Anatomy

I will briefly summarize anatomy of the anterior abdominal wall, which is essential for safe and effective trocar insertion. The anatomy of the space of Retzius has been summarized in the chapter of anatomic correlates. The umbilicus is at the L3-4 level in normal-sized women. In obese women, the umbilicus is caudal to the L4-5 level, which marks the aortic bifurcation. Therefore, the intraumbilical trocar should be introduced at a more acute angle relative to the abdominal wall and toward the pelvis in thin women and closer to 90 degrees in obese women. The left common iliac vein lies 4 to 7 cm inferior to the umbilicus. The superficial epigastric artery branches from the femoral artery, coursing cephalad, and can be transil-

Figure 6-6.1. Anatomy of the anterior abdominal wall and suggested laparoscopic trocar positions. (Reprinted from Urogynecology and Reconstructive Pelvic Surgery 2nd ed, MD Walters, MM Karram, 190-198,© 1999 Mosby,with permission from Elsevier.]

luminated. The inferior epigastric artery branches from the external iliac artery at the medial border of the inguinal ligament and runs lateral to and below the rectus sheath at the level of the arcuate line. It is accompanied by two inferior epigastric veins (Figure 6-6.1).3

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