1434 SUKFACE AND SURGICAL ANATOMY. 



a little above their insertion into the rectum. The posterior surface of the prostate, 

 covered with recto-vesical fascia, is now exposed. 



By continuing the separation of the rectum upwards in the cellular plane above 

 mentioned, the bottom of the recto-vesical pouch of peritoneum is reached ; it can 

 usually be stripped for some distance off the rectum, without opening into the peri- 

 toneal cavity. In freeing the rectum laterally, bands of connective tissue containing 

 branches of the middle and superior haemorrhoidal vessels are divided. If the 

 tumour is situated at the superior part of the rectum, the recto-vesical pouch of 

 peritoneum is freely opened in a transverse direction. The colo-rectal junction is 

 then mobilised by dividing the sacral attachment of the pelvic mesocolon and secur- 

 ing the superior haemorrhoidal artery. After dividing the rectum well above the 

 tumour, the opening into the peritoneal cavity is closed by suturing together the 

 anterior and posterior walls of the recto-vesical pouch. If a permanent colostomy 

 has been established, the divided bowel is closed ; if not, a sacral anus is made. 



FEMALE PELVIS. 



On opening the abdomen by a median incision extending from the umbilicus to 

 the pubes, and looking into the pelvis minor from above, after displacing some coils 

 of the small intestine upwards, the fundus of the uterus, directed forwards and 

 a little upwards, is seen resting upon the superior surface of the bladder. Behind 

 the uterus is the rectum, and between the two the recto-uterine pouch of Douglas, 

 containing the pelvic colon and the inferior part of the ileum. The ovary lies__ 

 little below the level of the superior aperture of the pelvis minor upon a triangular 

 shelf, bounded in front by the broad ligament, behind and medially by the uterp- 

 ^ sacral ligament, and behind and laterally by the pelvic wall. When the vermi- 

 7V- form process overhangs the superior aperture of the pelvis minor its tip may come 

 ff into close relation with the right ovary, a condition which often leads to a difficulty 

 in distinguishing an inflammation of that ovary from appendicitis. The round 

 ligaments are seen passing forwards and laterally from the upper parts of the right and 

 left borders of the uterus to the abdominal inguinal rings, which lie immediately in 

 front and to the medial side of the terminations of the external iliac arteries. 

 Inferiorly and at the medial side of the round ligament, as it leaves the pelvis, is 

 the inferior epigastric artery. By pulling the uterus upwards the attachments of 

 the broad ligament to the floor and side walls of the pelvis are brought into 

 evidence, as also are the utero-vesical and recto-vaginal peritoneal pouches ; the 

 former is shallow, while the deepest part of the latter covers the upper fourth of 

 the posterior wall of the vagina, and comes into relation, therefore, with the 

 posterior fornix. 



The utero-vesical peritoneal reflection takes place at the level of the junction 

 of the body of the uterus with the cervix. The anterior wall of the cervix comes 

 into relation, therefore, with the superior part of the base of the bladder, from which, 

 owever, it is separated by a layer of loose connective tissue. It is the existence 



this cellular plane which enables the surgeon to separate the bladder readily 

 from the uterus in the operation of hysterectomy. 



While the anterior wall of the vagina is firmly united to the urethra, its 

 posterior wall, on the other hand, can be readily separated from the rectum, in 

 consequence of the interposition between the two organs of the recto-vaginal fascia. 



The ureter crosses the brim of the pelvis in front of the bifurcation of the 

 common iliac artery 1J in. lateral to and a little below the centre of the sacral 

 promontory. The corresponding point on the anterior abdominal wall is at the 

 junction of the lateral and middle thirds of a line joining the anterior superior 

 spines of the ilium. 



After crossing the termination of the common iliac artery from lateral to 

 medial side, the ureter dips vertically into the pelvis minor behind the peri- 

 toneum covering the hypogastric artery. It then courses medially in the para- 

 metric cellular tissue below the base of the broad ligamenta. In this position 

 it lies a little above the lateral fornix of the vagina, about three-quarters of an 

 inch lateral to the superior part of the cervix uteri ; finally, just before it pierces 



