The endopelvic fascia and the pelvic ligaments Fig 107

Pelvic fascia is the term applied to the connective tissue floor of the pelvis covering levator ani and obturator internus. The endopelvic fascia is the extraperitoneal cellular tissue of the uterus (the parametrium), vagina, bladder and rectum. Within this endopelvic fascia are three important condensations of connective tissue which sling the pelvic viscera from the pelvic walls.

1 The cardinal ligaments (transverse cervical, or Mackenrodt's ligaments), which pass laterally from the cervix and upper vagina to the side walls of the pelvis along the lines of attachment of levator ani, are composed of white fibrous connective tissue with some involuntary muscle fibres and are pierced in their upper part by the ureters.

Pouch of Douglas

Bladder

Sacrum

Uterus

Pouch of Douglas

Bladder

Sacrum

Uterus

Cardinal Ligament

Pubocervical fascia

Uterosaerat ligament

Cardinal ligament

Rectum

Fig. 107 The pelvic ligaments seen from above.

Pubocervical fascia

Uterosaerat ligament

Cardinal ligament

Rectum

Fig. 107 The pelvic ligaments seen from above.

2 The uterosacral ligaments, which pass backwards from the posterolateral aspect of the cervix at the level of the isthmus and from the lateral vaginal fornices deep to the uterosacral folds of peritoneum in the lateral boundaries of the pouch of Douglas, are attached to the periosteum in front of the sacroiliac joints and the lateral part of the third piece of the sacrum.

3 The pubocervical fascia extends forward from the cardinal ligament to the pubis on either side of the bladder, to which it acts as a sling.

These three ligaments act as supports to the cervix of the uterus and the vault of the vagina, in conjunction with the important elastic muscular foundation provided by levator ani. In prolapse these ligaments lengthen (in procidentia — complete uterine prolapse—they may be 6 in (15 cm) long) and any repair operation must include their reconstitution.

Two other pairs of ligaments take attachments from the uterus.

1 The broad ligament is a fold of peritoneum connecting the lateral margin of the uterus with the side wall of the pelvis on each side. The uterus and its broad ligaments, therefore, form a partition across the pelvic floor dividing off an anterior compartment, containing bladder (the uterovesical pouch), from a posterior compartment, containing rectum (the pouch of Douglas or recto-uterine pouch).

The broad ligament contains or carries (Figs 104, 106):

• the Fallopian (uterine) tube in its free edge;

• the ovary, attached by the mesovarium to its posterior aspect;

• the ovarian ligament, crossing from the ovary to the uterine cornu (see ovary);

• the uterine vessels and branches of the ovarian vessels;

• lymphatics and nerve fibres.

The ureter passes forwards to the bladder deep to this ligament and lateral to and immediately above the lateral fornix of the vagina.

2 The round ligament—a fibromuscular cord—passes from the lateral angle of the uterus in the anterior layer of the broad ligament to the internal inguinal ring; thence it traverses the inguinal canal to the labium majus. Taken together with the ovarian ligament, it is equivalent to the male gubernaculum testis and can be thought of as the pathway along which the female gonad might have, but in fact did not, descend to the labium majus (the female homologue of the scrotum). Compare this process to descent of the testis, (page 121).

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