PELVIS 561 



The False Ligaments of the Bladder. The false ligaments of the 

 bladder are parts of the pelvic peritoneum. When the bladder is empty 

 a fold extends from the anterior end of its upper surface, the apex of the 

 bladder, to the posterior surface of the anterior abdominal wall. This is 

 the plica timbilicalis media (O.T. superior false ligament} of the bladder. 

 It separates the right and left paravesical and supravesical fossae from each 

 other, and is caused by the projection of the ligamentum umbilicale 

 medium formed by the urachus or fibrous remnant of the allantois. The 

 peritoneum, extending from each lateral border of the upper surface of 

 the bladder to the side wall of the pelvis, constitutes a lateral false liga- 

 ment, and forms the floor of the corresponding paravesical fossa. Not 

 uncommonly each lateral false ligament and the peritoneum on the upper 

 surface of the bladder are divided into anterior and posterior portions 

 by a transverse fold, the plica vesicalis transversa, which crosses from 

 one side of the pelvic brim to the other. It is questionable if the term 

 posterior false ligament should be retained ; it is still applied, however, to 

 the remnants of the sacro-genital folds which extend from the back of 

 the distended bladder to the sides of the distended rectum, or to the 

 front of the sacrum. 



Dissection from above. All the .peritoneum above the level of the 

 pelvic brim should now be removed, care being taken not to injure or 

 displace the ureter or the ductus deferens. The dissector should then stitch 

 the ureter to the artery it crosses at the brim, common or external iliac as 

 the case may be. He must also stitch the ductus deferens to the external 

 iliac artery close to the origin of the inferior epigastric branch. This being 

 done, he must carefully detach the peritoneum from the extraperitoneal 

 fat, separating any adhesions with the knife. The separation should be 

 commenced at the brim, and be carried medially until the root of the pelvic 

 meso -colon, the side of the rectum, and the lateral border of the upper 

 surface of the bladder are reached. When this has been done on both 

 sides, the dissector should displace the bladder backwards, and pass his finger 

 down between the viscus and the symphysis, through the soft extraperitoneal 

 fat, till it meets a resisting membrane. This is the visceral layer of the pelvic 

 fascia or upper layer of the fascia of the pelvic diaphragm. By his sense 

 of touch the dissector will recognise not only that it is attached to the 

 lower part of the posterior surface of the symphysis, but also that two 

 thickened bands of its substance extend backwards, one on each side 

 of the medial plane, from the back of the symphysis to the anterior 

 border of the bladder. These bands are the anterior true ligaments of 

 the bladder or the medial pubo-prostatic ligaments ; the latter name indicating 

 that, in the male, they are placed above the prostate. Having satisfied 

 himself regarding these ligaments the dissector should carry his finger 

 backwards, between the bladder and the wall of the pelvis, displacing the 

 soft fat, until he touches the ureter. The region which he will thus 

 investigate is the lower and anterior part of a large area, known as the 

 cave of Retzius, in which the extraperitoneal fat has very slight attachment 

 either to the peritoneum or to the pelvic fascia, and in which, therefore, it 

 is very easily displaced. The area extends from the hypogastric artery of 

 one side round the front of the bladder to the hypogastric artery of the 

 opposite side, downwards to the visceral layer of the pelvic fascia, and 

 upwards between the umbilical (O.T. obliterated hypogastric) arteries to the 

 umbilicus. The facility with which he displaces the fatty tissue should 

 demonstrate to the dissector how easy, in this area, will be the spread of 

 urine effused from a ruptured bladder, or of blood running from a divided 

 artery, or of effusions due to inflammatory conditions. The dissector must 

 now remove the extraperitoneal fat first from the ductus deferens, then from 

 VOL. I 36 



