Internal iliac Medial bifurcation of Descends sharply into the pelvis; Posterior division Deep to arteries, from (hypogastric) common iliac artery, divides into an anterior and 1. Iliolumbar—anastomoses with lumbar and complex plexus; drain artery begins opposite the posterior division 3–4 cm after deep circumﬂex iliac arteries; helps supply into common iliac lumbosacral joint; is origin lower abdominal wall, iliac fossa veins major blood supply to 2. Lateral sacral—supplies contents of sacral the pelvis canal, piriformis muscle 3. Superior gluteal—supplies gluteal muscles
Anterior division: 1. Obturator—supplies iliac fossa, posterior pubis, obturator internus muscle 2.
3.
Umbilical—remnant of fetal umbilical artery; after giving off branches, as the medial umbilical ligament 4. Superior, middle, inferior vesical—supply bladder and one or more branches to the ureter 5. Middle rectal (hemorrhoidal)—suppliesrectum, branches to midvagina 6.
Uterine—supplies uterine corpus and cervix, with branches to upper vagina, tube, round ligament, and ovary 7.
8. Inferior gluteal—supplies gluteal muscles, muscles of posterior thigh
Internal pudendal Internal iliac artery; artery provides the major blood supply to the perineum
Leaves the pelvis through the greater sciatic foramen, courses around the ischial spine, and enters the ischiorectal fossa through the lesser sciatic foramen. In its path to the perineum, lies with the pudendal nerve within Alcock’s canal, a fascial tunnel over the obturator internus muscle 1. Inferior rectal (hemorrhoids)—supplies anal Drain into internal iliac canal, external anal sphincter, perianal skin, veins with branches to levator ani 2. Perineal—supplies perineal skin, muscles of superficial perineal compartment (bulbocavernosus, ischiocavernosus, superficial transverse perineal) 3. Clitoral—supplies clitoris, vestibular bulb, Bartholin gland, and urethra
Middle sacral Midline unpaired vessel Courses over lower lumbar vertebrae, Supplies bony and muscular structures of Paired middle sacral artery arising from posterior sacrum, and coccyx posterior pelvic wall veins usually drain into terminal aorta left common iliac vein
Lumbar arteries Segmental branches Pass around the side of the 4 superior Supplies abdominal wall musculature Veins into inferior vena arising at each lumbar lumbar vertebrae, divide into (external/internal oblique, transversus cava level from posterior anterior and posterior branches abdominis) aorta
General Principles “Control blood supply” and “maintain meticulous hemostasis” are two of the most common exhortations to young surgeons. In developing familiarity with the pattern of blood ﬂow in the pelvis, several unique characteristics of this vasculature should be understood because of their potential implications to surgical practice: 1.
The pelvic vessels play an important role in pelvic support. They provide condensations of endopelvic fascia that act to reinforce the normal position of pelvic organs (16).
2.