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Normal Anatomy of the Female Pelvis and Sonographic Demonstration of Pelvic Abnormalities
Published in Asim Kurjak, Ultrasound and Infertility, 2020
Other anatomical structures that can be consistently demonstrated by sonography within lesser pelvis are the pelvic musculature and blood vessels. Visualization of these structures is less important from a clinical standpoint. The obturator internus muscle occupies a large part of the anterior and lateral pelvic walls and is demonstrated as a well-defined hypoechoic ovoid structure. The levator ani muscle is seen on a transverse scan at the level of the cervix and vaginal fornices and denotes the pelvic diaphragm. Other muscles forming the pelvic diaphragm are rarely seen because of their deep position.
Pelvis
Published in Harold Ellis, Adrian Kendal Dixon, Bari M. Logan, David J. Bowden, Human Sectional Anatomy, 2017
Harold Ellis, Adrian Kendal Dixon, Bari M. Logan, David J. Bowden
This section shows well the obturator internus muscle (25) as it sweeps around the lesser sciatic foramen, with the sciatic nerve (20) lying on its superficial (posterior) face, covered posteriorly by gluteus maximus (21).
Injuries of the pelvis
Published in Ashley W. Blom, David Warwick, Michael R. Whitehouse, Apley and Solomon’s System of Orthopaedics and Trauma, 2017
This is an extension of the posterior approach used in hip arthroplasty. It can be performed in the lateral or prone positions. It provides access to the posterior wall and entire posterior column of the acetabulum (Figure 29.31). The sciatic nerve should be exposed from the greater sciatic notch proximally to beneath the gluteal insertion on the femur distally. Care must be taken not to cauterize branches of the posterior circumflex femoral artery when detaching the short external rotators. The hip joint capsule must be left intact. Lifting the obturator internus muscle away from the bone will expose the ischial tuberosity — the hamstring tendons provide a useful marker of the distal extension of the approach. Proximal exposure involves dissecting the gluteus medius and minimus muscles away from the bone. Care must also be taken not to place the superior gluteal neurovascular bundle under too much traction as this will lead to nerve palsy. Utilizing the trochanteric ‘flip’ where the abductors are detached with a sliver of bone is kinder to these muscles in well-built individuals rather than fighting them through the procedure with retractors. This technique also allows a surgical dislocation of the hip joint.
Ten-Step Surgical Approach to Management of Pathology of the Ischiorectal Fossa—A Review of the Literature and Application in a Rare Pelvic Schwannoma
Published in Journal of Investigative Surgery, 2022
Sarah Louise Smyth, Sunanda Dhar, Miss Lucy Cogswell, Hooman Soleymani majd
The transichiorectal approach provides direct access to Alcock’s canal with minimal pelvic muscle and ligament disruption [5, 7]. The procedure requires an in-depth knowledge of the pelvic anatomical spaces [4]. The pudendal nerve arises from the S2-4 sacral nerve and travels forward laterally in the pelvis within the obturator internus fascial sheath [8]. It has both motor and sensory functions. The ischiorectal fossa is a pyramidal space lateral to the anal canal and below the pelvic diaphragm with the apex at the anal canal and obturator fascia boundary, and the base at the perineal surface. It is bound medially by the levator ani, external anal sphincter and anal fascia, laterally by the ischial tuberosity and obturator internus muscle, anteriorly by the urogenital diaphragm fascia and Colles’ transverse perineal muscle fascia and posteriorly by the gluteus maximus and sacrotuberous ligament [2, 9]. It contains the internal pudendal, posterior labial and inferior rectal vessels and nerve, the perineal S4 branch, the perforating cutaneous nerve and lymphatic tissue [1, 3].
An update on research and outcomes in surgical management of vaginal mesh complications
Published in Expert Review of Medical Devices, 2019
Dominic Lee, Philippe E. Zimmern
Intraoperative ultrasound can be utilized to assist in locating the MUS if identification during surgery proves difficult. This is especially so when a MUS placed long ago has embedded into the urethral wall or rolled on itself and displace proximally near the bladder neck and is not visible or palpable on the outer surface of the urethra. To minimize the risk of urethral injury, we start our sling localization laterally at the 3 or 9 o’clock position and divide the sling there. Identification of the sling at either of these locations appeared to minimize the risk of urethral injury. Surgical loops may be beneficial in the identification and dissection of the sling during its removal. Once the division of one side of the urethra is achieved, the sling can be carefully peeled off the under surface of the urethra from one side to the opposite side using diathermy on low current. We aim for maximal sub-urethral sling excision and the lateral extensions of the TOT mesh towards the obturator internus muscle or the retropubic tape extensions of the TVT is left intact since this has not been necessary in our experience. If the mesh was a mini-sling, we were able to completely remove the mesh in all cases [27]. Urethro-cystoscopy was repeated. If no urethral injury is visible, the urethral catheter is replaced, and the vaginal incision is closed, followed by a vaginal pack insertion for tamponade effect.
Investigation of pelvic floor disorders
Published in Climacteric, 2019
The use of two-dimensional ultrasound provides an important insight into the pathophysiology of prolapse. Athanasiou et al.42 showed that the anatomy, morphology, and levator hiatus can be reliably imaged using two-dimensional ultrasound, reporting that the levator hiatal area is significantly larger in women with POP versus controls and is correlated with prolapse severity. The advances of three- and four-dimensional ultrasound enhanced the visibility of the pelvic floor, either in real time during the examination or offline at a later time24. Tomographic ultrasound imaging allows processing of imaging information into parallel slices of a predetermined number and spacing, similar to computed tomography or magnetic resonance imaging (MRI)43. It has been shown that major morphological abnormalities of levator structure and function are common in vaginally parous women. More specifically, levator trauma due to vaginal delivery results in a disconnection of the levator ani from its insertion on the inferior pubic ramus (avulsion) and detachment of the iliococcygeus muscle from the arcus tendineus levator ani over the obturator internus muscle44. Dietz et al.45–47 proposed an assessment system based on the depth and width of the levator ani defects and found an association with the likelihood of symptoms of POP. Another sonographic finding is the degree of hiatal distension on Valsalva maneuver. Hiatal enlargement to >25 cm2 on Valsalva maneuver is defined as ‘ballooning’48,49. The degree of distension has been found to be strongly associated with POP severity, symptoms of POP, and prolapse recurrence after reconstructive surgery50.