624 ABDOMEN 



Dissection. The dissector should cut through the lateral false ligaments 

 of the bladder at their junctions with the lower borders of the anterior 

 surfaces of the broad ligaments : he should then turn the \ lateral 

 false ligaments medially to the lateral borders of the upper surface of 

 the bladder. Next he should draw the apex of the bladder backwards 

 and pass his index finger down through the soft fat, between the anterior 

 border of the bladder and the back of the symphysis pubis, till he feels the 

 resistance of the upper fascia of the pelvic diaphragm which passes medially 

 from the wall of the pelvis to the bladder, and which is thickened on each 

 side of the medial plane to form the medial pubo-vesical ligaments of the 

 bladder. These ligaments having been recognised, the finger should be 

 carried laterally and then backwards between the wall of the pelvis and 

 the bladder, above the visceral layer of the pelvic fascia, as far as the 

 lateral border of the broad ligament. The dissector will find he can 

 do this quite easily, and by doing it he will demonstrate the fact that 

 between the anterior border and infero-lateral surfaces of the bladder and 

 the wall of the pelvis there is a space filled with easily displaced extra- 

 peritoneal fat ; this is the lower and front part of the so-called cave of 

 Retzius. The finger should now be passed still farther backwards along 

 the lateral wall of the pelvis, beyond the lateral border of the broad 

 ligament, until the front of the hypogastric artery is reached ; but little 

 resistance will be met, and the dissector will be able to satisfy himself that 

 the lower part of the so-called cave extends round the sides and front of 

 the pelvis from the hypogastric artery of one side to the corresponding 

 vessel of the opposite side. The upper part of the cave lies behind the 

 anterior abdominal wall, extending upwards between the inferior epigastric 

 arteries to the level of the umbilicus. The cave is of practical importance 

 because, on account of the laxity of its fatty contents, urine escaping from 

 a ruptured bladder, or effused blood, or inflammatory exudations, can 

 spread rapidly throughout the area ; moreover it is an area in which the 

 surgeon can readily separate the abdominal contents from the abdominal 

 wall. Having satisfied himself of the presence and the boundaries of the 

 cave, the dissector should carefully remove the extra-peritoneal fat which 

 lies between the bladder and the wall of the pelvis, taking care to avoid 

 injuring any vessels which may be passing through the fat. When he has 

 completed this part of the dissection he will have displayed on the side wall 

 of the pelvis the following structures : The lateral umbilical ligament 

 lying a short distance below the level of the pelvic brim. 1 The obturator 

 nerve below the ligament, and at a still lower level the obturator artery 

 and vein. Crossing from the umbilical ligament to the bladder he will 

 find the superior vesical artery. Lateral to the obturator vessels and 

 nerve he will see the parietal pelvic fascia, and at the bottom of the 

 space he will find the visceral layer of the pelvic fascia passing medially 

 from the parietal layer to the bladder. Just to the lateral side of the 

 junction of the lateral border with the posterior border of the bladder he 

 will find the lower end of the ureter, and, if he passes a finger into the 

 vagina, he will recognise that the lower end of the ureter is crossing a 

 recess of the vagina, at the side of the lower end of the uterus, which is 

 called the lateral fornix of the vagina (Fig. 248). If the lower border of 

 the broad ligament is now carefully raised, the uterine artery will be found 

 passing medially above the ureter to the side of the uterus (Fig. 248). 



Having displayed the structures in front of the broad ligament, the 

 dissector should turn to the posterior part of the pelvis, where he must care- 

 fully divide the peritoneum along the back of the lower border of the 



1 See p. 599. 





