Surgical anatomy of the female pelvis

It is 09:30 and you are the gynaecology registrar starting a total laparoscopic hysterectomy. The Veress is in, the camera shows a steep Trendelenburg view, the bowel has fallen out of the pelvis, and the round ligament sits in the foreground. The consultant points: "Find me the ureter and open the pararectal space." This topic is the anatomy you need before that first cut — and the anatomy you name out loud at the viva.^[1]

Overview and definition

Surgical anatomy of the female pelvis is the anatomy of the retroperitoneal avascular spaces — the areolar planes created by embryological fusion of pelvic fasciae and condensation of connective tissue around neurovascular bundles. Operating in these planes is how the surgeon avoids bleeding, the ureter, the autonomic nerves, and the pelvic organs.^[1][2]

The pelvis has five named avascular spaces used in gynaecological surgery. Know each one by its boundaries, the named landmark that opens it, and the surgical step it enables.^[1][2]

• Pararectal space — divided into Latzko (lateral) between the internal iliac artery and the ureter, and Okabayashi (medial) between the ureter and the rectum. Opened by incising the medial leaf of the broad ligament peritoneum lateral to the infundibulopelvic ligament. Enables radical hysterectomy, lateral parametrial dissection, and internal iliac artery ligation.^[1][2][4]
• Paravesical space — divided into medial and lateral compartments by the obliterated umbilical artery (superior vesical). Opened by incising the lateral leaf of the broad ligament peritoneum lateral to the round ligament. Enables bladder dissection, paravaginal defect repair, and the lateral cervical step of hysterectomy.^[1][2]
• Retropubic (Retzius) space — between the pubic symphysis and the bladder. Opened by incising the peritoneum over the dome of the bladder and dissecting laterally to the pelvic sidewall. Enables colposuspension, Burch colposuspension, and mid-urethral sling placement.^[1]
• Presacral (retrorectal) space — between the rectum and the sacrum. Opened by incising the peritoneum over the sacral promontory and developing the areolar plane. Enables sacrocolpopexy and presacral neurectomy.^[1][2]
• Rectovaginal space — between the rectum and the vagina, opened by incising the cul-de-sac peritoneum and developing the areolar plane above the levator ani. Enables rectovaginal endometriosis excision and the posterior colpotomy step of hysterectomy.^[1][2][12]