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  • Print publication year: 2018
  • Online publication date: February 2018

1 - Surgical Anatomy of the Female Pelvis

from Section 1 - Basic Gynecologic Care Issues



A three-dimensional conceptual understanding of the abdomen and pelvis is essential for the gynecologic surgeon. Few things in medicine remain as constant as the anatomy. Yet there are nuances such that knowledge can be gained throughout one's entire career. This chapter will present the anatomy of the abdominal wall and of the female pelvis. The review focuses on benign gynecologic surgery.

Scope of the Problem

A common line in most consent forms for gynecologic surgical procedures includes “risk of bleeding, infection, injury to other organs including bowel, bladder, ureter, blood vessels, and nerves.” In the interest of patient safety and excellent health care, there is an increasing move nationally toward compensation being tied to outcomes. Surgical outcomes are a major component of this. A thorough understanding of anatomy will help to avoid complications, will improve surgical outcomes, and will provide safe and effective health care.

Abdominal Anatomy


The anterior abdominal wall is comprised of the internal and external oblique muscles, the transversus abdominis, and two strap-like muscles – the rectus abdominus and the pyramidalis. The pyramidalis provides minimal support to the abdominal wall. The oblique muscles and transversus abdominis serve, among other functions, to increase intraabdominal pressure to assist with respiration. The muscles insert centrally into the linea alba. Therefore a midline incision will interrupt this support and the suture line will be under greater tension than a transverse incision. The fascia of the internal oblique splits at the rectus muscle and travels anterior and posterior to the rectus muscle helping to form the rectus sheath. Inferior to the arcuate line, at about the level of the anterior superior iliac spine, the aponeurosis of this muscle passes only anterior to the rectus muscle. The fascia of the transversus abdominis passes behind the rectus muscle, fusing with the posterior portion of the internal oblique aponeurosis before contributing to the linea alba. At the level of the arcuate line it passes anterior to the rectus muscles. Below the arcuate line the abdominal wall is weaker and more susceptible to hernia formation. [1]


The inferior epigastric artery arises from the external iliac artery at the level of the inguinal ring and travels anteromedially to enter the transversalis fascia. It then travels along the lateral border of the rectus inferiorly before entering the rectus sheath at the arcuate line.

1. Delancey, JOL. Te Linde's Operative Gynecology. 11th ed. Philadelphia: Wolters Kluwer; c. 2015. Ch. 7, Surgical Anatomy of the Female Pelvis; pp. 93–122.
2. Wong, C, Merkur, H. Inferior epigastric artery: surface anatomy, prevention and management of injury. Australian & New Zealand Journal of Obstetrics & Gynaecology. 2016 Apr;56(2):137–141.
3. Cardosi, RJ, Cox, CS, Hoffman, MS. Postoperative neuropathies after major pelvic surgery. Obstetrics & Gynecology. 2002 Aug. 1;100(2):240–244.
4. Hurd, WW, Bude, RO, Delancey, JOL, Pearl, ML. The relationship of the umbilicus to the aortic bifurcation: implications for laparoscopic technique. Obstetrics & Gynecology. 1992 Jul. 1;80(1):48–51.
5. Palmer, R. Safety in laparoscopy. Journal of Reproductive Medicine. 1974 Jul. 1;13(1):1–5.
6. Dietrich, CS, Gehrich, A, Bakaya, S. Surgical exposure and anatomy of the female pelvis. Surgical Clinics of North America. 2008 Apr 30;88(2):223–243.
7. Reiffenstuhl, G. Gynecologic, Obstetric, and Related Surgery. 2nd ed. St. Louis: Mosby, Inc.; c. 2000. Ch. 2, Pelvic Anatomy for the Gynecologic Surgeon; pp. 27–68.
8. Lower, A. Gynaecology: Expert Consult: Online and Print. Elsevier Health Sciences; c. 2010. Ch. 1, Surgical Anatomy; pp. 1–16.
9. Moore, KL, Dalley, AF, Agur, AM. Clinically Oriented Anatomy. Lippincott Williams & Wilkins; c. 2013. Ch. 3, Pelvis and Perineum; pp. 361–424.
10. Siomou, E, Papadopoulou, F, Kollios, KD, Photopoulos, A, Evagelidou, E, Androulakakis, P, Siamopoulou, A. Duplex collecting system diagnosed during the first 6 years of life after a first urinary tract infection: a study of 63 children. The Journal of Urology. 2006 Feb. 28;175(2):678–682.
11. Vakili, B, Chesson, RR, Kyle, BL, Shobeiri, SA, Echols, KT, Gist, R, Zheng, YT, Nolan, TE. The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. American Journal of Obstetrics and Gynecology. 2005 May 31;192(5):1599–1604.
12. Adelman, MR, Bardsley, TR, Sharp, HT. Urinary tract injuries in laparoscopic hysterectomy: a systematic review. Journal of Minimally Invasive Gynecology. 2014 Aug 31;21(4):558–566.
13. Rothmund, R, Huebner, M, Kraemer, B, Liske, B, Wallwiener, D, Taran, FA. Laparoscopic transection and immediate repair of obturator nerve during pelvic lymphadenectomy. Journal of Minimally Invasive Gynecology. 2011 Dec 31;18(6):807–808.
14. Gallup, DG, Freedman, MA, Meguiar, RV, Freedman, SN, Nolan, TE. Necrotizing fasciitis in gynecologic and obstetric patients: a surgical emergency. American Journal of Obstetrics and Gynecology. 2002 Aug 31;187(2):305–311.