GynOnc

(3) layers of the uterus

(1) Endometrium lining of the uterine cavity, with a superficial layer that consists of glandular epithelium and stroma. (2) Myometrium - The myometrium is the thickest layer of the uterus, composed of smooth muscle fibers that are oriented diagonally and crisscross with fibers from the contralateral side of the uterus. (3) Serosa - thin outer lining layer of the uterus, investing the body of the uterus, consisting of visceral peritoneum.

(3) physiologic narrowings of the utreter (greatest concern for stricture, stones)

(1) the ureteropelvic junction, (2) the crossing over the iliac vessels, and (3) the ureterovesical junction

Posterior division of internal iliac

-Iliolumbar -Lateral sacral -Superior gluteal

External iliac (2 + terminal branch)

-Inferior epigastric -Deep circumflex iliac -Becomes femoral nerve after crossing under the inguinal ligament

Superior mesenteric (just think of this as supplying the small bowel and up to the transverse colon) (6)

-Inferior pancreaticoduodenal -Jejunal -Ileal -Ileocolic (colic, anterior cecal, posterior cecal, ileal branch, appendiceal artery) -Right colic -Middle

Inferior mesenteric (the rest of the colon - left side and distal) (3)

-Left colic -Sigmoid -Superior rectal

Anterior division of internal iliac

-Uterine -Superior vesicle -Inferior vesicle (aka vaginal) -Middle rectal -Obturator -Internal pudendal -Inferior gluteal

Vessels of the celiac trunk (3 main vessels and their branches)

1. Common hepatic (branches = gastroduodenal, right gastric, and right gastroepiploic (from gastroduodenal) 2. Splenic (branches = left gastroepiploic, short gastrics, pancreatic branches) 3. Left gastric (branches = esophageal branches)

8 potential spaces

1. Retropubic space (of Retzius) 2. Paravesicle space 3. Pararectal space 4. Vesicovaginal space 5. Rectovaginal space 6. Presacral space

Greater omentum A. Location B. Contents

A. "Apron" from greater curvature of stomach, drapes over intestines, reflects on itself and comes back to meet the transverse colon B. Covers small and large intestines

During a hysterectomy and an oophorectomy, the uterine and ovarian vessels must be ligated. These vessels can be found in which ligaments?

A. Broad ligament: contains uterine vessels B. Suspensory ligaments of the ovaries (aka. infundibulopelvic ligaments): contains ovarian vessels

Lesser omentum A. Location B. Contents

A. Double-layer extension of peritoneum connecting lesser curvature of stomach & first part of duodenum to the liver B. Hepatogastric and hepatoduodenal ligaments (portal triad: portal vein, hepatic artery, CBD)

Round ligament of liver (ligamentum teres) A. Origin and insertion B. Remnant

A. Extension of the falciform ligament B. Umbilical vein

Significance of following fallopian tube structures: A. Fimbria B. Infundibulum C. Tubal ampulla D. Tubal isthmus (closes to uterus)

A. Fimbria: site for tubal occlusion in PID B. Infundibulum: attachment site for infundibulopelvic ligament C. Tubal ampulla: MC site for ectopic pregnancy D. Tubal isthmus: ligated for sterilization 2-3 cm from cornual-tubal insertion

Abdominal cavity A. What are the greater and less sacs? B. Entrance into less sac

A. Greater sac: space between anterior abdominal wall and internal organs. Lesser sac (omental bursa) is space between posterior stomach and anterior pancreas B. Epiploic (omental) foramen (aka. foramen of Winslow) passage between greater and lesser sacs, found under caudate liver and above duodenum

Blood supply to the A. Superior rectum B. Middle and inferior rectum

A. IMA (inferior mesenteric artery) B. Hypogastric/internal iliac arteries

Falciform ligament A. Origin and insertion B. Divides what 2 spaces?

A. Liver to anterior abdominal wall and encloses round ligament of the liver B. Left and right subphrenic recesses

Chemo options for cervical cancer A. Local recurrence B. Metastasis

A. Local recurrence: surgery or radiation preferred (chemo if not candidate) B. Metastatic disease: cisplatin + paclitaxel OR carboplatin + paclitaxel (Carbo/Taxol) AND bevacizumab (angiogenesis inhibitor)

Fertility sparing options for endometrial cancer A. Good candidates B. Strategy

A. Low-risk endometrial carcinoma = grade 1 or 2, endometrioid endometrial carcinoma, confined to the endometrium B. Progestin therapy with medroxyprogesterone acetate [MPA] or megestrol acetate and deferral of surgical staging (hysterectomy, BSO) until after completion of childbearing

Abd recesses A. Space between liver anteriorly from kidney posteriorly B.

A. Morrison pouch (hepatorenal recess) B. Subphrenic recesses (space between anterior liver and diaphragm, divided into right and left sides by falciform ligament)

Abdominal intraperitoneal/ infraperitoneal viscera A. Definition B. Organs

A. Organs connected by peritoneal folds (parietal and visceral folds of same sheet), including omenta, mesenteries, ligaments B. Stomach, duodenum (1st, and 4th parts), jejunum, ileum, cecum, appendix, transverse colon, sigmoid colon, and the upper third of the rectum + liver, spleen, and the tail of the pancreas.

Round ligament of the uterus A. Origin and insertion B. Function C. Arterial supply D. Found between double layers of what ligament?

A. Originates at the uterine horns >> leaves the pelvis via the deep inguinal ring >> passes through the inguinal canal and continues on to the labia majora >>where its fibers spread and mix with the tissue of the mons pubis B. Flexion of the uterus during pregnancy C. Sampson artery (anastomosis of uterine and ovarian arteries) D. Broad ligament

Abdominal aorta A. Branches and levels B. Bifurcation

A. Paired: middle suprarenal arteries (L1), renal arteries (L1), gonadal/ovarian arteries (L2) Unpaired: median sacral (L4) Paired: inferior phrenic (T12), lumbar (4 pairs) B. L & R common iliac arteries (L4)

Borders of the A. Paravescile space B. Pararectal space

A. Paravesicle space: anterior - pubic rami, posterior - cardinal ligament, medial - obliterated umbilical artery (but basically the bladder pillars), lateral - external iliac vessels/obturator internus B. Pararectal space: anterior - cardinal ligament, posterior - sacrum, medial - rectum, lateral - hypogastric/internal iliac artery

Internal iliac A. 2 divisions B. Location of division

A. Posterior and anterior division of internal iliac aa. B. 3-4 cm after the common iliac bifurcation

Borders of A. Retropubic space (of Retzius) B. Presacral (retrorectal) space

A. Retropubic space (of Retzius): anterior - pubic ramus, posterior bladder B. Presacral space: anterior - distal sigmoid mesentery/posterior rectal fascia, posterior - sacrum, lateral - pararectal spaces

Venous drainage: A. Right ovarian vein B. Left ovarian vein

A. Right ovarian vein drains to IVC B. Left ovarian vein drains to left renal vein

Fertility sparing options for cervical cancer A. Tx based on stage B. Stats: success rate C. Delivery

A. Stage IA1 disease (no lymphovascular space involvement) >>cervical cold knife conization. Stage IA1 with LVSI or stage IA2 to IB1 at low risk of cancer recurrence (ie, lesion size <2 cm; no lymph node metastases) >> radical trachelectomy with placement of cervical cerclage B. ~2/3 pregnancies following vaginal radical trachelectomy (VRT) are expected to reach the third trimester. 50% of all pregnancies will end up with the birth of a healthy newborn at term. Rates of second trimester miscarriage and preterm birth are higher than in the general obstetric population. C. Cesarean delivery is performed at 37 to 38 weeks of gestation (avoid vaginal delivery due to increased risk of a lateral cervical tear in the short scarred cervix may extend into the uterine vessels > hemorrhage)

Abdominal retroperitoneal viscera A. Definition B. Organs: SAD PUCKER

A. Structures not suspended by mesentery in the abdominal cavity and that lie between the parietal peritoneum and abdominal wall; relatively immobile B. S= Suprarenal glands (aka the adrenal glands) A = Aorta/IVC D = Duodenum (second and third segments) P = Pancreas (only head, neck, and body. Tail is intraperitoneal) U = Ureters C = Colon (only the ascending and descending colons, as transverse and sigmoid retain mesocolon) K = Kidneys E = Esophagus R = Rectum (By system: aorta/IVC, esophagus > duodenum > colon > rectum, pancreas, adrenal glands, kidneys, ureters)

Left renal vein can be compressed by the ____ artery and cause _____

A. Superior mesenteric artery B. Nutcracker syndrome

Fertility sparing options for ovarian cancer A. Good candidates B. Strategy

A. Tumors with low malignant potential, nonepithelial ovarian cancers, or Stage 1A EOC B. Surgery: unilateral salpingo-oophorectomy is considered considered, but full surgical staging, including washings, omentectomy, appendectomy, and node biopsies, should be done and should be negative

Borders of A. Vesicovaginal space B. Rectovaginal space

A. Vesicovaginal space: anterior - bladder, posterior - vagina/cervix, lateral - bladder pillars B. Rectovaginal space: anterior - vagina, posterior - rectum, lateral - rectal pillars and uterosacrals

Borders of foramen of Winslow (between liver and duodenum)

Anterior: hepatoduodenal ligament (containing CBD, hepatic artery and portal vein) Posterior: peritoneum of IVC Superior: peritoneum of caudate liver Inferior: duodenum and hepatic artery Left later: gastrosplenic ligament and splenorenal ligament

What is the landmark for the level of the uterine artery?

Cervical os

Structure anterior to the rectum felt on manual exam

Cervix (feel for nodules suggestive of cervical cancer)

Embryonic origin of round ligaments

Gubernaculum

Blood supply to: Anterior abdominal wall

Inferior epigastrics (from external iliac), superior epigastrics (from internal thoracic artery), and deep circumflex iliac

Attaches ovary to pelvic sidewall

Infundibulopelvic (IP) ligament (aka. suspensory ligament of the ovary)

National Dysphagia Diet (levels)

Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability) >> most restrictive Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing) Level 3: Dysphagia-Advanced (soft foods that require more chewing ability) Level 4: Regular (all foods allowed)

What part of the broad ligament supports the fallopian tube?

Mesosalpinx

Chemo options for endometrial carcinoma

Only for high risk (stage III) endometrial cancer: carboplatin + paclitaxol (Carbo/taxol). Can enroll in clinical trials with +/- cisplatin and RT *Note: low risk >> surgery, intermediate risk >> radiation therapy (RT)

Chemo options for advanced stage epithelial ovarian cancer (EOC) e.g. Stage III, IV

Options: NACT, surgery, adjuvant chemo. Chemo of choice: carbo/taxol (carboplatin + paclitaxel)

Source of ovarian arteries (think gonadal arteries)

Ovarian arteries branch from the aorta

Ultrasound imaging reveals a cyst-like structure in the right uterine tube which you feel may be a tubal pregnancy. In order to confirm your diagnosis and to remove the tubal embryo, you can gain access to the patient's lower pelvic cavity by passing the culdoscope through:

Pass a culdoscope through vagina and the posterior fornix to gain entry into the rectouterine pouch. Can remove ectopic pregnancies this way.

FAST scan for free fluid

Perihepatic space (hepatorenal recess, Morison's pouch), perisplenic space, pericardium, and pelvis (especially rectovesicular or rectouterine space in supine pt)

Porta hepatis contents

Portal vein, R&L branches of hepatic arteries, R&L hepatic ducts, hepatic nerve plexus + lymphatics (NOT hepatic veins)

Path of ureters from kidney to bladder dome

Renal pelvis (starts retroperitoneal) >> descend on top of the psoas major muscle to pelvic brim >> cross OVER the common iliac arteries >> down along the sides of the pelvis >> curve forwards (anteriormedially into intraperitoneal space) >> ureters pass through mesometrium and UNDER uterine arteries (water under the bridge) >> enter the bladder from its left and right sides at the back of the bladder.

Blood supply to: Ureter

Small branches from common iliac, hypogastric, uterine, and superior/inferior vesicle arteries

Boarders of Morison's pouch (hepatorenal recess)

Space separating liver from right kidney that may become filled with fluid (blood, ascites) seen with U/S or CT.

Blood supply to: Rectum

Superior rectal (IMA), inferior/middle rectals (hypogastric)

Most common locations of ureteral injury in gyn cases

The most common sites of injury include: (1) the pelvic brim area during clamping of the infundibulopelvic (IP) ligament (2) the isthmic region during uterine artery ligation (3) the pelvic sidewall during suturing of the uterosacral ligament, and (4) the vaginal apex during clamping or suturing of the vaginal cuff.

Para-aortic lymph node dissection

Up to the level of the renals from the bifurcation of the aorta

During a hysterectomy, care must be taken in ligation of the uterine vessels because they cross the _________ superiorly

Ureter: "Water under the bridge". The uterine vessels cross over the ureter as the ureters pass through the base of the mesometrium.

Loss of this support leads to prolapse of the uterus

Uterosacral/cardinal ligament complex suspends the uterus and upper vagina in its normal orientation. It serves to maintain vaginal length and keep the vaginal axis nearly horizontal in a standing woman so that it can be supported by the levator plate

During abdominal hysterectomy, the ____________ is dissected to create the bladder flap, access the__________ space, and dissect the bladder off the lower uterine segment and anterior cervix

Vesicouterine fold, Vesicovaginal space