Figure 5.24 Schematic sectional drawing of the pelvis shows the firm connective tissue covering. The bladder, cervix, and rectum are surrounded by a connective tissue covering. The Mackenrodt ligament extends from the lateral cervix to the lateral abdominal pelvic wall. The vesicouterine ligament originating from the anterior edge of the Mackenrodt ligament leads to the covering of the bladder on the posterior side. The sagittal rectum column spreads both to the connective tissue of the rectum and the sacral vertebrae closely nestled against the back of the Mackenrodt ligament and lateral pelvic wall. Between the firm connective tissue bundles is loose connective tissue (paraspaces). (From Von Peham H, Amreich JA. Gynaekologische Operationslehre. Berlin, Germany: S Karger, 1930, with permission.) anterior wall of the bladder. It is separated from the paravesical space by the ascending bladder septum (bladder pillars).
Upon entering the prevesical space, the pubourethral ligaments may be seen inserting into the posterior aspect of the symphysis pubis as a thickened prolongation of the arcus tendineus fascia. With combined abdominal and vaginal bladder neck suspensory procedures, the point of entry is usually the Retzius space between the arcus tendineus and the pubourethral ligaments.
Rectovaginal Space The rectovaginal space extends between the vagina and the rectum from the superior border of the perineal body to the underside of the rectouterine Douglas pouch. It is bound anteriorly by the rectovaginal septum (firmly adherent to the posterior aspect of the vagina), posteriorly by the anterior rectal wall, and laterally by the descending rectal septa separating the rectovaginal space from the pararectal space on each side. The rectovaginal septum represents a firm membranous transverse septum dividing the pelvis into rectal and urogenital compartments, allowing the independent function of the vagina and rectum and providing support for the rectum. It is fixed laterally to the pelvic sidewall by rectovaginal fascia (part of the endopelvic fascia) along a line extending from the posterior fourchette to the arcus tendineus fasciae pelvis, midway between the pubis and the ischial spine (42). An anterior rectocele often results from a defective septum or an avulsion of the septum from the perineal body. Reconstruction of the perineum is critical for the restoration of this important compartmental separation and for the support of the anterior vaginal wall (43). Lateral detachment of the rectovaginal fascia from the pelvic sidewall may constitute a “pararectal” defect analogous to anterior paravaginal defects.
Presacral Space The presacral space is the superior extension of the retrorectal space and is limited by the deep parietal peritoneum anteriorly and the anterior aspect of the sacrum posteriorly. It harbors the middle sacral vessels and the hypogastric plexi between the bifurcation of the aorta invested by loose areolar tissue. Presacral neurectomy requires familiarity with and working knowledge of this space. Abdominal sacrocolpopexy involves dissection in the presacral space down to the anterior longitudinal ligament, which is the point of fixation for the tail of the Y-shaped mesh graft. The surgical space is bound superiorly by the bifurcation of the great vessels and laterally by the ureter on the right and the mesentery of the sigmoid colon and the left common iliac vein on the left. The left iliac vein lies medial to the left iliac artery bounding this space and is more prone to injury during laparoscopic entry or presacral dissection.
Peritoneal Cavity The female pelvic organs lie at the bottom of the abdominopelvic cavity covered superiorly and posteriorly by the small and large bowel. Anteriorly, the uterine wall is in contact with the posterosuperior aspect of the bladder. The uterus is held in position by the following structures: 1.
The round ligaments coursing inferolaterally toward the internal inguinal ring 2.