3D ANATOMICAL BASIS FOR TRANSOBTURATOR SURGERIES3D ANATOMICAL BASIS FOR TRANSOBTURATOR SURGERIES

Prof. Paulo Palma

Paradigm shifts

1. Integral Theory, 1993 (Peter Petros)– Creating neoligaments using tapes– Reinforcement of pubourethral ligament– Midurethral tape placement.

2. Transobturator Approach, 2001 (Delorme)

- Reinforcement of urethropelvic ligament

- Less visceral and vascular complications

- Less irritative voiding symptoms

Sacro UterineSacro Uterine LigamentLigament

BladderBladder

UterusUterus

PP

Tendineous Tendineous ArcArc

PubourethralPubourethralLigamentLigament

SacruSacrumm

Urethropelvic LigamentUrethropelvic Ligament

VaginaVagina

Anterior Median Posterior

CompartimentsCompartiments

PP

Tendineous ArcTendineous Arc

SacrumSacrum

VaginaVagina

PubourethralPubourethralLigamentLigament

Urethropelvic LigamentUrethropelvic Ligament

Sacro Sacro UterineUterine

LigamentLigament

LIGAMENTSLIGAMENTS

RestRest

StrainingStraining

VoidingVoiding

1

2 3

4

1. Superficial Transverse 1. Superficial Transverse Muscle of perineumMuscle of perineum

2. Isquiocavernosous muscle2. Isquiocavernosous muscle

3. Bulbocavernosous Muscle3. Bulbocavernosous Muscle

4. External Anal Esfincter 4. External Anal Esfincter

First muscular layer

5

5.Deep Transversal5.Deep TransversalMuscle of perineum Muscle of perineum

Second Muscular LayerSecond Muscular Layer

6677

886. Pubovaginal6. Pubovaginal7. Puborectal7. Puborectal

8. Ileococcigeous8. Ileococcigeous

White LineWhite Line

RECTOVAGINAL FASCIARECTOVAGINAL FASCIA

VESICOVAGINAL FASCIAVESICOVAGINAL FASCIA

Bony Anatomy

Ischial tuberosity

Pubic Symphysis

Ischiopubic ramus

Obturator Canal

Muscular Anatomy

Clitoris

GracilisGracilisAdductor longus

Adductor magnus

Muscular Anatomy

Muscle Function Innervation

Adductor longusAdducts & flexes

thighObturator (L2,3)

Adductor brevisAdducts & flexes

thighObturator (L2,

3)

Adductor magnus

Adducts, extends, flexes & rotates

thigh

Obturator (L2, 3) & Tibial (L4,

5)

GracilisAdducts thigh,

flexes kneeObturator (L2,

3)

Obturator internus

Lateral rotator of thigh

Obturator (L5, S1)

Obturator externus

Lateral rotator of thigh

Obturator (L3, 4)

PectineusFlexes thigh, Adducts thigh

Femoral (L2, 3)

Obturator VesselsRetroperitoneal View

Obturator vessels

Obturator nerve

Obturator canal

Obturator Vascular Anatomy

Obturator - Neuroanatomy

• From anterior division of L2-4• Innervates all muscles of the obturator region,

except pectineus• Passes through obturator canal and splits to

innervate the muscles that adduct the thigh and help with external rotation

• Small sensory area on the medial thigh

PPTendineous Arc

Tendineous Arc

UterusUterus

VaginaVagina

Anterior aginal Wall Defects

PPTendineous Arc

Tendineous Arc

UterusUterus

VaginaVagina

LateralLateralDefectDefect

Anterior aginal Wall Defects

LateralDefect

Anterior aginal Wall Defects

PPTendineous Arc

Tendineous Arc

UterusUterus

VaginaVagina Central DefectCentral Defect

Central Defect

Central Defect

Central Defect: Treatment

PPTendineous Arc

Tendineous Arc

UterusUterus

VaginaVagina

Anterior Vaginal Prolapse (AVP)Anterior Vaginal Prolapse (AVP)

PubourethralPubourethralLigamentLigament

PP

UterusUterus

VaginaVagina Lateral DefectLateral Defect

Anterior Vaginal Prolapse (AVP)Anterior Vaginal Prolapse (AVP)

Central DefectCentral Defect

Tendineous Arc

Tendineous Arc

PP

UterusUterus

VaginaVagina

Anterior Vaginal Prolapse (AVP)Anterior Vaginal Prolapse (AVP)

Evaluation of pelvic floor reconstructive surgery using tridimentional helical CTEvaluation of pelvic floor reconstructive surgery using tridimentional helical CT

Fig 3. Notice the well supported bladder base and the TOT arms

PPTendineous Arc

Tendineous Arc

RectumRectum

UterusUterus

VaginaVagina

Levator ani

Levator ani

Posterior Posterior DefectDefect

Posterior Vaginal Prolapse (PVP)Posterior Vaginal Prolapse (PVP)

SacrospinalSacrospinalLigamentLigament

PPTendineous Arc

Tendineous Arc

RectumRectum

UterusUterus

VaginaVagina

Levator a

ni

Levator a

ni

Posterior Vaginal Prolapse RepairPosterior Vaginal Prolapse Repair

Evaluation of pelvic floor reconstructive surgery using tridimentional helical CTEvaluation of pelvic floor reconstructive surgery using tridimentional helical CT

Fig 4. Infracoccigeal sacropexy showing indirectly the “neo rectovagianl fascia”

Posterior sling

Anchoring

Tails

BladderBladderRectum

MeshMesh