulent streaks from the lateral cellular spaces is possible in the retroperitoneal space, in the gluteal region, in the retrorectal and pre-vesical and other cellular spaces of the pelvis, the bed of the adductor muscles of the thigh.

Subcutaneous floor of the pelvis (cavum pelvis subcutaneum) - the lower part of the pelvis between the pelvic diaphragm and the integument related to the perineum. This section of the pelvis contains parts of the organs of the genitourinary system and the final section of the intestinal tube. The sciatic-rectal fossa (fossa ischiorectalis) is also located here - a paired depression in the perineal region, filled with fatty tissue, limited medially by the pelvic diaphragm, laterally by the obturator internus muscle with fascia covering it. The fiber of the ischiorectal fossa can communicate with the fiber of the middle floor of the pelvis.

16.2. TOPOGRAPHY OF THE MALE PELVIC ORGANS

The rectum is the final section of the large intestine, starting at the level of the III sacral vertebra. The rectum ends with an anal opening in the anal region of the perineum. Anterior to the rectum are the bladder and prostate gland, ampullae of the vas deferens, seminal vesicles

Rice. 16.3. Topography of the male pelvic organs (from: Kovanov V.V., ed., 1987): 1 - inferior vena cava; 2 - abdominal aorta; 3 - left common iliac artery; 4 - cape; 5 - rectum; 6 - left ureter; 7 - rectovesical fold; 8 - rectovesical deepening; 9 - seminal vesicle; 10 - prostate gland; 11 - muscle that lifts the anus; 12 - external anal sphincter; 13 - testicle; 14 - scrotum; 15 - vaginal membrane of the testicle; 16 - epididymis; 17 - foreskin; 18 - head of the penis; 19 - vas deferens; 20 - internal seminal fascia; 21 - cavernous bodies of the penis; 22 - spongy substance of the penis; 2 - spermatic cord; 24 - bulb of the penis; 25 - ischiocavernosus muscle; 26 - urethra; 27 - supporting ligament of the penis; 28 - pubic bone; 29 - bladder; 30 - left common iliac vein; 31 - right common iliac artery

and terminal sections of the ureters. Behind the rectum adjoins the sacrum and coccyx. The prostate gland is palpated through the anterior wall of the rectum, the rectovesical depression is punctured, and pelvic abscesses are opened. The rectum is divided into two parts: pelvic and perineal. The pelvic diaphragm serves as the boundary between them. In the pelvic region, the nadampullary part and the ampulla of the rectum, which is its widest part, are isolated. The supra-ampullary part is covered with peritoneum on all sides. At the level of the ampulla, the rectum is covered with peritoneum, first in front and from the sides, below only in front. The lower part of the ampulla of the rectum is no longer covered by the peritoneum. The perineal region is called the anal canal. On the sides of it is the fiber of the ischiorectal fossae. The rectum is supplied with blood by the unpaired superior rectal artery and the paired middle and inferior rectal arteries. The veins of the rectum form subcutaneous, submucosal (in the lower sections it is represented by glomeruli of the veins of the hemorrhoidal zone) and subfascial venous plexuses. Venous outflow from the rectum is carried out through the superior rectal vein into the portal vein system, and through the middle and inferior rectal veins into the inferior vena cava system. Thus, there is a porto-caval anastomosis in the wall of the rectum. Lymph outflow from the supra-ampullar part and the upper parts of the ampulla is carried out to the lymph nodes located near the inferior mesenteric artery, from the rest of the ampulla the lymph flows into the internal iliac and sacral lymph nodes, from the perineal part the lymph outflow is carried out to the inguinal nodes. The innervation of the rectum is carried out from the inferior mesenteric, aortic, hypogastric nerve plexuses, as well as the pudendal nerve.

The bladder is located in front of the small pelvis behind the pubic joint. The anterior surface of the bladder is also adjacent to the branches of the pubic bones and the anterior abdominal wall, separated from them by the prevesical tissue. Behind the bladder lie the ampullae of the vas deferens, the seminal vesicles, and the rectum. On the sides are the vas deferens. The ureters come into contact with the bladder at the border between the posterior and lateral walls. Above the bladder are loops of the small intestine. Below the bladder is the prostate gland. When full, the bladder extends beyond the pelvic cavity, rising above the pubic symphysis, displacing

the peritoneum upwards, and is located in the preperitoneal tissue. These features of the topography can be used for extraperitoneal access to the bladder. The bladder has the following parts: bottom, body, neck. The bladder is supplied with blood by the superior and inferior cystic arteries from the system of the internal iliac artery. The outflow of blood from the venous plexus of the bladder through the cystic veins is carried out into the system of the internal iliac vein. Lymph flows into the lymph nodes located along the internal and external iliac vessels, and sacral lymph nodes. The bladder is innervated from the hypogastric plexus.

The beginning of the pelvic ureter on each side corresponds to the boundary line of the pelvis. At this level, the left ureter crosses the common iliac artery and the right ureter crosses the external iliac artery. In the small pelvis, the ureters are adjacent to the side wall of the pelvis. They are located next to the internal iliac arteries. Going downward, the ureters cross the obturator neurovascular bundles from the respective sides. Inside of them is the rectum. Further, the ureters bend anteriorly and medially, adjoin the posterolateral wall of the bladder and rectum, cross the vas deferens, come into contact with the seminal vesicles, and flow into the bladder in the bottom area.

The prostate gland is adjacent to the bottom and neck of the bladder. Also, seminal vesicles and ampullae of the vas deferens adjoin the base of the prostate gland from above. The top of the gland is directed downward and lies on the urogenital diaphragm. Anterior to the prostate gland is the pubic symphysis, on the sides of it are the muscles that lift the anus. Behind the prostate gland is the rectum, and the gland can be easily felt through it. The prostate gland has two lobes connected by an isthmus and is covered by a capsule (visceral sheet of the pelvic fascia). The prostate gland is supplied with blood from the inferior cystic and middle rectal arteries. Venous blood flows from the venous plexus of the prostate gland into the system of the internal iliac vein. Lymph drainage is carried out to the lymph nodes lying along the internal and external iliac arteries, as well as to the lymph nodes located on the anterior surface of the sacrum.

The vas deferens in the small pelvis are adjacent to the side wall of the pelvis and to the bladder (to its side and back walls). At the same time, the vas deferens and ureters intersect on the posterolateral wall of the bladder. The vas deferens medially from the seminal vesicles form ampoules. The ducts of the ampullae, merging with the ducts of the seminal vesicles, enter the prostate gland.

The seminal vesicles in the small pelvis are located between the posterior wall of the bladder and the ureters in front and the rectum in the back. From above, the seminal vesicles are covered with peritoneum, through which loops of the small intestine can come into contact with them. From below, the seminal vesicles are adjacent to the prostate gland. Inside of the seminal vesicles lie the ampullae of the vas deferens.

16.3. TOPOGRAPHY OF THE FEMALE PELVIC ORGANS

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).

The 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

The uterus in the pelvis of women 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 that lie 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.

The ovaries are connected with the posterior layers of the broad ligament of the uterus with the help of the mesentery. 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.

The vagina is 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. In this case, the posterior fornix borders on the Douglas space, which allows access to the recto-uterine cavity through the posterior fornix of the vagina.

16.4. OPERATIONS ON THE URINARY BLADDER

Suprapubic puncture (syn.: bladder puncture, bladder puncture) is a percutaneous puncture of the bladder along the midline of the abdomen. Intervention is performed either in the form of a suprapubic capillary puncture, or in the form of a trocar epicystostomy.

Suprapubic capillary puncture (Fig. 16.5). Indications: evacuation of urine from the bladder if catheterization is impossible or contraindicated, if the urethra is injured, if the external genital organs are burned. Contraindications: low capacity

Rice. 16.5. Suprapubic capillary puncture of the bladder (from: Lopatkin N.A., Shvetsov I.P., ed., 1986): a - puncture technique; b - puncture scheme

bladder, acute cystitis or paracystitis, tamponade of the bladder with blood clots, the presence of bladder neoplasms, large scars and inguinal hernias that change the topography of the anterior abdominal wall. Anesthesia: local infiltration anesthesia with 0.25-0.5% novocaine solution. Position of the patient: on the back with a raised pelvis. puncture technique. A needle with a length of 15-20 cm and a diameter of about 1 mm is used. The bladder is punctured with a needle at a distance of 2-3 cm above the pubic fusion. After removing the urine, the puncture site is treated and a sterile sticker is applied.

Trocar epicystostomy (Fig. 16.6). Indications: acute and chronic urinary retention. Contraindications, position of the patient, anesthesia are the same as for capillary puncture of the bladder. Operation technique. The skin at the operation site is dissected for 1-1.5 cm, then the tissue is punctured using a trocar, the stylet mandrel is removed, a drainage tube is inserted into the bladder through the lumen of the trocar tube, the tube is removed, the tube is fixed with a silk suture to the skin.

Rice. 16.6. Scheme of the stages of trocar epicystostomy (from: Lopatkin N.A., Shvetsov I.P., ed., 1986):

a - the position of the trocar after injection; b - extracting the mandrin; c - insertion of a drainage tube and removal of the trocar tube; d - the tube is installed and fixed to the skin

Cystotomy is an operation to open the cavity of the bladder (Fig. 16.7).

High cystotomy (syn.: epicystotomy, high section of the bladder, section alta) is performed in the region of the apex of the bladder extraperitoneally through an incision in the anterior abdominal wall.

Rice. 16.7. Stages of cystostomy. (from: Matyushin I.F., 1979): a - skin incision line; b - fatty tissue, together with the transitional fold of the peritoneum, is exfoliated upwards; c - opening of the bladder; d - an exercise tube was inserted into the bladder, the wound of the bladder was sutured around the drainage; e - the final stage of the operation

Anesthesia: local infiltration anesthesia with 0.25-0.5% novocaine solution or epidural anesthesia. Access - lower median, transverse or arcuate extraperitoneal. In the first case, after dissection of the skin, subcutaneous fatty tissue, white line of the abdomen, the rectus and pyramidal muscles are bred to the sides, the transverse fascia is dissected in the transverse direction, and the prevesical tissue is peeled off along with the transitional fold of the peritoneum upward, exposing the anterior wall of the bladder. When performing a transverse or arcuate access after an incision in the skin and subcutaneous fatty tissue, the anterior walls of the sheaths of the rectus abdominis muscles are dissected in the transverse direction, and the muscles are bred to the sides (or crossed). The bladder should be opened as high as possible between two ligatures-holders, after emptying the bladder through the catheter. The wounds of the bladder are sutured with a two-row suture: the first row - through all layers of the wall with absorbable suture material, the second row - without stitching the mucous membrane. The anterior abdominal wall is sutured in layers, and the prevesical space is drained.

16.5. OPERATIONS ON THE UTERUS AND ADDITIONS

Operative access to the female genital organs in the pelvic cavity:

Abdominal wall:

Lower median laparotomy;

Suprapubic transverse laparotomy (according to Pfannenstiel);

Vaginal:

Anterior colpotomy;

Posterior colpotomy.

Colpotomy - operational access to the organs of the female pelvis by dissection of the anterior or posterior wall of the vagina.

Puncture of the posterior fornix of the vagina is a diagnostic puncture of the abdominal cavity, performed with a needle on a syringe by inserting it through a puncture of the wall of the posterior fornix of the vagina into the recto-uterine depression of the peritoneum of the small pelvis (Fig. 16.8). The position of the patient: on the back with legs drawn to the stomach and bent at the knee joints. Anesthesia: short-term anesthesia or local infiltration anesthesia. intervention technique. Mirrors wide open the vagina, bullet forceps

Rice. 16.8. Puncture of the recto-uterine cavity of the peritoneal cavity through the posterior fornix of the vagina (from: Savelyeva G.M., Breusenko V.G., ed., 2006)

capture the posterior lip of the cervix and lead to the pubic fusion. The posterior fornix of the vagina is treated with alcohol and iodine tincture. With a long Kocher clamp, the mucous membrane of the posterior fornix of the vagina is captured 1-1.5 cm below the cervix and slightly pulled forward. The fornix is ​​punctured with a sufficiently long needle (at least 10 cm) with a wide lumen, while the needle is directed parallel to the wire axis of the pelvis (to avoid damage to the rectal wall) to a depth of 2-3 cm.

Amputation of the uterus (subtotal, supravaginal supravaginal amputation of the uterus without appendages) is an operation to remove the body of the uterus: with preservation of the cervix (high amputation), with preservation of the body and supravaginal part of the cervix (supravaginal amputation).

Extended extirpation of the uterus with appendages (syn.: Wertheim operation, total hysterectomy) is an operation to completely remove the uterus with appendages, the upper third of the vagina, periuterine tissue with regional lymph nodes (indicated for cervical cancer).

Cystomectomy - removal of a tumor or ovarian cyst on the leg.

Tubectomy is an operation to remove the fallopian tube, most often in the presence of a tubal pregnancy.

16.6. OPERATIONS ON THE RECTUM

Amputation of the rectum is an operation to remove the distal part of the rectum with the reduction of its central stump to the level of the perineosacral wound.

An unnatural anus (syn.: anus praeternaturalis) is an artificially created anus, in which the contents of the large intestine are completely released to the outside.

Resection of the rectum is an operation to remove part of the rectum with or without restoring its continuity, as well as the entire rectum while preserving the anus and sphincter.

Resection of the rectum according to the Hartmann method - intraperitoneal resection of the rectum and sigmoid colon with the imposition of a single-barreled artificial anus.

Extirpation of the rectum - an operation to remove the rectum without restoring continuity, with the removal of the closing apparatus and suturing the central end into the abdominal wall.

Extirpation of the rectum according to the Quenu-Miles method is a one-stage abdomino-perineal extirpation of the rectum, in which the entire rectum is removed with the anus and anal sphincter, surrounding tissue and lymph nodes, and a permanent single-barreled artificial anus is formed from the central segment of the sigmoid colon.

16.7. TESTS

16.1. The main cellular spaces of the pelvic cavity are within:

1. Peritoneal floor of the pelvis.

2. Subperitoneal floor of the pelvis.

3. Subcutaneous floor of the pelvis.

16.2. The urogenital diaphragm is formed by two of the following muscles:

2. Coccygeal muscle.

16.3. The pelvic diaphragm is formed by two of the following muscles:

1. Deep transverse muscle of the perineum.

2. Coccygeal muscle.

3. The muscle that lifts the anus.

4. Ischiocavernosus muscle.

5. Sphincter of the urethra.

16.4. The prostate gland is located in relation to the bladder:

1. Front.

16.5. A digital rectal examination in men is performed to determine the condition primarily:

1. Bladder.

2. Ureters.

3. Prostate.

4. Anterior sacral lymph nodes.

16.6. The fallopian tube is located:

1. Along the upper edge of the broad ligament of the uterus.

2. Along the lateral edge of the body of the uterus.

3. In the middle section of the broad ligament of the uterus.

4. At the base of the broad ligament of the uterus.

16.7. The supraampullary part of the rectum is covered by the peritoneum:

1. From all sides.

2. Three sides.

3. Front only.

16.8. The ampulla of the rectum is covered for a greater extent by the peritoneum:

1. From all sides.

2. Three sides.

3. Front only.

16.9. The lower part of the rectum is covered by the peritoneum:

1. Three sides.

2. Front only.

3. Not covered by the peritoneum at all.

16.10. The ovary is attached to the broad ligament of the uterus:

1. On the anterior surface of the ligament at the uterine margin.

2. On the anterior surface of the ligament near the side wall of the pelvis.

3. On the posterior surface of the ligament at the uterine margin.

4. On the back surface of the ligament at the side wall of the pelvis.

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The main differences between the female pelvis and the male pelvis are clearly seen in adults. The main ones are as follows: the bones of the female pelvis, in comparison with the male, are thinner and smoother; the female pelvis is lower, more voluminous and wider, the wings of the ilium in women are deployed more strongly, as a result of which the transverse dimensions of the female pelvis are larger than those of the male; the entrance to the small pelvis of a woman is more extensive and does not narrow down in a funnel-like manner, as in men, but, on the contrary, expands; as a result, the exit from the pelvis of women is wider than that of men; the angle formed by the lower branches of the pubic pelvic bones in women is more obtuse (90-100 degrees) than in men (70-75 degrees). Thus, the pelvis of an adult woman, compared to a man's, is more voluminous and wide, and at the same time less deep.

All joints of the pelvic bones are fixed or slightly mobile, soften during pregnancy, and by the end of pregnancy they become so extensible that the pelvic bones to a certain extent become, as it were, mobile in relation to each other; this is most pronounced in the sacrococcygeal joint.

Of particular importance during childbirth is the pelvic floor of the female pelvis, which is included in the birth canal and contributes to the birth of the fetus.

The upper aperture of the small pelvis - or the entrance to the pelvic cavity is limited by the boundary line, the cape of the sacrum. The subpubic angle, ischial tubercles, sacro-tubercular ligaments, the apex of the sacrum and the coccyx - delimit the lower pelvic aperture (or the entrance to the pelvic cavity). The planes of entry and exit, as well as the so-called "wide part of the pelvis" are of particular importance in obstetric practice, they are evaluated by direct and transverse, right and left oblique dimensions.

The direct size of the entrance - between the upper edge of the symphysis and the cape is 11 cm; oblique size - from the pubic-crested eminence to the sacroiliac joint - 12 cm; the direct size of the exit between the pubic angle and the coccyx is 9.5 cm; transverse between ischial tubercles - 11 cm; the transverse and direct dimensions of the pelvic cavity are 1-3 cm larger than the dimensions of the entrance; the line connecting the middle of the straight dimensions and the pelvic cavity is its axis (wire line in obstetrics). The entrance plane is inclined anteriorly and forms an angle of 54-55 degrees with the horizontal plane (the angle of inclination).

The lower wall is located at the exit of the pelvis and belongs to the layers of the perineum, the deep muscles of which form the pelvic diaphragm and the urogenital diaphragm: the muscle that lifts the anus, the deep transverse muscle of the perineum; the anus passes through the first of them, the urethra and vagina pass through the second.

Rectum

In the female pelvis, anterior to the rectum are the uterus and vagina. In the peritoneal floor of the small pelvis, between the rectum and the uterus, there is the lowest part of the pelvic cavity - the recto-uterine cavity (excavatio rectouterina), where loops of the small intestine can be located. In the subperitoneal floor, the rectum is adjacent to the vagina. The peritoneal-perineal aponeurosis, or septim rectovaginale, separates the rectum and vagina. The lymphatic vessels of the rectum form connections with the lymphatic vessels of the uterus and vagina.

Bladder and ureters

In the female pelvis, the bladder lies deeper in the pelvic cavity than in men. In front, it is adjacent to the symphysis and is fixed to it by the pubic-cystic ligaments. The bottom of the bladder is located on the urogenital diaphragm. Behind the bladder is the uterus and the vagina in the subperitoneal space. The lymphatic vessels of the bladder in women form direct connections with the lymphatic vessels of the uterus and vagina at the base of the broad ligament of the uterus and in the regional iliac lymph nodes.

In the cavity of the female pelvis, the fascia of the bladder have similar relationships with the fascia of the cervix and vagina, here the most pronounced is the frontally located peritoneal-perineal aponeurosis (Denonville) between the posterior wall of the vagina and the rectum.

The ureters in the female pelvis, as in the male, are located under the peritoneum and are surrounded by paraurethral tissue, have their own fascial case. In the cavity of the small pelvis, the ureters of the seachal lie on the side wall of the pelvis, on the anterior surface of the internal iliac artery, anterior to the auterina, then in the thickness of the base of the broad ligaments of the uterus. Here the ureters are crossed again a. uterina, located under it and 1.5-2 cm from the internal cervical os. Further, the ureter is adjacent to the anterior wall of the vagina for a short distance and flows into the bladder at an acute angle.

B. D. Ivanova, A.V. Kolsanov, S.S. Chaplygin, P.P. Yunusov, A.A. Dubinin, I.A. Bardovsky, S. N. Larionova

The pelvic cavity is the anatomical space bounded by the pelvic bones. Depending on the sex, the structure of this part of the body is different. In a woman, the area is more protected, since it contains important organs for conceiving and bearing a child. You can see the differences in more detail on the diagrams of the structure of the female and male organs of the small pelvis. Injury to the pelvic cavity is fraught with anal incontinence, impaired reproductive function, and pathologies of the genitourinary system.

Anatomy of the small pelvis in men and women

In medicine, the small pelvis (in Latin pelvis minor) is a collection of bones and soft tissues located below the border line. In men, the pelvis is narrower and longer; in women, it is shorter and wider. This is due to the reproductive function inherent in the female body by nature. The male skeleton, in turn, must be hardy, strong and withstand a variety of loads. The exit from the small pelvis is closed by the pelvic and urogenital diaphragms, formed from muscles and fascia.

The urogenital diaphragm in men is perforated by the urogenital canal, in women by the urethra and vagina. Both have a rectum passing through it.

Features of this area, characteristic of both sexes:

• variability of the volume, shape and position of organs;
• several operational accesses to organs.

For examinations and surgical interventions on the pelvic organs, there are separate specializations - gynecology and urology.

Skeletal system

The upper borders of the pelvic girdle are the iliac crests. You can feel them yourself if you put your hands on both sides just below the waist. Long bone formations stretch from the sacrum and go around the side surfaces of the body.

The pelvis itself is a symmetrical bone formation (pictured right). It consists of a sacrum with a coccyx, a pair of nameless and a pair of pelvic bones. In turn, each nameless includes three interconnected bones:

• iliac;
• pubic;
• ischial.

The place of their articulation is the acetabulum - a deep fossa covered with cartilage. The iliac crest is formed along the edge of the flat and curved ilium. Behind, in front and below, it is surrounded by iliac spines. On the posterior lateral inner surface of the ilium is the sacroiliac joint. From top to bottom, the bone passes into the ischium, and then into the ischial tuberosity. On the right and on the left, this zone is covered with muscle and adipose tissue, which creates support for a person when sitting.

Anteriorly and downwards, the ilium fuses with the pubis or pubis. The right and left sides of the womb are fused together with cartilage. To palpate this area, it is enough to find a triangle under the abdomen.

In women, the large trochanters of the thighs protrude more than in men. The amount of adipose tissue in this zone prevails in them. Visually, it seems that the lower part is much wider than the shoulders.

Ligaments and muscles

Joints and ligaments provide a connection between the left and right parts of the pelvic cavity. Several elements are involved in the formation of pubic fusion:

• symphysial surfaces of the pubic bones;
• interpubic disc;
• superior pubic ligament;
• inferior arcuate pubic ligament.

Ligaments also strengthen the sacroiliac joint capsule. Dorsal ligaments run along the dorsal surfaces of the bones, and ventral ligaments run along the ventral surfaces. The sacro-spinous and sacro-tuberous ligaments run from the sacrum to the ischial tuberosity. With their help, large and small ischial notches turn into ischial openings.

The iliac-lumbar ligament is responsible for connecting the bones to the vertebral region. It performs flexion and supination of the hip in the hip joint, flexes the lumbar spine with a fixed leg.

The muscles of the small pelvis are called levators (pictured right). They are very elastic, ways to greatly contract and stretch. The main task is to maintain the abdominal cavity. Other functions of the pelvic muscle group:

• keep organs in an anatomically correct position;
• contribute to the normal functioning of organs;
• prevent urinary and fecal incontinence.

Being in good shape, the muscles help women enjoy intimacy and facilitate the process of natural childbirth.

To strengthen the pelvic muscles, a special system of Kegel exercises has been developed. They are aimed at maintaining tone, improving blood circulation and stimulating cell renewal. To achieve a long-term effect, classes must be regular.

The pelvic musculature consists of two layers:

• perineum - the surface layer of fibrous muscles;
• pelvic diaphragm - a deep layer of dense, large muscles.

Fibrous muscles are directed from the inside out and intertwine three openings: the sphincter, urethra and vagina. The latter is typical only for women. The vagina is an elastic muscular tube 7-12 cm long. Its walls consist of inner, middle and outer layers. The middle one is a smooth muscular frame, the bundles of which are directed in the longitudinal direction. In the upper part, it passes into the muscles of the uterus.

The lower part of the vagina is much stronger than the upper part, however, it can lose its elasticity over time. To control the process of contraction of the vaginal muscles, it is enough to change the intra-abdominal pressure.

For the development of intra-abdominal pressure management, there are pneumatic simulators. The most popular are vaginal balls.

Blood supply, lymphatic system and innervation

The blood flow to the pelvis and lower extremities is provided by ducts extending from the abdominal aorta. The most important role in this system is played by the internal iliac artery. Additional vessels involved in blood circulation:

• superior rectal artery;
• ovarian arteries;
• median sacral artery.

The internal iliac artery is the medial branch of the common iliac artery. Its length is about 4 cm, in some it reaches 6 cm. In the region of the sciatic foramen, the vessel is divided into anterior and posterior trunks. The visceral and parietal branches depart from them, forming the vascular system of the small pelvis.

Visceral branches are directed to the pelvic organs, and parietal - to the walls of the pelvis.

The visceral branches of the internal iliac artery include:

• superior cystic arteries;
• uterine artery;
• middle rectal artery;
• internal pudendal artery.

The parietal branches are represented by the following vessels:

• iliac-lumbar artery;
• lateral sacral artery;
• gluteal arteries;
• obturator artery.

The outflow of blood to the heart occurs through the veins or their plexuses. In particular, along the internal and external iliac veins.

The lymphatic system of the pelvis is represented by several groups of nodes:

• Iliac. They are located along the common and external iliac arteries. They receive lymph from the lower extremities, buttocks, perineum and lower part of the abdominal wall.
• Internal iliac. They take lymph from large pelvic organs and pelvic walls. Pass along the same name artery.
• sacral. Collect lymph from the rectum and the back wall of the pelvis. They are located on the anterior surface of the sacrum.

The efferent lymphatic vessels of these groups anastomose perfectly with the inferior vena cava and portal vein.

Lymphatic venous anastomoses of the pelvis are dangerous if a woman has cancer of the genital organs. This increases the risk of tumor cells entering the bloodstream.

Pleasant or painful sensations are transmitted to the brain through nerve endings. If the system is working correctly, you should analyze the situation and identify the cause of the discomfort.

Two types of nervous system are involved in the innervation of the pelvic organs:

• Somatic (animal). Transmits impulses from the skin, muscles, periosteum, pelvic bones and parietal peritoneum.
• Autonomous (vegetative). Represented by the superior hypogastric plexus, sacral nerves and pelvic sympathetic trunk. Nerve fibers are located in the genitals, bladder, ureters, blind and rectum, appendix.

The nerve endings of the autonomic nervous system differ from the somatic one by incomplete myelin coverage. This significantly slows down the process of passage of a pain impulse through them. For a person, pain is felt as poorly localized, spilled. Discomfort cannot be determined by palpation.

Innervation of the sigmoid and rectum, bladder triangle, urethra, upper vagina, cervix and sacro-uterine ligaments is provided by sensory fibers of the parasympathetic system. The pain in these areas is sharp, radiating to the buttocks, lower back or lower limbs.

Sympathetic fibers serve as a link between the central nervous system (CNS) and the fundus of the uterus, the inner surface of the fallopian tubes, the broad ligaments of the uterus, the bottom of the bladder, the appendix, and the dome of the caecum. Symptoms of any pathological processes in these areas are localized in the lower abdomen.

Impulses from the ovaries, the lateral two-thirds of the fallopian tubes, the ureters and the surrounding cellular spaces move along the afferent fibers to the spinal cord. They are responsible for pain in the umbilical region.

excretory organs

The excretory organs are an integral part of the pelvis. Here are the bladder and ureters, urethra, rectum and anus. Depending on the gender, the arrangement of the elements changes. The main differences between the male and female excretory systems:

• In a woman, the bladder is located in the lower part of the pelvis: in front of the vagina and ureters, behind the pubic bone. The length of the urethra is 3-4 cm.
• In men, the bladder occupies the space between the pubic bone and the rectum. The urethra is much longer and passes through the penis.

Pelvic organs in women

The bladder acts as a reservoir for urine. On the back side, two ureters are attached to it. When a sufficient amount of fluid accumulates, nerve impulses enter the brain and the person receives the urge to urinate. The walls of the bubble are very elastic, so they are easily stretched. The process of excretion of urine occurs through the urethra (urethra). Since this organ is wider and shorter in the female half, they urinate more often and faster.

The final link in the food chain is the rectum. The organ has bends in the places where the sacrum and coccyx pass. In women, it also passes through the perineum and adheres to the wall of the vagina.

In the rectum, the process of complete breakdown of food and the accumulation of feces takes place. The lumen is closed by sphincters, which, when receiving a signal from the brain, facilitate the passage of feces.

The area around the anus, where the mucous membrane passes into the skin, is called hemorrhoidal. It can form hemorrhoids.

reproductive system

One of the most important functions of a person is assigned to the reproductive system - reproductive. Any pathology in this area can lead to infertility or difficulty conceiving. Only a regular examination by a gynecologist or urologist, testing and knowledge of your body will help to avoid this.

Each person must have information about how his reproductive system works. In a woman, it consists of the following organs:

• small and large labia;
• clitoris;
• hymen (hymen or crown);
• ovaries;
• fallopian tubes;
• uterus;
• vagina.

For reproduction, the eggs are the most valuable. Their maturation takes place in the ovaries. After they go outside and move through the fallopian tubes to the uterus. If conception does not occur during this period, menstruation occurs.

The male reproductive system also consists of external and internal genital organs. These include:

• penis;
• scrotum;
• testicles;
• epididymis;
• prostate;
• vas deferens;
• urethra.

The formation and maturation of sperm occurs in the testicles. During sexual intercourse, they mix with seminal fluid and are pushed out during ejaculation.

The testicles synthesize male sex hormones - testosterone and androgen. They have the greatest influence during puberty.

Crotch

It is a mistake to consider the perineum as part of an exclusively female body. In fact, the term characterizes a complex of soft formations located between the pubic bones in front, ischial tuberosities on the sides and the coccyx in the back. The space is occupied by muscles and fascia (sheaths of connective tissue).

Conventionally, the perineum can be divided into two parts: the anterior (urogenital diaphragm) and the posterior (pelvic diaphragm). The border between them is the line connecting the ischial tubercles. In women, the vagina and urethra pass through the anterior diaphragm, while in men, only the urethra passes through. The anus is located in the region of the posterior diaphragm.

The perineum, like any other area, is prone to various diseases. A boil or herpes, diaper rash, infectious lesions, hernias may appear here. In girls at an early age and adult men, there are specific tumors - teratomas. The formations have a high chance of becoming malignant. The main symptoms of any pathology are sharp pain, swelling, bleeding.

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Pelvis and perineum.

COMMON DATA

The name "pelvis" in topographic anatomy is understood to mean that part of the body that is externally limited by the bone pelvis and tissues that form the so-called pelvic diaphragm. The soft tissues and skin covering the pelvic bones are other areas.

The exit from the pelvis is closed by soft tissues that make up a special area - the perineum, which will be discussed in the same chapter. Have with the anterior perineum is usually described and the area of ​​the external genital organs - the pudendal region (regio pudendalis).

Part of the organs enclosed in the pelvis belongs to the abdominal cavity, in particular, the sections of the large intestine located in the iliac fossae. The latter make up what is commonly called the large pelvis. Below the boundary line (linea terminalis, s. innominata), the small pelvis begins, the topography of which is the content of this chapter.

Since access to the pelvic cavity and the organs enclosed in it is carried out either from the side of the anterior abdominal wall, or from the side of the sacrum, coccyx and gluteal region, or from the side of the perineum and, finally, from the side of the thigh, it seems necessary to note the main landmarks (bone, muscle and etc.), which surgeons and doctors of other specialties (for example, gynecologists) use both for diagnostic purposes and for surgical treatment.

Of the bone landmarks, here it is necessary to name first of all the symphysis (its upper edge) and the parts of the horizontal branches of the pubic bones adjacent to it, with the pubic tubercles located on them outward from the symphysis. Feeling them is not difficult. Further, the always well-palpable anterior superior iliac spines are important landmarks. Outside and behind them, the iliac crests are palpable. Behind, parts of the sacrum and coccyx are well defined, and within the gluteal regions - ischial tubercles. Outside and slightly above the latter, large skewers of the femur are palpated. The lower edge of the symphysis and the pubic arch in men can be palpated behind the scrotal root. In women, the lower edge of the pubic fusion, as well as the pelvic cape (promontorium), is determined during vaginal examinations. Other landmarks include the inguinal ligament, which can be felt deep in the inguinal fold.

The determination of certain changes in the configuration and consistency of the pelvic organs is often made from the side of the rectum with a finger inserted into the anus, and in women - also from the side of the vagina (often simultaneously from the side of the vagina and the anterior abdominal wall - the so-called bimanual study). In men, for example, by examining the rectum (per rectum), pathological changes in the prostate gland and seminal vesicles are determined.

THREE STORIES OF THE PELVIC CAVITY

The pelvic cavity is divided into three sections, or floors: cavum pelvis peritonaeale, cavum pelvis subperitonaeale and cavum pelvis subcutaneum (Fig. 350 and 351).

The first floor - cavum pelvis peritonaeale - is the lower part of the peritoneal cavity and is limited (conditionally) from above by a plane passing through the pelvic inlet. It contains those organs or parts of the pelvic organs that are covered by the peritoneum. In men, in the peritoneal cavity of the pelvis, the part of the rectum covered with the peritoneum is located, and then the upper, partially postero-lateral and, to a small extent, the anterior walls of the bladder.

Rice. 350. The relationship of muscles and fascia on the frontal cut of the female pelvis (diagram; according to A.P. Gubarev).

1 - vagina; 2 – m. levator ani; 3 - arcus tendineus fasciae pelvis; 4 - m. obturator interims; 5 - spatium ischiorectale; 6 - m. transversus perinei profundus; 7 - m. transversus perinei superficialis; 8 - m. constrictor cunni (s. bulbocavernosus); 9 - bulbus vestibuli; 10 - labium pudendi minus; 11 - labium pudendi majus; 12 - fascia perinei superficialis; 13 - tuber ischii dextrum; 14 - fascia perinei media; 15 - acetabulum dextrum; 16 - fascia perinei superior (s. profunda).

Passing from the anterior abdominal wall to the anterior and upper walls of the bladder, the peritoneum forms a transverse cystic fold, more clearly visible when the bladder is empty. Further, in men, the peritoneum covers part of the lateral and posterior walls of the bladder. the inner edges of the ampullae of the vas deferens and the tops of the seminal vesicles (the peritoneum is about 1 cm away from the prostate gland). Then the peritoneum passes to the rectum, forming the rectovesical space, or notch, - excavatio rectovesicalis. From the sides, this recess is limited by rectovesical folds (plicae rectovesicales), stretched in the anterior-posterior direction between the bladder and the rectum. They contain ligaments of the same name, consisting of fibrous and smooth muscle fibers, partly reaching the sacrum.

In the space between the bladder and the rectum, part of the loops of the small intestine, sometimes the transverse colon or sigmoid colon, can be placed; in very rare cases, a caecum with a appendix is ​​placed here. It should, however, be noted that the deepest part of the rectovesical space is a narrow gap, bounded above and on the sides by the indicated folds of the peritoneum; intestinal loops usually do not penetrate into this gap, but effusions and streaks can accumulate in it. Similar conditions occur in the recto-uterine space of the female pelvis.

The sharply stretched rectum occupies most of the first floor of the pelvic cavity; then, as the cuts made by N.I. Pirogov show, intestinal loops do not penetrate into the rectovesical space (Fig. 352).

The position of the anterior and posterior folds of the peritoneum (as N.I. Pirogov called the folds of the peritoneum, which are formed during its transition from the anterior abdominal wall to the bladder and from the bladder to the rectum) is largely related to the degree of filling of the bladder. N. I. Pirogov found that with a high degree of bladder filling, the anterior fold of the peritoneum extends 4–6 cm upwards from the symphysis, while the posterior (bottom of the rectovesical space) is 9 cm away from the anus. in the collapsed bladder, the anterior fold of the peritoneum adjoins the upper edge of the symphysis, while the posterior fold is 4–5 cm away from the anus (Fig. 353). These data were confirmed in the work of V. N. Shevkunenko on anterior extraperitoneal incisions.

With an average degree of bladder filling, the bottom of the rectovesical space in men is located at the level of the sacrococcygeal joint and is 6–7 cm away from the anus.

Rice. 351. The cavity of the male pelvis on the frontal cut (according to E. G. Salishchev).

1 - bladder; 2 - cystic opening of the ureter; 3 - seminal vesicle and vas deferens; 4 - aponeurosis peritonaeoperinealis; 5 - rectum; 6 - visceral sheet of the pelvic fascia; 7 - m. levator ani; 8 - fascia of the perineum (spur of the parietal leaf of the fascia of the pelvis); 9, 15 - cavum pelvis subperitonaeale; 10 - m. sphincter ani externus; 11 - cavum pelvis subcutaneum (fossa ischiorectalis); 12 - vasa pudenda interna and n. pudendus; 13 - m. obturator interims; 14 - parietal sheet of the pelvic fascia; 16 - peritoneum; 17 - cavum pelvis peritoneale.

In women, in the first floor of the pelvic cavity, the same parts of the bladder and rectum are placed as in men, most of the uterus and its appendages (ovaries and fallopian tubes), wide uterine ligaments, as well as the uppermost part of the vagina (throughout 1–2 cm).

Rice. 352. Cross section of the male pelvis at the level of the upper edge of the symphysis (according to N. I. Pirogov). The cut was made through the pubic tubercles, hip joints, large skewers. The figure depicts the bottom surface of the cut.

1 - the bladder and the internal opening of the urethra; 2 - m. pectineus; 3-n. obturatorius and vasa obturatoria; 4 - inguinal lymph nodes; 5 - mucous bag located between the tendon m. iliopsoas and hip joint capsule; 6 - m. sartorius; 7 - m. iliopsoas; 8 - m. rectus femoris; 9 - m. tensor fasciae latae; 10 - m. glutaeus medius; 11 - capsule of the hip joint; 12 - common tendon m. obturator interims and stumps. gemelli; 13 - mucous bag, located motnu tendon m. glutaeus medius and greater skewer; 14 - trochanter major; 15-lig. teres femoris; 10 - m. obturator internus; 17 - extrapelvic part m. obturator internus with bundles mm. gemelli; 18 - incisura ischiadica minor, dissected near the ischial spine, and a mucous bag located between the tendon in. obturator interims and ischium; 19 - in. levator ani; 20 - the cavity of the rectum (stretched) and the semilunar fold of its mucous membrane; 21 - coccyx (dissected at a distance of 1.5 cm from the connection with the sacrum); 22 - vas deferens; 23 - seminal vesicle; 24 - vasa pudenda interna and n. pudendus; 25-n. ischi adieus and vasa glutaea inferiora; 26-m. glutaeus maximus; 27 - head of the femur, dissected almost in the middle; 28 - n. femoralis; 29 - Femoral vessels and a septum between them; 30 - anterior leaf of the wide fascia of the thigh; 31 - aponeurosis of the external oblique muscle of the abdomen; 32 - horizontal branch of the pubic bone; 33 - spermatic cord; 34 - symphysis.

In women, when the peritoneum passes from the bladder to the uterus, and then to the rectum, two peritoneal spaces (recesses) are formed: the anterior - excavatio vesicouterina (vesicouterine space) and the posterior - excavatio rectouterina (rectal-uterine space).

Rice. 353. The position of the transitional folds of the peritoneum in the pelvis with varying degrees of filling of the bladder on the sagittal cut (according to N. I. Pirogov). Both figures depict the left segment of the section:

A - with an empty bladder; B - with a filled bubble. 1 - I sacral vertebra; 2 - small intestines; 3 - rectus abdominis; 4 - anterior transitional fold of the peritoneum; 5 - bladder; 6 - symphysis; 7 - prostate gland; 8 - seed tubercle; 9 -urethra; 10 - bulbus urethrae; 11 - rectum; 12 - posterior transitional fold of the peritoneum; 13 - excavatio rectovesicalis.

When moving from the uterus to the rectum, the peritoneum forms two lateral folds that stretch in the anterior-posterior direction and reach the sacrum. They are called sacro-uterine folds (plicae sacrouterinae) and contain ligaments consisting of muscular-fibrous bundles (ligamenta sacrouterina).

In the recto-uterine space, intestinal loops can be placed, in the vesico-uterine space - a greater omentum (Fig. 354).

Rice. 354. Transverse cut / horse pelvis, carried out 2 cm above the upper edge of the symphysis (according to N. I. Pirogov). The figure depicts the bottom surface of the cut.

l - rectus abdominis; 2 - Greater omentum (performs excavatio vesicouterina); 3 - ilium (near its connection with the pubis); 4 - m. obturator interims; 5 - m. glutaeus minimus; 6-n. ischiadicus and vasa glutaea inferiora; 7 - m. piriformis; 8 - m. glutaeus maximus; 9 – excavatio rectouterina (end of excavation); 10 - fallopian tube; 11 - sacrum (near the junction with the coccyx); 12 - rectum; 13 - the uterus, dissected between its body and the bottom (located in the left part of the pelvic cavity); 14 - bladder.

The second floor - cavum pelvis subperitonaeale - is enclosed between the peritoneum and the sheet of the pelvic fascia covering m. levator ani on top. Here, in men, there are the extraperitoneal sections of the bladder and rectum, the prostate gland, seminal vesicles, the pelvic sections of the vas deferens with their ampullae, and the pelvic sections of the ureters. In women, in this floor of the pelvic cavity there are the same sections of the ureters, bladder and rectum as in men, the cervix, the initial section of the vagina (with the exception of a small area covered by the peritoneum and belonging to the first floor of the pelvic cavity). The organs located in the cavum pelvis subperitonaeale are surrounded by connective tissue cases formed by the pelvic fascia (see below about these fascial formations). In addition to these organs, in the fiber layer between the peritoneum and the pelvic fascia there are blood vessels, nerves, lymphatic vessels and nodes (for convenience, their topography is described in the next section).

The third floor - cavum pelvis subcutaneum - is enclosed between the lower surface of the pelvic diaphragm and integuments. This section belongs to the perineum and contains parts of the organs of the genitourinary system and the final section of the intestinal tube. This, therefore, also includes the fat-filled fossa ischiorectalis, located on the side of the perineal rectum.

VESSELS, NERVES AND LYMPH NODES OF THE PELVIS

The hypogastric artery - a. hypogastrica - arises from the common iliac at the level of the sacroiliac joint and goes downward, outward and backward, located on the posterolateral wall of the pelvic cavity. The accompanying hypogastric vein runs posterior to the artery. The trunk of the artery is usually short (3–4 cm) and splits into parietal and visceral branches. The first go to the walls of the pelvis and the external genital organs, the second - to the pelvic viscera (Fig. 355).

From parietal branches a. obturatoria goes into the canal of the same name, accompanied by n. obturatorius. Approximately in 1/3 cases a. obturatoria starts from a. epigastrica inferior (V.P. Vorobyov). In 10% of cases, the obturator artery originates not from the hypogastric artery, but from the superior gluteal artery, and in half of these cases it arises from two sources (“two-rooted” obturator artery): the branch that departs from the superior gluteal artery merges with the obturator artery from the external iliac (T. I. Anikina).

Ah. glutaea superior and inferior through foramen supra- and infrapiriforme, accompanied by the nerves of the same name, go to the gluteal region. A. pudenda interna through the foramen infrapiriforme, accompanied by p. pudendus, goes to the lower floor of the pelvic cavity, giving the final branches to the external genital organs. A. iliolumbalis goes backwards, upwards and outwards under m. psoas and splits into two branches, one of which anastomoses with branches a. circumflexa ilium profunda, the other with the lumbar arteries. A. sacralis lateralis goes inwards and downwards and sends branches to the spinal nerves and to the muscles of the pelvis.

Visceral branches are aa. vesicalis superior and inferior, haemorrhoidalis media and uterina.

The parietal veins accompany the arteries in the form of paired vessels, the visceral veins form massive venous plexuses.

Blood flows into the hypogastric vein (partially into the portal vein system).

A number of works from the school of V. N. Shevkunenko are devoted to the study of the venous plexuses of the pelvic organs. Differences in the structure of this section of the venous system are associated with varying degrees of reduction of the primary venous cloacal network, since the distal intestine and pelvic sections of the genitourinary system arose from the cloaca that once existed, which had a single venous network. The differentiation of these organs and their functions was naturally accompanied by the differentiation of their venous systems. Thus, in cases of extreme reduction of the primary venous cloacal network, the maximum dissociation of these systems is observed, and quite the opposite occurs with delayed reduction.

It has been established that in some cases the veins pl. urogenitalis have a network structure, and there are a large number of connections with the parietal veins and veins of neighboring organs, especially with the veins of the rectum (delayed reduction of the primary venous network); in other cases, the veins of the urogenital plexus look like isolated trunks with a very small number of anastomoses between them and connections with the veins of neighboring organs (an extreme degree of reduction of the primary venous network).

Rice. 355. The position of the hypogastric artery and its branches, the ureter and the vas deferens on the parasagittal section of the pelvis (according to N. I. Pirogov).

1 - left common iliac artery and vein; 2 - right hypogastric artery; 3 - rami sacrales dorsales (often extending from a. sacralis lateralis) 4 - a. glutaea superior; 5 - part of the rectum; 6 - part of the bladder 7 - a. umbilicalis; 8-a. obturatoria; 9 - entrance to canalis obturatorius; 10 - pelvic fascia; 11 - vas deferens; 12 - transverse fascia; 13 - n. obturatorius; 14 - vasa spermatica interna; 15 - iliac fascia; 16 - right external iliac vein; 17 - common trunk a. glutaea inferior and a. pudenda interna; 18 - ureter 19 - right external iliac artery; 20 - right common iliac artery and vein; 21 - inferior vena cava; 22 - inferior mesenteric artery; 23 - abdominal aorta.

Similar differences are observed in the venous system pl. uterovaginalis in women. With an extreme degree of reduction of the primary network in this system, the venous outflow from the internal genital organs is carried out mainly through the veins of the ovaries, while with a delayed reduction there are many ways of outflow.

The sacral plexus lies directly on the piriformis muscle. It is formed by the anterior branches of the IV and V lumbar nerves and the I, II, III sacral nerves, exiting through the anterior sacral foramen (Fig. 356). The nerves arising from the plexus, with the exception of short muscular branches, are sent to the gluteal region through the foramen suprapiriforme (n. glutaeus superior with the vessels of the same name) and foramen infrapiriforme (n. glutaeus inferior with the vessels of the same name, as well as n. cutaneus femoris posterior, n. ischiadicus). Together with the last nerves, n comes out of the pelvic cavity. pudendus accompanied by vessels (vasa pudenda interna). This nerve arises from pl. pudendus, lying at the lower edge of the piriformis muscle under the sacral plexus and formed by II, III and IV sacral nerves.

Along the side wall of the pelvis, below the innominate line, somewhat obliquely behind and from top to front and down, passes n. obturatorius (from the lumbar plexus), which crosses the sacroiliac joint on its way, and in the small pelvis is located first posteriorly, then outwards from the hypogastric vessels; on the border of the anterior and middle third of the lateral wall of the small pelvis, the entertaining nerve, together with the vessels of the same name, penetrates into the canalis obturatorius and through it into the region of the adductor muscles of the thigh (Fig. 355).

Along the inner edge of the anterior sacral foramina lie nodes (3-4) of the sympathetic nerve, interconnected by interganglionic branches, and through rami communicantes - with the anterior branches of the sacral nerves that form the sacral plexus. On fig. 356 shows the topography of the sacral sympathetic nerve, as well as differences in its structure.

The main sources of nerve supply to the pelvic organs are the right and left hypogastric plexuses, branches of the right and left border trunk of the sympathetic nerve (the so-called nn. hypogastrici) and branches III and IV of the sacral nerves, which provide parasympathetic innervation (the so-called nn. splanchnici sacrales, also known under the name nn. erigentes, or nn. pelvici) (Fig. 357). The branches of the border trunks and the branches of the sacral nerves are not directly involved in the innervation of the pelvic organs, but are part of the hypogastric plexuses, from which secondary plexuses arise that innervate the pelvic organs. In addition, along the course of the superior rectal artery, branches from the inferior mesenteric plexus extend to the rectum, forming here the superior rectal plexus (plexus haemorrhoidalis superior). The latter connects to the middle rectal plexus, arising from the right and left hypogastric plexuses.

The details of the formation and branching of the hypogastric plexuses have recently been developed by R. D. Sinelnikov, who used methods of macromicroscopic radiation of innervation (according to V. P. Vorobyov) with staining of preparations. According to him, each of the hypogastric plexuses (plexus hypogastricus dexter and sinister) is, as it were, a branch of the unpaired so-called prelumbosacral plexus (plexus praelumbosacralis) (see p. 567), which is a continuation of the preaortic plexus, which in turn arises from the solar plexus (Fig. 358).

Plexus hypogastricus dexter and sinister arise below the promontory and lie on either side of the rectum, between it and the hypogastric vessels. In each of these plexuses, two parts should be topographically distinguished - the back (pars dorsalis plexus hypogastrici), which has the shape of an elongated cord and usually does not contain nodes, and the front (pars ventralis plexus hypogastrici), which has the shape of a powerful plate and contains, in addition to trunks, a large number nodes.

The dorsal parts of the hypogastric plexuses are located medially from the vasa hypogastrica, at a distance of several centimeters from the ureter, blind - closer to the ureter (2-3 cm), to the right - farther from it (3-5 cm). Landmarks in finding the posterior part of the hypogastric plexus are the vasa hypogastrica and the ureter, near which, by dissecting the parietal peritoneum, one can find the dorsal part of the hypogastric plexus enclosed in the retroperitoneal tissue.

Rice. 356. Differences in the structure of the sacral part of the border trunk of the sympathetic nerve (own preparations).

On fig. A: 6 nodes of the sympathetic trunk are noted on the right, 4 on the left; nodes have different shapes and sizes. 1,2,3,4 - sacral nodes of the left border trunk; 5 - coccygeal node; 6,7,8,9,10,11 - sacral nodes of the right border trunk.

On fig. B: 3 nodes of the sympathetic trunk are noted on the right, 2 on the left; nodes are spindle-shaped; the coccygeal node is barely grown. 1,2 - sacral nodes of the left border trunk; 3 - coccygeal node; 4,5,6 - sacral nodes of the right border trunk.

The ventral parts of the hypogastric plexuses are projected from the side of the pelvic cavity in the deep sections of the plicae rectovesicales in men and plicae rectouterinae in women. These areas are therefore the most sensitive during surgical interventions on the organs of the upper floor of the pelvic cavity. To expose the ventral part of the hypogastric plexus, the bladder should be displaced anteriorly (in women - the uterus), posteriorly - the rectum, and then, having identified the stretched plica rectovesicalis in men and plica rectouterina in women, incise the parietal peritoneum at the outer periphery of this fold, behind which v fiber and the central part of the hypogastric plexus is located.

The dorsal part of the hypogastric plexus, which usually does not have nodes, sends branches mainly to the rectum and ureter. The ventral part, which forms three clusters of nodes (upper, anterior and posterior), gives rise to several plexuses that innervate the pelvic organs: plexus haemorrhoidalis medius et inferior, plexus vesicalis, plexus deferentialis, plexus prostaticus, plexus cavernosus (Fig. 358); in women, in addition to the plexus of the rectum and bladder, there are plexus uterovaginalis (utero-vaginal nerve plexus of Rhine-Yastrebov), plexus cavernosus clitoridis.

The elements of the sympathetic nervous system in the pelvic cavity are subject to significant variations in terms of the shape, size and number of nodes and their connections. In particular, differences in the structure of the sacral part of the border trunk of the sympathetic nerve can be seen from Fig. 356 showing the topography of this nerve and its rami communicantes.

There are three groups of lymph nodes in the pelvis: one group is located along the external and common iliac arteries, the other along the hypogastric artery, and the third on the anterior concave surface of the sacrum (see Fig. 344). The first group of nodes receives lymph from the lower limb, superficial vessels of the gluteal region, the walls of the abdomen (their lower half), the superficial layers of the perineum, from the external genitalia. The hypogastric nodes collect lymph from most of the pelvic organs and formations that make up the pelvic wall. The sacral nodes receive lymph from the posterior wall of the pelvis and from the rectum.

The nodes of the iliac lymphatic plexus are combined into two groups (D. A. Zhdanov): the lower iliac nodes (lymphonodi iliaci inferiores) adjacent to the external iliac artery, and the upper iliac nodes (lymphonodi iliaci superiores) adjacent to the common iliac artery.

Rice. 357. Plexus hypogastricus dexter and nn. splanchnici sacrales dextri (nn. erigentes) (scheme; according to R. D. Sinelnikov).

1 - plexus praelumbosacralis; 2 - plexus hypogastricus sinister (pars dorsalis); 3 - plexus hypogastricus dexter (pars dorsalis); 4 - branches extending from the upper nodal thickening to the bladder; 5 - plexus hypogastricus (pars ventralis); 6 - branches extending from the anterior nodular thickening to the prostate gland and seminal vesicle; 7 - branches extending from the posterior nodular thickening to the rectum; 8 - ramus anterior n. sacralis IV; 9 - plexus sacralis; 10 - ramus anterior n. sacralis III; 11 - nn. splanchnici sacrales (nn. erigentes); 12 - ramus anterior n. sacralis II; 13 - n. hypogastrici; 14 - ramus anterior n. sacralis I; 15 - ramus anterior n. lumbalis V; 16 - ganglion lumbosacrale; 17 - truncus sympathicus.

Rice. 358. Plexus praeaorticus abdominalis, praelumbosacralis, haemorrhoidalis and hypogastricus sinister (according to R. D. Sinelnikov).

1 - left ureter; 2 - plexus mesentericus inferior; 3 - m. psoas major; 4-a. iliaca communis sinistra; 6-v. iliaca communis sinistra; 6 - plexus praelumbosacralis; 7 - truncus sympathicus; 8 - stem descending along the ureter from the plexus praelumbosacralis; 9 - promontorium; 10 - rami communicantes; 11 - ramus anterior n. lumbalis V; 12 - pars dorsalis plexus hypogastrici sinistri; 13 - ganglion lumbosacrale; 14 - branch descending along the ureter from pars dorsalis plexus hypogastrici; 15 - ramus anterior n. sacralis I; 16 - branch from ganglion lumbosacrale to pars dorsalis plexus hypogastrici; 17 - rami communicantes; 18 - truncus sympathicus; 19 - branches from the border trunk to pars dorsalis plexus hypogastrici; 20 - ramus anterior n. sacralis II; 21 - ganglion sacrale II trunci sympathici; 22 - rami communicantes; 23 -pars ventralis plexus hypogastrici; 24 - ganglion sacrale III trunci sympathici; 25 - ramus anterior n. sacralis III; 26 - rami communicantes; 27–nn. splanchnici sacrales from S III; 28 - plexus sacralis; 29-nn. splanchnici sacrales from S IV; 30-nn. splanchnici sacrales formed by links between S III and S IV; 31 - ramus anterior n. sacralis IV; 32 - branch from truncus sympathicus to pars ventralis plexus hypogastrici; 33-nn. splanchnici sacrales from S IV; 34 - branches to m. levator ani; 35 - m. levator ani; 36-nn. haemorrhoidales medii; 37-m. sphincter ani externus; 38 - prostata and plexus prostaticus; 39 - seminal vesicle and nerves lying on it; 40 - nerves suitable for the bladder below the confluence of the ureter; 41 - symphysis; 42 - nerves suitable for the bladder above the confluence of the ureter; 43 - vas deferens and nerves accompanying it; 44 - bladder; 45 - branches descending along the ureter and entering partly into the plexus deferentialis, partly into the plexus paravesicalis; 46-a. vesicalis superior; 47 - branch from pars dorsalis plexus hypogastrici to plexus paravesicalis; 48 - excavatio rectovesicalis; 49 - branch lost in the wall of the ureter; 50 - plexus haemorrhoidalis superior; 51 - peritonaeum parietale; 52 - branches from pars dorsalis plexus hypogastrici to plexus haemorrhoidalis superior; 53 - pars dorsalis plexus hypogastrici dextri; 54 - rectum and its peritoneal cover; 55-a. sacralis media; 56-a. haemorrhoidalis superior and accompanying nerves; 57-a. iliaca communis dextra; 58-v. iliaca communis dextra; 59 - vasa spermatica interna and their accompanying nerves; 60 - plexus praeaorticus abdominalis; 61-v. cava inferior; 62 - aorta abdominalis.

The lower iliac nodes form three chains: external, middle (prevenous) and internal. The lowest of the lower iliac nodes receive a special name "- lymphonodi suprafemorales; they are located immediately above the inguinal ligament and are usually represented by two large nodes - external and internal, of which the external lies next to the artery or in front of the artery.

The upper iliac nodes form two chains: external and posterior, and the node lying at the bifurcation of the common iliac artery is designated as lymphonodus interiliacus. The latter is important because it is the end node of the chain of iliac nodes and two lymph currents meet in it - from the pelvic organs and from the lower limb. In the chains of the iliac nodes, retrograde movement of the lymph is possible.

The afferent vessels of the iliac nodes are sent to the nodes lying at the inferior vena cava (right) and the aorta (left). Some of these vessels are interrupted in the so-called subaortic nodes, which lie at the level of the aortic bifurcation near the right and left common iliac arteries. From the hypogastric nodes, the vessels end partly in the iliac nodes (on the external and common iliac arteries), and partly in the lower lumbar nodes. From the sacral nodes, the referring vessels terminate in the iliac nodes.

R. A. Kurbskaya (in the laboratory of D. A. Zhdanov) established the existence of direct and indirect connections between the draining lymphatic vessels of the organs of the male and female pelvis. In the male pelvis, in the paravesical tissue, a direct connection was found between the efferent lymphatic vessels of the posterior wall of the body and the top of the bladder and the base of the prostate gland. In addition, the draining lymphatic vessels of both organs were noted to flow into the same regional lymph node, either into the hypogastric or the lower node of the medial chain of iliac nodes located between the external iliac vein and the obturator nerve.

In the lymph nodes located along the course of the superior rectal artery, there are efferent lymphatic vessels of the prostate and rectum.

Connections between the efferent lymphatic vessels of both testicles exist in the form of a common lymphatic plexus located around the ampullae of the vas deferens; in addition, lymphatic flows from both testicles are found in the subaortic nodes and in the nodes located in the circumference of the abdominal aorta. Separate lymphatic vessels of the testis are connected in the pelvis with the lymphatic vessels of the bottom of the bladder and prostate gland.

In the female pelvis, direct connections were noted between the efferent lymphatic vessels of the bladder and vagina, vagina and rectum (in the latter case, the lymphatic vessels of both organs merge in the thickness of the rectovaginal septum or flow into the regional hypogastric lymph node common to both organs). There is also a fusion of the efferent lymphatic vessels of the body or the bottom of the bladder with the efferent lymphatic vessels of the body and cervix at the base of the wide uterine ligament or the confluence of these vessels into one common regional node (the lower node of the middle chain of the iliac nodes located in front of the external iliac vein).

Under the peritoneum in the region of the recto-uterine space, a network of lymphatic vessels was found, in which the draining lymphatic vessels of the uterus and rectum merge. There is also a meeting of these vessels in the nodes located along the superior rectal artery.

The efferent lymphatic vessels of the fundus of the uterus, fallopian tube and ovary form a plexus (plexus subovaricus) located in the thickness of the mesentery of the tube and ovary. Part of the lymphatic vessels of the uterine fundus is directed along the round ligament to the inguinal nodes.

In addition to direct connections between the efferent lymphatic vessels of the pelvic organs, there are indirect connections. These are observed in the system of efferent lymphatic vessels of the vagina. These vessels, on the one hand, are associated with the efferent lymphatic vessels of the bottom of the bladder and the beginning of the urethra, and on the other hand, with the lymphatic vessels of the rectum.

The given data on the connections between the efferent lymphatic vessels of the pelvic organs are important for studying the processes of the spread of malignant neoplasms and infection in the pelvis.

FASCIA AND CELLULAR SPACES OF THE PELVIS

The walls and insides of the small pelvis are covered with pelvic fascia (fascia pelvis). It is, as it were, a continuation of the visceral fascia of the abdomen and, by analogy with it, is called the visceral fascia of the pelvis (fascia endopelvina).

Fascia endopelvina in the definitive state appears to be one. The concept of the fascia of the pelvis as a single fascia with numerous spurs converging in the circumference of the prostate gland was first put forward by N. I. Pirogov back in the 40s of the last century. In the explanations to the atlas of cuts, N. I. Pirogov points out that in academic lectures and demonstrations of anatomical preparations he recommended adhering to such a view of the pelvic fascia. He then already believed that capsula pelvioprostatica is the place of confluence (locus confluxus) of all fibrous plates of the pelvis and perineum.

The location of the sheets of the pelvic fascia is notable for its considerable complexity, which was also noted by N.I. Pirogov. This complexity can be explained by the difference in the origin of the different sections of the pelvic fascia. In the early stage of embryonic development, the pelvic cavity is filled with a homogeneous loose connective tissue, in which the pelvic organs are located. With further development, differentiation of this fiber occurs, fascial plates are organized from it on the surface of organs (visceral sheet) and on the muscles of the walls and pelvic floor (parietal sheet).

Part of the parietal fascia, lining mainly the bottom of the pelvis, is the remnant of the reduced muscle (m. pubococcygeus). The fascial septum, located frontally between the prostate gland and the rectum and known as the peritoneal-perineal aponeurosis (aponeurosis peritonacoperinealis), represents a duplication of the primary peritoneum, dividing the cloaca into two sections (urogenital sinus and rectum).

As noted above, it is customary to distinguish between two sheets of the pelvic fascia - parietal and visceral. The first lines the walls and bottom of the pelvic cavity, the second covers the organs of the pelvis. On the side wall of the pelvis, the parietal sheet covers m. obturator interims, and along the length from the lower part of the pubic fusion to the ischial spine, the parietal leaf of the pelvic fascia thickens, forming a tendon arc, arcus tendineus fasciae pelvis.

Inwardly, the parietal sheet covers the upper surface of the muscle that lifts the anus (m. levator ani) and starts from the tendon arch; in the posterior part of the pelvic floor, the parietal sheet covers m. piriformis.

Stretching between the symphysis and the prostate gland in men or the bladder in women, the fascia forms two thick longitudinal folds or ligaments: ligamenta puboprostatica (in men) or ligamenta pubovesicalia (in women). Between them there is a deep hole, at the bottom of which there are several holes in the fascia, through which the veins pass, connecting pl. vesicalis with pl. pudendalis.

In the region of the vessels and nerves, the pelvic fascia not only forms holes that allow individual branches to pass through, but fuses with them, continuing along their sheaths, which is of great importance in the spread of pelvic abscesses through the vessels and nerves.

The visceral sheet of the pelvic fascia is not a direct continuation of the parietal sheet, but represents a plate that. as mentioned above, it occurs by compacting the loose fiber surrounding the rectum and bladder, and then grows together with the parietal sheet. The line along which the parietal sheet on the lateral surfaces of the organs fuses with the visceral sheet is indicated by a not always pronounced tendon arch (the so-called median arch of the pelvic fascia) (A. V. Starkov). In the area of ​​the urogenital diaphragm, the fascial cover of the prostate gland is fused with the upper fascial layer of this diaphragm.

In the middle section of the pelvic cavity, the visceral fascia forms a chamber closed on all sides. This chamber is divided into two sections, anterior and posterior, by a special septum extending in the frontal direction from the bottom of the peritoneal sac to the perineum. This is the peritoneal-perineal aponeurosis (aponeurosis peritonaeoperinealis), representing the duplication of the primary peritoneum (Fig. 359). The peritoneal-perineal aponeurosis is located between the rectum and the prostate gland, so that the anterior chamber contains the bladder, prostate gland, seminal vesicles and ampullae of the vas deferens in men, the bladder and vagina in women; the posterior section contains the rectum (Fig. 360, 361 and 382).

In the formation of the fascial cover of one or another pelvic organ, as recently shown by L.P. Kraizelburd, the fascial sheaths of neighboring organs can take part. So, the fascial cover of the bladder is made up of two elements: the prevesical fascia and the sheath of the umbilical artery. The prevesical fascia is located in front of the wall of the bladder, extending from the lower semicircle of the navel to the bottom of the pelvis. It does not reach the side walls of the pelvis, but ends on the side walls of the urinary bladder.

The sheath of the umbilical artery is a fascial plate, which is divided into two sheets: lateral and medial. The lateral leaf of the sheath of the umbilical artery on the lateral wall of the bladder adheres to the prevesical fascia and gives off the lateral process to the wall of the small pelvis, forming a lateral valve. The latter separates the prevesical cellular space from the lateral cellular space of the pelvis. The medial sheath of the umbilical artery covers the posterior wall of the bladder.

With regard to the peritoneal-perineal aponeurosis, it has been established that it does not pass into the lateral sections of the pelvis, but is attached to the posterior wall of the rectum, bending around its side walls.

Both between individual organs and between the organs and walls of the pelvis there are cellular spaces

URETHRA

female urethra (urethra femina) has a length of 3-4 cm, its inner diameter is 7-8 mm. Begins at the bottom of the bladder with an internal opening (ostium urethrae internum), passes through the urogenital diaphragm, where the urethral sphincter is located (i.e. sphincter urethrae), and ends with an opening (ostium urethrae externum). The external opening is the most narrowed part of the urethra, located on the eve of the vagina (vestibulum vaginae) between the clitoris in front and the opening of the vagina behind. The wall of the urethra consists of muscular, spongy and mucous membranes.

Muscular membrane (tunica muscularis) consists of outer circular and inner longitudinal layers of smooth muscles. The circular layer of the initial part is

the battle is a continuation of the muscular membrane of the bladder and plays the role of an involuntary internal sphincter of the bladder

Under the mucous base is loose, contains a choroid plexus, giving the tissue a cavernous appearance on the cut, which is why it is called a spongy membrane (tunica spongiosa).

mucous membrane (tunica mucosa) forms longitudinal folds, the largest of which is located in the upper part of the posterior wall and is called the crest of the urethra (crista urethralis). Above the urogenital diaphragm to the female

the vesical venous plexus adjoins the urethra in front (plexus venosus vesicalis), and behind it fuses with the anterior wall of the vagina (Fig. 13-32).

blood supply the female urethra is carried by the branches of the inferior vesical (a. vesicalis inferior) and internal genital (a. pudenda interna) arteries arising from the internal iliac artery (a. iliaca interna). Venous blood flows into the vesical venous plexus (plexus venosus vesicalis) and further along the vesical veins (w. vesicales) into the internal iliac vein (v. iliaca interna).

Lymph drainage from the upper part of the urethra goes to the internal iliac lymph nodes (nodi lymphatici iliaci interni), from the lower part - to the inguinal lymph nodes (nodi lymphatici inguinales).

Innervation. The female urethra receives autonomic innervation from the sympathetic fibers of the inferior hypogastric plexus. (plexus hypogastric inferior) and from the parasympathetic fibers of the pelvic splanchnic nerves (pp. splanchnici pelvini). Somatic innervation is carried out by the pudendal nerve (n. pudendus), which innervates the sphincter of the urethra and gives sensory fibers to its mucous membrane.

VAGINA

Vagina (vagina) is a tube 8-10 cm long. The anterior and posterior walls are isolated in the vagina (paries anterior et paries posterior). In the distal direction, the vagina opens with a vaginal opening

338 ♦ TOPOGRAPHICAL ANATOMY AND OPERATIONAL SURGERY ♦ Chapter 13

In front, it comes into contact only with the urethra, since the bladder lies higher than in adults. In a one-year-old child, due to the lowering of the bladder, the upper part of the vagina is already adjacent to the bottom of the bladder. In two-year-old children, the upper end of the vagina lies at the level of the urinary triangle and the ureters are adjacent to the anterior fornix. The length of the vagina increases with age, most rapidly from 10 to 14 years of age.

UTERUS AND ITS ADDITIONS

The uterine appendages include the fallopian tubes and ovaries (Fig. 13-33).

Uterus (uterus s. metra; see fig. 13-33) located in the pelvic cavity between the rectum at the back and the bladder at the front. The fundus is isolated in the uterus (fundus uteri), body (corpus uteri), isthmus (isthmus uteri), neck (cervix uteri).

The uterus has intestinal and cystic surfaces (fades intestinalis et fades vesicalis), separated from each other by the right and left edges (margo uteri dexter et sinister), ending in uterine horns (sorry uterinum).

uterine cavity (cavitas uteri)- a triangular slit, with its base facing the bottom, where the uterine openings of the tubes open in the area of ​​​​the horns (ostium uterinum tubae), and from the isthmus to the opening of the uterus (ostium uteri) stretches the cervical canal (canalis cervicalis uteri), connects the uterine cavity with the lumen of the vagina.

relation to the peritoneum. The peritoneum passes to the uterus from the bladder, lines the anterior surface of the isthmus and body of the uterus, the fundus, posterior surface of the body and the supravaginal part of the cervix, after which it covers the upper quarter of the posterior wall of the vagina and passes to the rectum. Thus, in front of and behind the uterus, the peritoneum forms the vesico-uterine and recto-uterine depressions. (excavatio vesicouterina et excavatio rectouterine), and the latter is distinguished by greater depth. The edges of the uterus are not covered by the peritoneum, since the abdomen

Topographic anatomy of the pelvis and perineum

lines from the anterior and posterior walls of the uterus pass into the wide ligament of the uterus.

Syntopy of the uterus. In front and below, the bladder is adjacent to the uterus, behind it is a straight * lsh! Ka, loops of the colon, sigmoid, and sometimes the transverse colon can adjoin the uterus from above.

Ligaments of the uterus. The following ligaments of the satka are distinguished (Fig. 13-34).

Broad ligament of uterus (lig. latum uteri) is a duplication of the peritoneum, stretching from the edge of the uterus to the pelvic wall and playing the role of a paired mesentery of the uterus (mesometrium).

Round ligament of uterus (lig. teres uteri) passes from the uterine horn to the deep inguinal ring and further through the inguinal canal to the labia majora.

From the cervix to the bladder and further to the pubic symphysis, paired vesico-uterine (ligg. vesicouterina) and pubic-vesical (ligg. pubovesicalia) ligaments that limit the ability to move the cervix to the sacrum.

From the cervix to the side walls of the pelvis along the uterine artery at the base of the broad ligament of the uterus, the main, or cardinal, ligaments pass (ligg. cardinalia uteri), keeping the cervix from lateral movements.

The ligaments described above form the suspensory (round and wide ligaments of the uterus) and the gnxing (vesicouterine, pubic--> zygomatic, sacro-uterine and main uterine ligaments) apparatuses of the uterus. In addition, the supporting apparatus, the urogenital diaphragm, to which the vagina is attached, is also important for the gnxation of the female genital organs. Glnako, despite the powerful ligamentous apparatus, the uterus retains relative mobility, which is a condition for its normal functioning. The position of the uterus in the pelvic cavity is described by its inclination [the angle between the axis of the pelvis and the uterus (version)] and bend [the angle between the body and the cervix (flexio)]. The position of the uterus is affected by the degree of filling of the pelvic organs. Normally, the uterus in relation to: the pelvis is tilted forward (anteversio uteri) And

Rice. 13-34. Ligaments attached to the cervix. 1 -

pubic symphysis, 2 - bladder, 3 - vesicouterine ligament, 4 - uterus, 5 - cardinal ligament, 6 - sacro-uterine ligament, 7 - rectum, 8 - sacrum.

an obtuse angle is formed between the body and the cervix, open anteriorly (anteflexio uteri).

blood supply

The uterus is supplied with blood by the uterine artery (a. uterine). The uterine artery departs in the lateral cellular space of the pelvis from the anterior branch of the internal iliac artery, located below the ureter, then, arcuately curving, passes in the lower part of the periuterine space, where it crosses with the ureter at a distance of 1.5-2 cm from the cervix, passing in front of it, then goes to the cervix, located above the ureter, gives down the vaginal artery (a. vaginalis), rises, wriggling, between the sheets of the broad uterine ligament, gives off branches to the cervix and body of the uterus, reaches along the edge of the uterus to its horn, where it gives off the tubal and ovarian branches (rr. tubarius et ovaricus), anastomosing with ovarian artery (a. ovarica). Thanks to these anastomoses, the ovarian artery also takes part in the blood supply to the uterus. Venous blood flows from the uterus into the uterine venous plexus (plexus venosus uterinus), surrounding the cervix, from which blood flows mainly through the uterine veins (w. uterinae) into the internal iliac vein (v. iliaca interna). From the bottom

uterus outflow of venous blood can also occur through the ovarian veins (vv. ovaricae) into the lower hollow on the right (v. cava inferior) and left renal vein (v. renalis sinistra) left.

innervation uterus is carried out by the uterovaginal plexus (plexus uterovaginal), receiving sympathetic fibers from the sacral nodes of the sympathetic trunk through the lower hypogastric plexus and parasympathetic fibers - from the pelvic splanchnic nerves (pp. splanchnici pelvini).

Lymph drainage from the lower body and cervix goes to the internal iliac (nodi lymphatici iliaci interni) and sacral (nodi lymphatici sacrales) lymph nodes, from the bottom - along the ovarian vessels to the right and left lumbar lymph nodes located around the aorta and inferior vena cava.

Age features. The uterus in newborns has a length of about 3-3.5 cm, and the length of the neck is twice the length of the body. Soon after birth, the reverse development of the uterus is observed (the length of the uterus decreases by 2 years to 2.75 cm). In the future, there is a slow growth of the uterus, mainly due to an increase in the length of the body of the uterus. By the age of 16, the uterus reaches a length of 6.6 cm. The uterus in newborns and young children has an elongated shape, by the age of 12-14 it becomes pear-shaped, like in adult women. The uterus, as in adults, is usually tilted and curved forward. (anteversio et anteflexio).

OVIDUCT

Oviduct (tuba uterina s. salpinx; see fig. 13-33) connects the uterine cavity with the abdominal cavity in the region of the recto-uterine cavity (excavatio rectouterina). Abdominal opening of fallopian tube (ostium abdominale tubae uterinae) surrounded by fringed pipes (fimbria tubae) and leads into the funnel (infundibulum tubae uterinae), followed by an ampoule (ampulla tubae uterinae), narrowed isthmus (isthmus tubae uterinae), fallopian tube (pars uterine), uterine tube ending (ostium uterine tubae). The fallopian tube runs along the upper edge of the broad ligament of the uterus, which forms its mesentery (mesosalpinx).

blood supply fallopian tube carry out the fallopian (a. uterina) and ovarian (a. ovarica) arteries. Near the horn of the uterus from the uterine artery (a. uterina) branch pipe departs (r. tubarius), passing through the mesentery of the fallopian tube (mesosalpinx) and anastomosing with the ovarian artery (a. ovarica). Venous blood flows from the fallopian tube through the ovarian veins (vv. ovaricae) into the inferior vena cava (v. cava inferior) right and left renal vein (v. renalis sinistra) left. Another direction of outflow from the fallopian tube is through the uterine venous plexus (plexus venosus uterinus), surrounding the cervix, blood flows from it through the uterine veins (vv. uterinae) into the internal iliac vein (v. iliaca interna).

Lymph drainage from the fallopian tube occurs along the course of the ovarian vessels to the right and left lumbar lymph nodes (nodi lymphatici lumbales dextri et sinistri), located around the aorta and inferior vena cava.

innervation the fallopian tube is carried out by the uterovaginal (plexus uterovaginalis) and ovarian (Plexus ovaricus) plexus.

The uterovaginal plexus receives sympathetic fibers from the sacral nodes of the sympathetic trunk through the inferior hypogastric plexus. (plexus hypogastricus inferior), parasympathetic fibers - from the pelvic splanchnic nerves (pp. splanchnici pelvini).

Ovarian plexus along the same name

vessels reaches the ovary through the abdominal aortic plexus (plexus aorticus abdominalis) receives sympathetic and sensory fibers of the small and lower splanchnic nerves

Ovary (ovarium; see fig. 13-33) has medial and lateral surfaces (facies medialis et fades lateralis), free and mesenteric edges (margo liber et margo mesovaricus). tubal and uterine ends (extremitas tubaric et extremitas uterina). On the mesenteric edge of the ovary there is a gate (hilum ovarii), through which the vessels enter. From the uterine end of the ovary to the uterine horn (cornu uterine) stretches own ligament of the ovary (lig. ovariiproprium)

The ovary is located in the ovarian fossa, bounded in front by a wide ligament of the uterus.

ki, behind - a fold of the peritoneum, in which the internal iliac artery passes, from above - a fold of the peritoneum formed by the passage of the external iliac artery, which corresponds to the boundary line. The ovary is almost completely deprived of the peritoneal cover, with the exception of a small area between the free and mesenteric edges, to which an annular strip of peritoneum is attached (ring Farr-Waldeyera) that strengthens the ovary in the posterior leaf of the broad ligament of the uterus. Thus, the entire free surface of the ovary is not covered by the peritoneum. The fold of the posterior leaf of the broad ligament of the uterus, formed by the passage of the own ligament of the ovary from the horn of the uterus to the uterine end of the ovary, is called the mesentery of the ovary (mesoovarium). The outer part of the broad ligament of the uterus forms a fold of the peritoneum, stretching from the ovary and fallopian tube to the boundary line, called the ligament that suspends the ovary (Jig. suspensorium ovarii). The ovarian artery and vein pass through this ligament.

Blood supply. IN The blood supply to the ovary involves the following arteries:

ovarian artery (a. ovarica), which originates from the abdominal aorta (pars abdominalis aortae), from the boundary line goes to the tubal end of the ovary. When approaching the ovary, it forms a fold of the peritoneum, which is called the suspensory ligament of the ovary. (lig. suspensorium ovarii).

Ovarian branches of the uterine artery (rami

ovarici a. uterinae), approaching the ovary from its uterine end. Bleeding from the ovary occurs:

Through the ovarian veins (vv. ovaricae), from co-

of which the right one flows into the inferior vena cava (v. cava inferior) and the left one - into the renal vein (v. renalis);

In the uterine venous plexus (plexus venosus

uterine) and further through the uterine veins (w. uterinae) into the internal iliac vein. Lymph drainage from the ovary occurs along the course of the ovarian vessels to the right and left lumbar lymph nodes (nodi lymphatici lumbales dextri et sinistri), located around the aorta and inferior vena cava.

innervation ovary is carried out by the ovarian plexus (Plexus ovaricus) which, along the course of the vessels of the same name, reaches the ovary, receives sympathetic and sensitive

fibers of the lesser and lower splanchnic nerves (pp. splanchnici minor et imus).

TOPOGRAPHY OF THE PERINE

The perineum is “a place so called from the powder to the weedy parts; powder - the opening of the anus (V.I. Dal). Perineum (regio perinealis), forming the lower wall of the pelvic cavity, has the shape of a rhombus and is limited in front by the pubic symphysis, in front and laterally by the lower branch of the pubis and the branch of the ischium, laterally by the ischial tuberosities, laterally and posteriorly by the sacrotuberous ligaments, and posteriorly by the coccyx. A line connecting the ischial tuberosities (linea biischiadica). The perineum is divided into the urogenital and anal regions (Fig. 13-35). In the middle of the line connecting the ischial tubercles, the tendon center of the perineum is usually projected.

Rice. 13-35. The boundaries of the male (a) and female (b) perineum. 1 - anal region, 2 - genitourinary region. (From: Zolotko Yu.L.

342 ♦ TOPOGRAPHICAL ANATOMY AND OPERATIONAL SURGERY ♦ Chapter 13

ANAL REGION

Anal area (regio analis) limited in front by a line connecting the ischial tubercles, behind - by the coccyx, from the sides - by the sacrotuberous ligaments. The anus is located within the area (anus).

The layered topography of the anal area in men and women is the same. Leather (derma) the anal region is thicker at the periphery and thinner in the center, contains sweat and sebaceous glands, and is covered with hair. At the anus, the skin is pigmented, fused with the external sphincter of the anus, forms radial folds and along the anal-skin line (tinea anocutanea) passes into the mucous membrane of the rectum.

Fat deposits (panniculus adiposus) well developed on the periphery of the region, in them superficial vessels and nerves pass to the skin of the anal region (Fig. 13-36)

♦ Perineal nerves (pp. perineales), arising from the pudendal nerve (n. pudendus), innervating the central part of the region.

♦ Perineal branches of the posterior femoral cutaneous nerve (rr. perineales n. cutaneus femora, posterior), innervating the skin of the outer part of the area.

♦ Cutaneous branches of the lower gluteal (a. em v. glutea inferior) and rectal (a. et v. rectalis inferior) arteries and veins; subcutaneous veins forming a plexus around the anus.

♦ Under the skin of the central part of the region is the external sphincter of the posterior

passage, in front attached to the tendon center of the perineum (centrum tendineum perinei), and behind - to the posterior coccygeal ligament (lig. anococcygeum). Superficial fascia of the perineum very thin within the anal triangle. Fat body of the ischiorectal fossa (corpus adiposum fossae ischiorectalis) fills the hole of the same name (Fig. 13-37). Ischiorectal fossa (fossa ischiorectalis) limited in front by the superficial transverse muscle of the perineum, behind - by the lower edge of the gluteus maximus muscle, laterally - by the obturator fascia located on the internal obturator muscle, above and medially - by the lower fascia of the pelvic diaphragm (fascia diaphragmatis pelvis inferior), lining the lower surface of the muscle that lifts the anus. The ischiorectal fossa in front forms a pubic pocket (recessus pubicus), located between the deep transverse muscle of the perineum and the muscle that lifts the anus, behind -

buttock pocket (recessus glutealis), located under the edge of the gluteus maximus muscle. At the lateral wall of the ischiorectal fossa, between the layers of the obturator fascia, there is a genital canal (canalis pudendalis); it contains the pudendal nerve and the internal pudendal artery and vein (n. pudendus, a. et v. pudenda interna), entering the ischiorectal fossa through the lesser sciatic foramen (foramen ischiadicum minus) and giving here the lower rectal vessels and nerve (a., v. et n. rectalis inferior), suitable for the anus. Inferior fascia of the pelvic diaphragm from below it lines the muscle that lifts the anus, limits the ischiorectal fossa from above.

(t. levator ani), represented in this area by the iliococcygeal muscle (t. iliococcygeus), originates from the tendinous arch of the fascia of the pelvis (arcus tendineus fasciae pelvis), located on the inner surface of the obturator internus muscle.

Rice. 13-37. Ischiorectal fossa and superficial space of the perineum of a man (a) and a woman (b).

1 - muscle that understands the anus, 2 - sacrotuberous ligament, 3 - internal pudendal artery and vein and pudendal nerve in the genital canal, 4 - external sphincter of the anus, 5 - superficial transverse muscle of the perineum, 6 - lower fascia of the urogenital diaphragm, 7 - ischiocavernosus muscle, 8 - bulbospongy muscle, E - head of the penis (clitoris), 10 - frenulum of the foreskin, 11 - foreskin, 12 - deep transverse perineal muscle, 13 - perineal artery, 14 - body of the clitoris , 15 - dorsal artery, vein and nerve of the clitoris, 16 - vestibule bulb. (From: Zolotko Yu.L. Atlas of topographic human anatomy. - M., 1976.)

The muscle is woven with its medial bundles into the external sphincter of the anus, the upper and lower fascia of the urogenital diaphragm are attached to the latter in front, forming the tendon center of the perineum (centrum tendineum perinei). Behind the anal canal, the levator ani muscle attaches to the anal-coccygeal ligament.

- part of the parietal fascia of the pelvis (fascia pelvis parietalis), lines the levator ani muscle from above.

Subperitoneal cavity of the pelvis (cavum pelvis subperitoneale) contains the extraperitoneal part of the ampulla of the rectum, perirectal, retrorectal and lateral cellular spaces of the pelvis.

parietal peritoneum (peritoneum parietale).

Peritoneal cavity of the pelvis (cavum pelvis perito-

URINARY REGION

Genitourinary area (regio urogenitalis) limited in front by the pubic arch (subpubic angle), behind - by the line connecting the ischial tuberosities, from the sides - by the lower branches of the pubis and branches of the ischial bones (ramus inferior ossis pubis et ramus ossis ischii).

Layered topography of the genitourinary region:

Leather (cutis) genitourinary area is covered

hair, has sweat and sebaceous glands. In men, in the midline of the urethral surface of the penis (fades urethralis) goes through the suture of the penis (raphe penis) running into the suture of the scrotum (raphae scroti) and further into the median crotch seam (raphae mediana perinei).

Fat deposits (panniculus adiposus) You-

are usually less affected than in the anal area, contain perineal nerves (pp. perineales), arising from the pudendal nerve (n. pudendus), areas innervating the skin, as well as branches of the perineal arteries and veins (a. et v. perineales), arising from the internal genital vessels (a. et v. pudenda interna), lymphatic vessels that flow into the inguinal lymph nodes.

superficial fascia (fascia superficialis) at-

attached to the lower branch of the pubic and vet-

view of the ischium and from below limits the surface space of the perineum. Superficial space of the perineum (spatium perinei superficialis) contains the following formations:

♦ Superficial muscles of the perineum,
located on each side in the form
triangle.

Superficial transverse perineal muscle (t. transversum perinei superficialis) - a thin muscle bundle that starts from the ischial tuberosity and attaches to the tendon center of the perineum.

Ischiocavernosus muscle (i.e. is-chiocavernosus) starts from the ischial tuberosity and attaches to the cavernous body of the penis in men (the clitoris in women), squeezing the venous vessels, promotes erection.

bulbospongiosus muscle (i.e. bulbo-spongiosus) starts from the tendinous center of the perineum, covers the inferolateral surface of the bulb of the penis in men, fuses along the midline with the muscle of the opposite side and is attached to the albuginea and superficial fascia on the back of the penis. When contracted, it compresses the urethra, which contributes to the ejection of its contents. In women, the ischiocavernosus muscle, like in men, starts from the tendon center of the perineum, covers the bulbs of the vestibule, passes the lateral opening of the vagina and attaches to the albuginea of ​​the clitoris.

♦ Legs of the penis (crura penis)[clitoral legs (crura clitoridis)] are located under the ischiocavernosus muscle and are attached to the lower branches of the pubic bones.

♦ In the center of the area in men under the bulbous-spongy muscle is the bulb of the penis (bulbus penis). In women, under the muscle of the same name, there is a lobe of the bulb of the vestibule (bulbus vestibuli) and a large gland of vestibule (gl. vestibularis major).

♦ Perineal nerves (pp. perineales) depart from the pudendal nerve (n. pudendus). innervate the muscles of the perineum and

give posterior scrotal (labial) nerves innervating the skin [pp. scrotales (labiates) posteriores.♦ Perineal artery (a. perinealis), branch of the internal pudendal artery (a. pudenda interna), enters the superficial space of the perineum from the side of the ischiorectal fossa, in the anterior part of the urogenital triangle gives off the posterior scrotal (labial) branches .

Inferior fascia of the urogenital diaphragm
(perineal membrane) from below
lines the deep transverse muscle
perineum, separating the superficial
crotch space (spatium perinei
superficialis) from deep.

* Deep perineal space (spatium
perinei profundum) contains a deep ass
river muscle of the perineum, sphincter mo
urethra (i.e. transversus
perinei profundus et m. sphincter urethrae), bul-

borethral glands (gl. bulbourethralis) in men, or large vestibular glands (gl. vestibularis major) in women, as well as vessels and nerves (Fig. 13-38).

♦ Deep transverse perineum (t. transversus perinei profundus) - a thin flat muscle, starts from the branches of the pubic and ischial bones and fuses along the midline with the same muscle of the opposite side, is attached to the tendon center of the perineum from behind; gives strength to the urogenital diaphragm. Innervated by branches of the pudendal nerve (n. pudendus).

♦ Urethral sphincter (i.e. sphincter urethrae) surrounds the membranous part of the urethra. Innervated by branches of the pudendal nerve (n. pudendus).

♦ Bulbourethral glands in men (gl. bulbourethralis) are located above the back of the bulb of the penis behind the membranous part of the urination;

body channel. The excretory ducts of the bulbourethral glands pass through the inferior fascia of the urogenital diaphragm and open in the region of the bulb into the spongy part of the urethra.

♦ Women have large vestibule glands (gl. vestibularis major) located behind the lobes of the bulb of the vestibule (bulbus vestibuli), excretory ducts open on the threshold of the vagina on the border of the posterior and middle thirds of the labia minora.

♦ Arteries and nerves leading to the penis (clitoris):

Internal pudendal artery (a. pudenda interna) from behind, from the ischiorectal fossa, it enters the deep space of the perineum and goes forward, where it divides into the deep and dorsal arteries of the penis (clitoris) 5. Inferior fascia of the urogenital diaphragm (perineal membrane) 3. Deep perineal space (spatium perinei orofundum), containing deep transverse perineal muscle and urethral sphincter t. transversus perinei profundus et m. sphincter urethrae) 6. Deep perineal space (spatium perinei pro-fundum), containing deep transverse perineal muscle and urethral sphincter (i.e. transversus perinei profundus et m. sphincter urethrae) 7. Superior fascia of the urogenital diaphragm (fascia diaphragmatis urogenitalis superior) 7. Superior fascia of the urogenital diaphragm (fascia diaphragmatis urogenitalis superior) 3. Inferior fascia of the pelvic diaphragm (fascia diaphragmatis pelvis inferior) 8. Inferior fascia of the pelvic diaphragm (fascia diaphragmatis pelvis inferior) Uh, levator ani (t. levator ani), presented in the genitourinary region by the pubic-coccygeal muscle (i.e. pubococcygeus) 9. Muscle that lifts the anus (t. levator ani), presented in the genitourinary region by the pubococcygeal muscle (i.e. pubococcygeus) (fascia diaphragmatis pelvis superior) 10. Superior fascia of the pelvic diaphragm (fascia diaphragmatis pelvis superior) 11. Prostate capsule (capsula prostatica) 11. No 12. Prostate gland (prostate) 12. No 13. Bladder (fundus vesicae urinariae) 13. The bottom of the bladder (fundus vesicae urinariae)

surrounding areas, has sebaceous glands. The fleshy membrane lines the skin of the scrotum from the inside, is a continuation of the subcutaneous connective tissue, devoid of fat, contains a large number of smooth muscle cells and elastic fibers. The fleshy membrane forms the septum of the scrotum (septum scroti), dividing it into two parts, into each of them in the process of lowering the testicles (descensus testicularum) testicles surrounded by shells (testis) with an epididymis (epididymis) and spermatic cord (funiculus spermaticus).

Layered structure of the scrotum(rice. 13-39)

Leather (derma).

fleshy shell (tunica dartos), gathering the skin into folds.

External seminal fascia (fascia spermatica externa) - superficial fascia descending into the scrotum (fascia superficialis).

Fascia of the muscle that lifts the testis (fascia