BASIC INFORMATION

Date & Time: 15 June 2026, 18:03:24 IST

Lecture Handout Prepared from the Teaching Session by: Dr. R. K. Mishra

SUMMARY

This lecture was a comprehensive high-yield revision of applied anatomy for postgraduate surgeons and gynecologists, with emphasis on examination-oriented facts and operative safety. The session covered pelvic anatomy, pelvic diameters, pelvic floor, perineum, uterus, cervix, uterine supports, ovaries, fallopian tubes, reproductive vessels, lymphatic drainage, ureteric anatomy, anterior abdominal wall, inguinal region, femoral triangle, anal sphincter complex, vulval anatomy, fetal circulation, placental anatomy, hepatobiliary surgical anatomy, regional anesthesia anatomy, breast anatomy, referred pain pathways, and Müllerian embryology.

The pelvic anatomy component emphasized the shape, boundaries, and diameters of the pelvic inlet and outlet, including the true conjugate, obstetric conjugate, diagonal conjugate, transverse diameter, oblique diameter, bituberous diameter, bispinous diameter, and the clinical role of the ischial spine. The Caldwell classification of pelvis was reviewed, with the gynecoid pelvis identified as most favorable for vaginal delivery and android and platypelloid pelvises associated with deep transverse arrest.

The posterior pelvic wall, piriformis, sacral plexus, pudendal nerve, pelvic diaphragm, perineal pouches, perineal body, ischiorectal fossa, and anal sphincter complex were discussed in relation to obstetric practice, pudendal nerve block, pelvic support, continence, episiotomy, and obstetric anal sphincter injuries.

The uterus, cervix, ovaries, fallopian tubes, uterine artery, ureter, internal iliac artery branches, and lymphatic drainage were reviewed with direct surgical relevance. Particular emphasis was placed on the cardinal ligament as the main support of the uterus, the broad ligament as a peritoneal fold rather than a true support, the uterine artery crossing above the ureter at the internal os, and the ureteric danger points during hysterectomy. The ampulla was identified as the commonest site of tubal ectopic pregnancy and the usual site of fertilization.

The abdominal wall and laparoscopic anatomy section covered the rectus sheath, arcuate line, umbilical folds, inferior epigastric vessels, trocar safety, Palmer’s point, inguinal canal, femoral triangle, and related nerves. The anal canal was discussed in relation to the pectinate line, sphincters, innervation, blood supply, lymphatics, and classification of obstetric anal sphincter injuries.

The later sections reviewed vulval anatomy, fetal circulation, placental anatomy, hepatobiliary surgical landmarks, breast anatomy, regional anesthesia anatomy, referred pain pathways, and Müllerian duct anomalies. Important concepts included the TAP block plane, pudendal block at the ischial spine, breast lymphatic drainage, Cooper’s ligaments, ovarian pain referral to T10, OHVIRA syndrome, septate uterus, renal associations of Müllerian anomalies, and three-dimensional ultrasound as the gold standard investigation for Müllerian duct anomalies.

KEY KNOWLEDGE POINTS

• The pelvic inlet is heart-shaped and transversely oval.

• The pelvic inlet is bounded posteriorly by the sacral promontory, laterally by the iliopectineal lines, and anteriorly by the pubic symphysis.

• The true conjugate measures 11 cm.

• The obstetric conjugate measures 10.5 cm and is the shortest anteroposterior diameter.

• The diagonal conjugate measures 12.5 cm and is the only clinically measurable anteroposterior pelvic diameter.

• The obstetric conjugate may be estimated by subtracting 1.5 cm from the diagonal conjugate.

• The widest diameter at the pelvic inlet is the transverse diameter, measuring 13.5 cm.

• The oblique diameter of the pelvic inlet measures 12 cm; the right oblique diameter is greater than the left due to the sigmoid colon.

• The pelvic outlet is diamond-shaped and is divided into anterior and posterior triangles.

• The pelvic outlet is bounded by the pubic symphysis, ischial tuberosities, and coccyx.

• The widest diameter at the pelvic outlet is the anteroposterior diameter, measuring 13 cm.

• The bituberous diameter measures 11 cm.

• The bispinous diameter measures approximately 10 cm and is clinically the narrowest pelvic diameter.

• The ischial spine marks station zero, is a landmark for pudendal block, and gives attachment to the sacrospinous ligament.

• The gynecoid pelvis is most favorable for normal vaginal delivery.

• Android and platypelloid pelvises may be associated with deep transverse arrest.

• Anthropoid pelvis is associated with occipitoposterior delivery.

• Piriformis arises from the anterior sacrum and inserts into the upper border of the greater trochanter.

• Piriformis divides the greater sciatic foramen into suprapiriformis and infrapiriformis spaces.

• The sacral plexus has root value L4 to S4 and lies anterior to piriformis.

• The pudendal nerve arises from S2, S3, and S4 and loops around the ischial spine.

• The pelvic diaphragm is formed by levator ani and coccygeus.

• Levator ani consists of puborectalis, pubococcygeus, and iliococcygeus.

• The superficial perineal pouch contains the Bartholin gland, clitoral crura, and vestibular bulb.

• The deep perineal pouch contains the deep transverse perineal muscles and sphincter urethrae.

• The perineal body is a central fibromuscular node important for pelvic support.

• The uterus is normally anteverted and anteflexed.

• The cardinal ligament, also called the ligament of Mackenrodt, is the main support of the uterus.

• The broad ligament is a peritoneal fold and is not a true support.

• The round ligament is a derivative of the female gubernaculum, passes through the inguinal canal to the labia majora, and contains the artery of Sampson.

• The uterine artery crosses above the ureter at the level of the internal os, remembered as “water under the bridge.”

• The squamocolumnar junction is the transformation zone and the common site of cervical intraepithelial neoplasia.

• The ovary measures approximately 3 × 2 × 1 cm.

• The ovarian artery arises directly from the abdominal aorta at L2.

• The right ovarian vein drains into the inferior vena cava; the left ovarian vein drains into the left renal vein.

• Ovarian lymphatics drain to para-aortic lymph nodes.

• The fallopian tube is approximately 10 cm long.

• The ampulla is the widest part of the fallopian tube, the usual site of fertilization, and the commonest site of tubal ectopic pregnancy.

• Isthmic ectopic pregnancy ruptures early; interstitial ectopic pregnancy ruptures late and may cause massive hemorrhage.

• The uterine artery arises from the anterior division of the internal iliac artery.

• The internal iliac artery divides into anterior and posterior divisions.

• Cervical lymphatic spread commonly involves external iliac nodes first, followed by obturator and parametrial nodes.

• Para-aortic lymph node involvement in cervical cancer corresponds to stage IIIC2.

• The ureter is approximately 25 cm long and has a diameter of approximately 3 mm.

• The three ureteric constrictions are the pelviureteral junction, pelvic brim, and vesicoureteral junction.

• The ureter crosses the common iliac bifurcation at the pelvic brim.

• The commonest site of ureteric injury during hysterectomy is at the uterine artery crossing, approximately 2 cm lateral to the cervix.

• The ureteric bud arises from the mesonephric or Wolffian duct at 4 to 6 weeks.

• The ureter is lined by transitional epithelium, also called urothelium.

• Ureteric innervation is from T11 to L2.

• The anterior abdominal wall layers, rectus sheath, arcuate line, umbilical folds, and inferior epigastric vessels are important for safe laparoscopic access.

• The median umbilical fold represents the urachus.

• The medial umbilical folds represent obliterated umbilical arteries.

• The lateral umbilical folds contain the inferior epigastric vessels.

• Palmer’s point is 3 cm below the left costal margin in the midclavicular line.

• The femoral triangle contains femoral nerve, artery, vein, empty canal, and lymphatics from lateral to medial.

• The pectinate line divides the anal canal into upper and lower halves with different epithelium, innervation, blood supply, and lymphatic drainage.

• The internal anal sphincter is involuntary smooth muscle derived from circular rectal muscle.

• The external anal sphincter is voluntary skeletal muscle supplied by the pudendal nerve.

• Obstetric anal sphincter injuries are classified as 3A, 3B, 3C, and fourth-degree tears.

• Bartholin glands open at four and eight o’clock and lie in the superficial perineal pouch.

• Skene glands are paraurethral glands and are the female equivalent of the prostate.

• The umbilical cord contains one vein and two arteries.

• The umbilical vein carries the highest oxygen content in fetal circulation.

• The fetal shunts are ductus venosus, foramen ovale, and ductus arteriosus.

• The placenta weighs approximately 500 g at term and has 15 to 20 maternal cotyledons.

• Syncytiotrophoblast persists to term; cytotrophoblast thins out by the third trimester.

• The hepatoduodenal ligament contains the portal triad.

• Pringle’s maneuver clamps the hepatoduodenal ligament but does not control hepatic vein bleeding.

• Calot’s triangle contains the cystic artery and node of Calot.

• TAP block is performed between internal oblique and transversus abdominis muscles and blocks T6 to L1 nerves.

• Pudendal block is given at the ischial spine.

• The breast has 15 to 20 lobes, an axillary tail of Spence, Cooper’s ligaments, and predominant lymphatic drainage to axillary nodes.

• Nipple innervation corresponds to T4.

• Ovarian visceral pain is referred to the umbilicus through T10.

• Diaphragmatic irritation causes shoulder tip pain through the phrenic nerve.

• Müllerian ducts form the fallopian tubes, uterus, cervix, and upper two-thirds of the vagina.

• The lower one-third of the vagina develops from the urogenital sinus.

• Septate uterus is the commonest Müllerian anomaly and has a high miscarriage rate.

• Three-dimensional ultrasound is the gold standard investigation for Müllerian duct anomalies.

• Müllerian duct anomalies may be associated with renal anomalies in 30 to 50% of cases.

INTRODUCTION

Applied anatomy is fundamental to safe surgical and gynecological practice. In obstetrics, pelvic diameters, fetal station, pelvic types, pelvic floor support, fetal circulation, and placental anatomy are essential for understanding labor mechanics and fetal physiology. In gynecology, knowledge of the uterus, cervix, ureter, uterine artery, ovarian vessels, fallopian tubes, lymphatic drainage, and Müllerian development is central to operative safety, oncology staging, and reproductive assessment.

Surgical anatomy also extends beyond the pelvis. Safe laparoscopic entry requires knowledge of the anterior abdominal wall, rectus sheath, arcuate line, umbilical folds, and inferior epigastric vessels. Perineal and anorectal anatomy is essential for obstetric anal sphincter injury recognition and repair. Breast anatomy is important for clinical examination, cancer spread, and axillary node assessment. Regional anesthesia requires accurate understanding of fascial planes and nerve landmarks. Referred pain pathways assist in clinical diagnosis of gynecological and abdominal pathology.

This lecture integrated these topics into a structured postgraduate revision format, emphasizing anatomical facts that are both examination-relevant and directly applicable to operative decision-making.

LEARNING OBJECTIVES

• To revise high-yield pelvic, abdominal, perineal, breast, fetal, placental, hepatobiliary, anesthetic, and embryological anatomy relevant to postgraduate surgeons and gynecologists.

• To understand clinically important pelvic relationships, especially the ureter, uterine artery, pelvic nerves, pelvic vessels, pelvic floor, and lymphatic drainage.

• To identify safe operative landmarks for hysterectomy, adnexal surgery, laparoscopy, pudendal block, TAP block, anal sphincter repair, and hepatobiliary surgery.

• To correlate anatomical knowledge with obstetric mechanisms, fetal circulation, ectopic pregnancy, pelvic pain, oncology staging, and congenital Müllerian anomalies.

• To recognize common examination traps and apply anatomy to patient safety and complication prevention.

CORE CONTENT

1. Bony Pelvis and Pelvic Diameters

1.1 Pelvic Inlet

The pelvic inlet is heart-shaped and transversely oval. Its boundaries are the sacral promontory posteriorly, iliopectineal lines laterally, and pubic symphysis anteriorly.

Important pelvic inlet diameters include the true conjugate, obstetric conjugate, diagonal conjugate, transverse diameter, and oblique diameter.

The true conjugate is the anteroposterior diameter from the sacral promontory to the upper border of the pubic symphysis and measures 11 cm. The obstetric conjugate measures 10.5 cm and is the shortest anteroposterior diameter. The diagonal conjugate measures 12.5 cm and is the only clinically measurable anteroposterior pelvic diameter. The obstetric conjugate may be estimated by subtracting 1.5 cm from the diagonal conjugate.

The widest diameter at the pelvic inlet is the transverse diameter, measuring 13.5 cm. The oblique diameter measures 12 cm. The right oblique diameter is greater than the left due to the sigmoid colon.

1.2 Pelvic Outlet

The pelvic outlet is diamond-shaped and represents the lower limit of the true pelvis. It is bounded anteriorly by the pubic symphysis, laterally by the ischial tuberosities, and posteriorly by the coccyx. It may be divided into anterior and posterior triangles.

The widest diameter at the pelvic outlet is the anteroposterior diameter, measuring 13 cm. The transverse diameter between the ischial tuberosities is the bituberous diameter and measures 11 cm. During delivery, the coccyx may be pushed backward, increasing the anteroposterior diameter of the outlet by approximately 2 cm.

1.3 Midpelvis and Obstetric Diameters

The plane of greatest dimension lies in the midpelvis and has an anteroposterior diameter of approximately 12.5 cm. The bispinous diameter measures approximately 10 cm and is clinically the narrowest pelvic diameter. Engagement occurs when the biparietal diameter of the fetal head passes through the pelvic inlet.

1.4 Ischial Spine

The ischial spine is a critical clinical landmark. It marks station zero in obstetrics. A presenting part above the ischial spine is assigned a negative station; a presenting part below it is assigned a positive station. The ischial spine is also the landmark for pudendal nerve block, the attachment site of the sacrospinous ligament, and a point around which the pudendal nerve loops.

2. Caldwell Classification of Pelvis

2.1 Gynecoid Pelvis

The gynecoid pelvis is the most favorable pelvis for normal vaginal delivery. It has a round inlet, wide subpubic arch, and divergent side walls. The subpubic arch angle in a gynecoid pelvis is approximately 85 to 90 degrees.

2.2 Android Pelvis

The android pelvis is a male-type pelvis with a heart-shaped inlet, convergent pelvic side walls, and narrow subpubic arch. It is associated with deep transverse arrest.

2.3 Anthropoid Pelvis

The anthropoid pelvis has an oval inlet with the anteroposterior diameter greater than the transverse diameter. Occipitoposterior delivery is common.

2.4 Platypelloid Pelvis

The platypelloid pelvis is flat, with a transverse diameter greater than the anteroposterior diameter. It is rare and may be associated with deep transverse arrest.

3. Posterior Pelvic Wall, Piriformis, and Sacral Plexus

3.1 Piriformis

Piriformis originates from the anterior surface of the sacrum, especially S2, S3, and S4, and inserts into the upper border of the greater trochanter. It is supplied by nerves from S1 and S2 and produces lateral rotation and abduction of the extended hip.

Piriformis exits the pelvis through the greater sciatic foramen and divides it into suprapiriformis and infrapiriformis spaces. The superior gluteal nerve and vessels pass through the suprapiriformis space. The sciatic nerve, pudendal nerve, inferior gluteal nerve and vessels, and posterior cutaneous nerve of the thigh pass through the infrapiriformis space.

3.2 Sacral Plexus

The sacral plexus has root value L4 to S4 and lies anterior to piriformis. It is related anteriorly to pelvic fascia, posteriorly to piriformis, and medially to internal iliac vessels. Important branches include the sciatic nerve, pudendal nerve, superior gluteal nerve, and inferior gluteal nerve.

The sciatic nerve has root value L4 to S3 and is the largest nerve in the body. It exits below piriformis through the greater sciatic foramen in most cases.

3.3 Obturator Internus and Coccygeus

Coccygeus lies inferior to piriformis and completes the pelvic diaphragm posteriorly. Obturator internus passes through the lesser sciatic foramen. Alcock’s canal, or the pudendal canal, lies on the fascia of obturator internus.

4. Pudendal Nerve and Pudendal Block

The pudendal nerve arises from S2, S3, and S4. It loops around the ischial spine and enters Alcock’s canal. It is the principal motor and sensory nerve of the perineum. Its branches include the dorsal nerve of the clitoris, perineal nerve, and inferior rectal nerve.

Pudendal nerve block is given at the level of the ischial spine, using transvaginal or transperineal approaches. It provides anesthesia for outlet forceps delivery, vaginal repair, and vulval surgery.

5. Pelvic Floor, Perineum, and Perineal Pouches

5.1 Pelvic Diaphragm

The pelvic diaphragm is formed by levator ani and coccygeus. Levator ani consists of puborectalis, pubococcygeus, and iliococcygeus. It is supplied by S3, S4, S5, and pudendal branches. Its functions include support of pelvic viscera, continence, and assistance in defecation.

5.2 Hiatus Genitalis

The hiatus genitalis is the midline gap through which the urethra, vagina, and rectum pass.

5.3 Perineum

The perineum is a diamond-shaped region divided by a line joining the ischial tuberosities into the anterior urogenital triangle and posterior anal triangle. The posterior triangle contains the ischiorectal fossa and anal canal.

5.4 Superficial Perineal Pouch

The superficial perineal pouch contains the Bartholin gland, clitoral crura, and vestibular bulb. Ischiocavernosus is located in the superficial perineal pouch and is not part of the pelvic floor.

5.5 Deep Perineal Pouch

The deep perineal pouch contains the deep transverse perineal muscles and sphincter urethrae.

5.6 Perineal Body

The perineal body is a central fibromuscular node essential for pelvic support. It is also the target area during episiotomy.

5.7 Ischiorectal Fossa

The ischiorectal fossa contains the pudendal nerve, pudendal vessels, Alcock’s canal, and inferior rectal nerve. Its lateral wall is formed by obturator internus and the ischium.

6. Uterus, Cervix, and Uterine Supports

6.1 Uterine Position and Dimensions

The uterus is normally anteverted and anteflexed. It measures approximately 7.5 cm in length. Its weight is approximately 70 g in nullipara and 90 g in multipara.

The body-to-cervix ratio changes with age:

• Prepubertal: 1:2

• Reproductive age: 2:1

• Postmenopausal: 1:1

6.2 Layers of the Uterus

The layers of the uterus from inside outward are endometrium, myometrium, and parametrium or serosa.

The endometrium has two layers:

• Functionalis, which is shed during menstruation

• Basalis, which regenerates the endometrium

The myometrium has three layers:

• Inner longitudinal layer

• Middle spiral layer

• Outer longitudinal layer

The middle spiral layer acts as a living ligature by compressing spiral arteries and contributes to control of postpartum hemorrhage.

6.3 Cervix and Transformation Zone

The ectocervix is lined by squamous epithelium, while the endocervix is lined by columnar epithelium. The squamocolumnar junction is the transformation zone and is the common site of cervical intraepithelial neoplasia.

6.4 Uterine Supports

The important supports of the uterus are:

• Cardinal ligament, also called Mackenrodt ligament

• Uterosacral ligament

• Pubocervical ligament

The cardinal ligament is the main support of the uterus. The broad ligament is a peritoneal fold and is not a true support.

6.5 Round Ligament and Broad Ligament

The round ligament is a derivative of the female gubernaculum. It passes through the inguinal canal to the labia majora and contains the artery of Sampson.

The broad ligament is a peritoneal fold with subdivisions including mesovarium, mesosalpinx, and mesometrium.

6.6 Uterine Artery and Ureter

The uterine artery crosses above the ureter at the level of the internal os. This relationship is remembered as “water under the bridge.” The ureter passes under the uterine artery approximately 2 cm lateral to the cervix. This is the commonest site of ureteric injury during hysterectomy.

7. Ovary, Fallopian Tube, and Ectopic Pregnancy

7.1 Ovary

The ovary measures approximately 3 × 2 × 1 cm. It is suspended by the mesovarium, infundibulopelvic ligament, and ovarian ligament. The infundibulopelvic ligament contains ovarian vessels and lymphatics. The ovarian ligament connects the ovary to the uterine cornu.

The ovarian artery arises directly from the abdominal aorta at L2. The right ovarian vein drains into the inferior vena cava, whereas the left ovarian vein drains into the left renal vein. Ovarian lymphatics follow the ovarian vessels to para-aortic lymph nodes.

7.2 Fallopian Tube

The fallopian tube is approximately 10 cm long and has four parts:

1. Interstitial part

2. Isthmus

3. Ampulla

4. Infundibulum

The ampulla is the widest part, the usual site of fertilization, and the commonest site of tubal ectopic pregnancy. The isthmus is the narrowest part and is associated with early rupture in ectopic pregnancy. The interstitial part traverses the uterine wall and may rupture late with massive hemorrhage.

Distribution of tubal ectopic pregnancy discussed:

• Ampulla: 70%

• Isthmus: 12%

• Fimbria: 10%

• Interstitial part: 3%

The tube receives blood supply medially from the uterine artery and laterally from the ovarian artery. This dual supply explains the risk of life-threatening hemorrhage after rupture.

8. Pelvic Blood Supply and Lymphatic Drainage

8.1 Internal Iliac Artery

The internal iliac artery is the main pelvic blood supply and divides into anterior and posterior divisions.

Anterior division branches discussed include:

• Umbilical artery

• Superior vesical artery

• Obturator artery

• Inferior vesical artery

• Middle rectal artery

• Internal pudendal artery

• Inferior gluteal artery

• Uterine artery

• Vaginal artery

Posterior division branches include:

• Iliolumbar artery

• Lateral sacral artery

• Superior gluteal artery

8.2 Rectal Arterial Supply

The superior rectal artery is the terminal branch of the inferior mesenteric artery. The middle rectal artery arises from the anterior trunk of the internal iliac artery. The inferior rectal artery arises from the internal pudendal artery.

8.3 Important Vascular Levels

Important vascular levels are:

• Celiac trunk: T12

• Superior mesenteric artery: L1

• Ovarian artery: L2

• Inferior mesenteric artery: L3

The appendicular artery is a branch of the ileocolic artery, which arises from the superior mesenteric artery.

8.4 Lymphatic Drainage

Lymphatic drainage often follows arterial supply.

Important lymphatic pathways:

• Uterine body: para-aortic and internal iliac nodes

• Uterine fundus: para-aortic nodes

• Cervix: external iliac, obturator, and internal iliac nodes

• Upper one-third of vagina: external iliac nodes

• Middle one-third of vagina: internal iliac nodes

• Lower one-third of vagina: superficial inguinal, deep inguinal, then external iliac nodes

• Vulva: superficial inguinal nodes first

• Ovary: para-aortic nodes

• Fallopian tube: para-aortic and internal iliac nodes

• Anal canal below pectinate line: superficial inguinal nodes

• Anal canal above pectinate line: internal iliac nodes

In cervical cancer, external iliac nodes are commonly involved first, followed by obturator and parametrial nodes. Para-aortic lymph node involvement corresponds to stage IIIC2.

9. Surgical Anatomy of the Ureter

9.1 Length, Diameter, and Constrictions

The ureter is approximately 25 cm long, with 12.5 cm abdominal and 12.5 cm pelvic portions. Its diameter is approximately 3 mm.

The three anatomical constrictions are:

• Pelviureteral junction

• Pelvic brim

• Vesicoureteral junction

These are common sites of ureteric stone impaction.

9.2 Pelvic Course

At the pelvic brim, the ureter crosses the bifurcation of the common iliac artery. In the pelvis, it runs in the base of the broad ligament and passes beneath the uterine artery approximately 2 cm lateral to the cervix at the level of the internal os.

9.3 Ureteric Injury Points

Important sites of ureteric injury during pelvic surgery include:

• Pelvic brim

• Ovarian fossa

• Uterine artery crossing

• Ureteric tunnel

• Vesicoureteral junction

The commonest site of injury during hysterectomy is the uterine artery crossing.

9.4 Embryology, Histology, Blood Supply, and Innervation

The ureteric bud arises from the mesonephric or Wolffian duct at 4 to 6 weeks and interacts with the metanephric blastema. The ureter is lined by transitional epithelium, or urothelium. It has segmental blood supply. The pelvic ureter receives small branches from the internal iliac artery. Ureteric innervation is from T11 to L2.

10. Anterior Abdominal Wall and Laparoscopic Anatomy

10.1 Layers of the Anterior Abdominal Wall

From superficial to deep, the layers are:

• Skin

• Camper’s fascia

• Scarpa’s fascia

• External oblique aponeurosis

• Internal oblique aponeurosis

• Transversus abdominis

• Transversalis fascia

• Preperitoneal fat

• Peritoneum

10.2 Rectus Sheath and Arcuate Line

Above the arcuate line, the anterior rectus sheath is formed by external oblique aponeurosis and half of internal oblique aponeurosis. The posterior sheath is formed by the other half of internal oblique aponeurosis and transversus abdominis aponeurosis.

Below the arcuate line, all aponeuroses pass anterior to rectus abdominis, and the posterior rectus sheath is absent. The arcuate line lies midway between the umbilicus and symphysis pubis and marks the level where the inferior epigastric vessels enter the rectus sheath.

10.3 Umbilical Folds

The median umbilical fold represents the urachus. The medial umbilical folds represent obliterated umbilical arteries. The lateral umbilical folds contain the inferior epigastric vessels.

The lateral umbilical fold is an important laparoscopic landmark because injury may cause bleeding from the inferior epigastric vessels.

10.4 Trocar Safety and Palmer’s Point

A lateral trocar placed too medially may injure the inferior epigastric vessels. Safe trocar placement requires identification of the umbilical folds and avoidance of the lateral umbilical fold containing the inferior epigastric vessels.

Palmer’s point is located 3 cm below the left costal margin in the midclavicular line and may be used as an alternative laparoscopic entry site.

11. Inguinal Region and Femoral Triangle

11.1 Inguinal Canal

The inguinal ligament is the thickened lower border of the external oblique aponeurosis and extends from the anterior superior iliac spine to the pubic tubercle.

In females, the inguinal canal contains the round ligament, ilioinguinal nerve, and genital branch of the genitofemoral nerve. The deep inguinal ring lies lateral to the inferior epigastric vessels. The superficial inguinal ring lies medial to the inferior epigastric vessels.

11.2 Important Nerves

The lateral cutaneous nerve of the thigh passes under the inguinal ligament just medial to the anterior superior iliac spine. The ilioinguinal nerve pierces internal oblique and exits through the superficial inguinal ring. The iliohypogastric and ilioinguinal nerves have root value L1. The genitofemoral nerve has root value L1 and L2.

11.3 Femoral Triangle

The femoral triangle is bounded superiorly by the inguinal ligament, laterally by sartorius, and medially by adductor longus.

Its contents from lateral to medial are:

• Femoral nerve

• Femoral artery

• Femoral vein

• Empty canal

• Lymphatics

The skin of the femoral triangle is supplied by the femoral branch of the genitofemoral nerve. Injury during posterior external iliac lymph node dissection may cause sensory loss over the femoral triangle.

The femoral nerve has roots L2, L3, and L4. The obturator nerve also has roots L2, L3, and L4 and supplies the medial thigh skin and adductor muscles. Medial thigh pain suggests obturator nerve involvement.

12. Anal Canal and Obstetric Anal Sphincter Injuries

12.1 Anal Canal and Pectinate Line

The anal canal is approximately 4 cm long. The pectinate line divides it into upper and lower halves.

Above the pectinate line:

• Epithelium: columnar and transitional

• Innervation: autonomic

• Blood supply: inferior mesenteric artery

• Lymphatic drainage: internal iliac nodes

Below the pectinate line:

• Epithelium: stratified squamous

• Innervation: somatic via pudendal nerve

• Blood supply: inferior rectal artery from internal pudendal artery

• Lymphatic drainage: superficial inguinal nodes

12.2 Anal Sphincters

The internal anal sphincter is the thickened distal continuation of circular smooth muscle of the rectum. It is involuntary and autonomically supplied.

The external anal sphincter is skeletal muscle, voluntary, and supplied by the pudendal nerve. It has deep, superficial, and subcutaneous parts.

The puborectalis sling maintains the anorectal angle, which is approximately 90 degrees at rest and straightens during defecation.

12.3 Obstetric Anal Sphincter Injury Classification

• 3A: Less than 50% external anal sphincter thickness involved

• 3B: More than 50% external anal sphincter thickness involved

• 3C: Internal anal sphincter involved

• Fourth-degree tear: Anal mucosa involved

Episiotomy is a second-degree perineal injury involving skin and muscles. External anal sphincter repair may be performed by overlap or end-to-end technique. If the internal anal sphincter is torn, it should be repaired separately.

13. Vulval Anatomy

The vulva includes the mons pubis, labia majora, labia minora, clitoris, vestibule, and glands.

The labia majora is the female homologue of the scrotum and receives the terminal part of the round ligament. The labia minora contain no hair and no fat and meet anteriorly at the clitoral hood.

The clitoris contains two crura and two corpora cavernosa. It has no corpus spongiosum. The vestibular bulbs are the equivalent of the corpus spongiosum.

The vestibule lies between the labia minora and contains the openings of the urethra, vagina, and Bartholin ducts.

The Bartholin glands lie in the superficial perineal pouch and open at four and eight o’clock positions. They are the female equivalent of bulbourethral glands. The Bartholin duct is lined by transitional epithelium.

Skene glands are paraurethral glands and are considered the female equivalent of the prostate. Skene ducts open beside the external urethral meatus.

The distal urethra is lined by stratified squamous epithelium, while the proximal urethra is lined by transitional epithelium.

Hidradenoma papilliferum is a benign apocrine sweat gland tumor occurring in the intercrural region and is curable by simple excision.

14. Fetal Circulation and Placental Anatomy

14.1 Umbilical Cord

The umbilical cord contains one umbilical vein and two umbilical arteries in Wharton’s jelly. The umbilical vein carries the highest oxygen content, approximately 80% saturation. The umbilical arteries return deoxygenated blood to the placenta. Single umbilical artery may be associated with congenital anomalies in approximately 20% of cases.

14.2 Fetal Shunts

The three fetal shunts are:

• Ductus venosus, which bypasses the liver

• Foramen ovale, which connects the right atrium to the left atrium

• Ductus arteriosus, which connects the pulmonary artery to the descending aorta

Functional closure of the ductus venosus occurs immediately after birth, with anatomical closure in one to three months. Functional closure of the foramen ovale occurs at birth due to increased left atrial pressure, with anatomical closure in about three months. Functional closure of the ductus arteriosus occurs within 24 to 72 hours, with anatomical closure in two to three weeks.

14.3 Placenta

The placenta weighs approximately 500 g at term, about one-sixth of fetal weight. The maternal surface is rough and contains 15 to 20 cotyledons. The fetal surface is smooth and forms the chorionic plate. Syncytiotrophoblast persists to term, while cytotrophoblast thins out by the third trimester.

During engagement, the biparietal diameter of the fetal skull passes through the inlet.

15. Hepatobiliary Surgical Anatomy

The liver is the largest abdominal organ and has four anatomical lobes: right, left, caudate, and quadrate. It has eight functional segments based on portal venous supply.

The hepatoduodenal ligament forms the free edge of the lesser omentum and contains the portal triad:

• Hepatic artery

• Portal vein

• Common bile duct

The foramen of Winslow lies posterior to the hepatoduodenal ligament. Pringle’s maneuver clamps the hepatoduodenal ligament to control hepatic inflow bleeding from the hepatic artery and portal vein. It does not control hepatic vein bleeding because hepatic veins drain directly into the inferior vena cava.

The portal vein is formed by the union of the superior mesenteric vein and splenic vein behind the neck of the pancreas. The right and left hepatic ducts form the common hepatic duct, which joins the cystic duct to form the common bile duct. The bile duct continues to the ampulla of Vater, where the sphincter of Oddi is located.

Calot’s triangle is bounded by the cystic duct, common hepatic duct, and inferior border of the liver. It contains the cystic artery and node of Calot.

The falciform ligament extends from the anterior abdominal wall to the liver and contains the ligamentum teres. The coronary ligament reflects to and from the bare area of the liver.

16. Regional Anesthesia Anatomy

16.1 Transversus Abdominis Plane Block

TAP block is performed by depositing local anesthetic between the internal oblique and transversus abdominis muscles. It targets thoracolumbar nerves from T6 to L1 and is used for analgesia after cesarean section, hysterectomy, and lower abdominal surgery.

The lateral approach is performed between the iliac crest and costal margin in the triangle of Petit. The posterior approach was described as more reliable in pregnancy. Bupivacaine 0.25% to 0.5% was discussed, with a maximum dose of 2 mg/kg.

16.2 Pudendal Block

Pudendal block is administered at the ischial spine and anesthetizes the pudendal nerve branches for outlet forceps delivery, vaginal repair, and vulval surgery.

16.3 Spinal, Epidural, and Caudal Anesthesia

Spinal anesthesia is administered at L3–L4 or L4–L5. Epidural anesthesia is commonly administered at L2–L3 or L4–L5. Caudal block is administered through the sacral hiatus. The intercristal line corresponds to L4.

17. Breast Anatomy

The breast extends from the second to sixth rib and laterally toward the mid-axillary line. The axillary tail of Spence extends into the axilla. The breast contains 15 to 20 lobes, each drained by lactiferous ducts.

Cooper’s ligaments separate the lobes and provide support. In breast cancer, traction on Cooper’s ligaments produces dimpling and peau d’orange.

The fascia immediately deep to the breast is the pectoralis major fascia. The retromammary space lies between the breast and pectoralis fascia.

Breast innervation is derived from anterior and lateral cutaneous branches of intercostal nerves. The nipple corresponds to T4.

Blood supply includes internal mammary perforating branches, lateral thoracic artery, and intercostal perforators. Approximately 60% of blood supply comes from internal mammary branches.

Lymphatic drainage is approximately 75% to axillary lymph nodes and 25% to internal mammary nodes. Axillary nodes are grouped into anterior, posterior, lateral, central, and apical groups. Axillary nodal levels are defined in relation to pectoralis minor:

• Level I: lateral to pectoralis minor

• Level II: behind pectoralis minor

• Level III: medial to pectoralis minor

The sentinel lymph node in breast cancer is usually level I. The upper outer quadrant is the commonest site of breast cancer.

18. Referred Pain Pathways

Visceral pain is referred to dermatomes corresponding to the spinal segment of the affected organ.

Ovarian visceral pain travels with sympathetic fibers to T10 and is referred to the umbilicus. Ovarian inflammation may irritate the obturator nerve, causing medial thigh pain.

Uterine pain corresponds to T11, T12, L1, and L2 and may produce suprapubic and sacral referral. Cervical and upper vaginal pain travels through S2, S3, and S4 and may be referred to the lower back. Fallopian tube pain may be referred to the ipsilateral lower quadrant and medial thigh.

Diaphragmatic irritation causes shoulder tip pain through the phrenic nerve, with roots C3, C4, and C5. Ectopic pregnancy with hemoperitoneum may produce shoulder tip pain. Appendicular pain begins in the periumbilical region due to T10 visceral afferents and later localizes to the right iliac fossa. Gallbladder pain is referred to the right inferior scapular region. Cardiac pain may be referred to the left arm, jaw, and neck. Kidney and ureteric pain presents as loin pain. Pancreatic pain is referred to the back and epigastrium. Splenic rupture may cause left shoulder pain, known as Kehr’s sign.

19. Müllerian Embryology and Congenital Anomalies

19.1 Embryological Derivatives

The Müllerian ducts, or paramesonephric ducts, form the fallopian tubes, uterus, cervix, and upper two-thirds of the vagina. The lower one-third of the vagina, urethra, and bladder develop from the urogenital sinus.

The Wolffian ducts, or mesonephric ducts, form male reproductive structures including vas deferens, seminal vesicles, epididymis, and ejaculatory ducts. Female Wolffian remnants include Gartner duct cyst, epoophoron, and paroophoron. Gartner duct cyst is located in the lateral vaginal wall.

The bladder trigone is mesonephric duct in origin, whereas the rest of the bladder is endodermal. The ureteric bud arises from the mesonephric duct. The round ligament and ovarian ligament are derivatives of the gubernaculum. The appendix testis is a Müllerian remnant. The appendix of epididymis is a Wolffian remnant. Hydatid of Morgagni is a Müllerian remnant in females.

Ovaries develop from the genital ridge, derived from intermediate mesoderm, at approximately 5 to 6 weeks. The SRY gene on the Y chromosome determines testicular development at approximately 7 weeks. In the absence of SRY-driven testicular differentiation, ovarian development occurs by default.

Renal agenesis results from failed interaction between the ureteric bud and metanephric blastema.

19.2 Müllerian Duct Anomalies

Müllerian duct anomalies result from failure of formation, fusion, or septal resorption. Formation occurs from 4 to 12 weeks, fusion around 10 weeks, and septal resorption from 12 to 20 weeks.

The American Society of Reproductive Medicine classification includes:

1. Agenesis or hypoplasia

2. Unicornuate uterus

3. Didelphys uterus

4. Bicornuate uterus

5. Septate uterus

6. Arcuate uterus

7. Diethylstilbestrol-related T-shaped uterus

Müllerian agenesis, or Mayer-Rokitansky-Küster-Hauser syndrome, is characterized by absent uterus, absent upper vagina, and normal ovaries.

Septate uterus is the commonest Müllerian anomaly and results from failure of septal resorption. It has a high miscarriage rate, discussed as approximately 65%, and may be treated by hysteroscopic septal resection.

Bicornuate uterus results from partial fusion failure and has a cleft external fundal contour. Septate uterus and bicornuate uterus are distinguished by external fundal contour. In septate uterus, the external fundal contour is normal with an internal septum. In bicornuate uterus, the external fundal contour is cleft with fundal indentation greater than 1 cm.

Three-dimensional ultrasound is the gold standard investigation for Müllerian anomalies. MRI is used for complex cases. Renal imaging is important because renal anomalies occur in 30 to 50% of Müllerian duct anomalies.

19.3 OHVIRA Syndrome

OHVIRA syndrome, also called Herlyn-Werner-Wunderlich syndrome, consists of:

• Didelphys uterus

• Obstructed hemivagina

• Ipsilateral renal agenesis

It results from defects around 10 weeks involving fusion and canalization. Patients may present after menarche with cyclical pelvic pain and hematocolpos.

SURGICAL PEARLS

• The pelvic inlet is widest transversely, while the pelvic outlet is widest anteroposteriorly.

• The diagonal conjugate is the only clinically measurable anteroposterior pelvic diameter.

• The ischial spine is a key landmark for station zero and pudendal nerve block.

• The gynecoid pelvis is most favorable for vaginal delivery; android and platypelloid pelvises may cause deep transverse arrest.

• The sacral plexus lies anterior to piriformis; superior gluteal structures pass above piriformis, while sciatic and pudendal nerves pass below it.

• The pudendal nerve root value S2, S3, and S4 is a frequent examination point.

• The Bartholin gland lies in the superficial perineal pouch, not the deep pouch.

• The cardinal ligament is the main support of the uterus; the broad ligament is not a true support.

• During hysterectomy, the ureter must be identified before clamping the uterine artery.

• The uterine artery crossing is approximately 2 cm lateral to the cervix at the internal os and is the commonest site of ureteric injury.

• The infundibulopelvic ligament contains ovarian vessels and lymphatics; careless handling may cause significant bleeding.

• Tubal ectopic pregnancy most commonly occurs in the ampulla.

• Isthmic ectopic pregnancy ruptures early, whereas interstitial ectopic pregnancy ruptures late and may cause massive hemorrhage.

• External iliac nodes are commonly first involved in cervical cancer.

• Para-aortic nodal involvement in cervical cancer corresponds to stage IIIC2.

• Inferior epigastric vessels lie under the lateral umbilical fold and may be injured by medially placed lateral trocars.

• Palmer’s point is an alternative entry site 3 cm below the left costal margin in the midclavicular line.

• Posterior external iliac lymph node dissection may injure the genitofemoral nerve and cause sensory loss over the femoral triangle.

• Medial thigh pain suggests obturator nerve involvement.

• Obstetric anal sphincter injuries must be classified accurately; internal anal sphincter tears should be repaired separately.

• Pringle’s maneuver controls hepatic artery and portal vein inflow but not hepatic vein bleeding.

• In fetal circulation, distinguish the vessel with the highest oxygen content, the umbilical vein, from oxygenated blood reaching the descending aorta through the ductus arteriosus.

• Septate uterus is common, has a high miscarriage rate, and may be treated hysteroscopically.

• Septate and bicornuate uterus must be differentiated by external fundal contour before planning treatment.

• Renal imaging is required when Müllerian duct anomalies are diagnosed.

• TAP block must be placed between internal oblique and transversus abdominis muscles.

ANESTHETIC AND PHYSIOLOGICAL CONSIDERATIONS

TAP block provides abdominal wall analgesia by targeting thoracolumbar nerves from T6 to L1 in the plane between the internal oblique and transversus abdominis muscles. It is used for cesarean section, hysterectomy, and lower abdominal surgery.

Pudendal nerve block is administered at the ischial spine and provides perineal anesthesia for outlet forceps delivery, vaginal repair, and vulval surgery.

Spinal anesthesia is administered at L3–L4 or L4–L5. Epidural anesthesia is commonly administered at L2–L3 or L4–L5. Caudal block is administered through the sacral hiatus. The intercristal line corresponds to L4.

The pelvic diaphragm supports pelvic viscera, maintains continence, and assists defecation. The puborectalis sling maintains the anorectal angle, which straightens during defecation.

The middle spiral layer of the myometrium acts as a living ligature and contributes to control of postpartum hemorrhage.

The umbilical vein carries the highest oxygen content in fetal circulation. The ductus venosus bypasses the liver, the foramen ovale connects the right atrium to the left atrium, and the ductus arteriosus connects the pulmonary artery to the descending aorta.

Functional closure of the ductus arteriosus occurs within 24 to 72 hours, with anatomical closure in two to three weeks. Functional closure of the foramen ovale occurs at birth, with anatomical closure in approximately three months. Functional closure of the ductus venosus occurs immediately, with anatomical closure in one to three months.

COMPLICATIONS AND THEIR MANAGEMENT

Intraoperative

• Ureteric injury during hysterectomy:

  The commonest site is the uterine artery crossing, approximately 2 cm lateral to the cervix at the level of the internal os. Prevention requires identification of the ureter and respect for the “water under the bridge” relationship.

• Ureteric injury at other pelvic danger points:

  Injury may also occur at the pelvic brim, ovarian fossa, ureteric tunnel, and vesicoureteral junction. Prevention requires awareness of the ureteric course and careful dissection.

• Vascular injury during adnexal surgery:

  The infundibulopelvic ligament contains ovarian vessels. Careless ligation or dissection may cause significant bleeding.

• Hemorrhage from ruptured ectopic pregnancy:

  Tubal rupture may cause massive hemorrhage due to dual tubal blood supply from uterine and ovarian arteries. Interstitial ectopic pregnancy is particularly dangerous because rupture may be delayed but severe.

• Incorrect pudendal block placement:

  The ischial spine must be correctly identified as the landmark.

• Inferior epigastric vessel injury:

  A lateral trocar placed too medially may injure the inferior epigastric vessels. Prevention requires recognition of the lateral umbilical fold and appropriate trocar placement.

• Genitofemoral nerve injury:

  Posterior external iliac lymph node dissection may injure the genitofemoral nerve and cause sensory loss over the femoral triangle.

• Obturator nerve involvement:

  Pain radiating to the medial thigh suggests obturator nerve irritation or involvement.

• Hepatic bleeding not controlled by Pringle’s maneuver:

  Pringle’s maneuver controls hepatic inflow through the hepatic artery and portal vein but does not control hepatic vein bleeding.

Early Postoperative

Specific early postoperative complications were not discussed in detail in the lecture.

Late Postoperative

Specific late postoperative complications were not discussed in detail. However, in Müllerian duct anomalies, reproductive consequences discussed included miscarriage, preterm birth, malpresentation, and intrauterine growth restriction.

MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS

Accurate anatomy is essential for operative safety, informed decision-making, and prevention of avoidable complications.

During hysterectomy and pelvic surgery, the ureter must be actively identified near the broad ligament, uterine artery, cervix, pelvic brim, and bladder. Failure to recognize the uterine artery-ureter relationship may result in preventable ureteric injury.

During adnexal surgery, the infundibulopelvic ligament must be handled with awareness of ovarian vessels and lymphatics.

During laparoscopy, safe trocar placement requires recognition of the umbilical folds and inferior epigastric vessels. Palmer’s point may be considered as an alternative entry site when appropriate.

Obstetric anal sphincter injuries require accurate classification and documentation because management depends on the structures involved. Internal anal sphincter tears should be recognized and repaired separately.

Pelvic type, fetal station, and the ischial spine are important in obstetric decision-making. The gynecoid pelvis favors vaginal delivery, while android and platypelloid pelvises may be associated with deep transverse arrest.

In gynecologic oncology, lymphatic drainage patterns influence staging and surgical planning. Para-aortic lymph node involvement in cervical cancer corresponds to stage IIIC2. Vulval cancer requires attention to inguinal lymph nodes.

In Müllerian duct anomalies, renal imaging is important because renal anomalies occur in 30 to 50% of cases. Septate and bicornuate uterus must be distinguished before treatment. Septate uterus may benefit from hysteroscopic septum resection, whereas bicornuate uterus should not be treated as a septate uterus.

Regional anesthesia requires correct localization of anatomical planes and landmarks. TAP block requires identification of the plane between internal oblique and transversus abdominis. Pudendal block requires accurate localization of the ischial spine. Neuraxial anesthesia requires correct vertebral level identification.

SUMMARY AND TAKE-HOME MESSAGES

• The pelvic inlet is widest transversely; the pelvic outlet is widest anteroposteriorly.

• The diagonal conjugate is the only clinically measurable anteroposterior pelvic diameter.

• The ischial spine is essential for station zero and pudendal nerve block.

• The gynecoid pelvis is most favorable for vaginal delivery.

• The sacral plexus lies anterior to piriformis.

• The pudendal nerve arises from S2, S3, and S4.

• The pelvic diaphragm is formed by levator ani and coccygeus.

• The Bartholin gland lies in the superficial perineal pouch.

• The cardinal ligament is the main support of the uterus.

• The broad ligament is not a true uterine support.

• The uterine artery crosses above the ureter at the internal os.

• The commonest site of ureteric injury during hysterectomy is the uterine artery crossing.

• The ovarian artery arises from the aorta at L2.

• The right ovarian vein drains into the inferior vena cava; the left drains into the left renal vein.

• The ampulla is the commonest site of tubal ectopic pregnancy and the usual site of fertilization.

• The ureter has three constrictions: pelviureteral junction, pelvic brim, and vesicoureteral junction.

• The median umbilical fold represents the urachus.

• The lateral umbilical fold contains inferior epigastric vessels.

• Palmer’s point is located 3 cm below the left costal margin in the midclavicular line.

• The femoral triangle contents from lateral to medial are nerve, artery, vein, empty canal, and lymphatics.

• The pectinate line divides the anal canal into two anatomically distinct regions.

• A 3C obstetric anal sphincter injury involves the internal anal sphincter.

• The umbilical vein carries the highest oxygen content in fetal circulation.

• The three fetal shunts are ductus venosus, foramen ovale, and ductus arteriosus.

• Syncytiotrophoblast persists to term.

• Pringle’s maneuver clamps the hepatoduodenal ligament but does not control hepatic vein bleeding.

• TAP block is performed between internal oblique and transversus abdominis.

• Nipple innervation corresponds to T4.

• Ovarian visceral pain is referred to the umbilicus through T10.

• Septate uterus is the commonest Müllerian anomaly and has a high miscarriage rate.

• Three-dimensional ultrasound is the gold standard investigation for Müllerian duct anomalies.

• Renal imaging is important in Müllerian duct anomalies.

MULTIPLE CHOICE QUESTIONS (MCQs)

1. Which is the widest diameter of the pelvic inlet?

A. True conjugate

B. Obstetric conjugate

C. Transverse diameter

D. Bituberous diameter

Correct Answer: C. Transverse diameter

2. Which anteroposterior pelvic diameter is clinically measurable?

A. True conjugate

B. Obstetric conjugate

C. Diagonal conjugate

D. Anatomical conjugate

Correct Answer: C. Diagonal conjugate

3. The obstetric conjugate measures approximately:

A. 9.5 cm

B. 10.5 cm

C. 12.5 cm

D. 13.5 cm

Correct Answer: B. 10.5 cm

4. The presenting part at the level of the ischial spine is described as:

A. Station minus 3

B. Station minus 1

C. Station zero

D. Station plus 3

Correct Answer: C. Station zero

5. The pelvic type most favorable for normal vaginal delivery is:

A. Android

B. Anthropoid

C. Platypelloid

D. Gynecoid

Correct Answer: D. Gynecoid

6. The pudendal nerve root value is:

A. L1, L2

B. L2, L3, L4

C. S2, S3, S4

D. S4, S5

Correct Answer: C. S2, S3, S4

7. The sacral plexus lies in relation to which muscle?

A. Obturator internus

B. Piriformis

C. Iliopsoas

D. Levator ani

Correct Answer: B. Piriformis

8. The main support of the uterus is the:

A. Broad ligament

B. Round ligament

C. Cardinal ligament

D. Mesosalpinx

Correct Answer: C. Cardinal ligament

9. The relationship “water under the bridge” refers to:

A. Ovarian artery above ovarian vein

B. Ureter passing below uterine artery

C. Uterine artery passing below ureter

D. Fallopian tube crossing ovarian ligament

Correct Answer: B. Ureter passing below uterine artery

10. The commonest site of ureteric injury during hysterectomy is:

A. Pelviureteral junction

B. Uterine artery crossing

C. Renal pelvis

D. Sacral promontory

Correct Answer: B. Uterine artery crossing

11. The ovarian artery arises from the abdominal aorta at:

A. T12

B. L1

C. L2

D. L3

Correct Answer:

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