welcome to section two of reproductive Anatomy in this section we will discuss the ligaments surrounding the female pelvic organs and some other important structures let's get started this is a table with the major ligaments associated with the female reproductive organs let's start our discussion with the infundibulum pelvic ligament which is also called the suspensory ligament jumping over to the local Anatomy it's important to recognize that this structure connects the ovary to the lateral pelvic wall and therefore it suspends the ovary hence the term suspensory ligament here is an image showing the anterior view of the uterus which we introduced in the first lecture we have the fallopian tube over here and we can see the suspensory ligament over here and it connects to the lateral most portion of the ovary and in this image it's covered up by the femur EA of the fallopian tube but just know that the suspensory ligament goes and connects to this lateral portion of the ovary now notice that traveling through the suspensory ligament is the ovarian artery and the ovarian vein so this brings us to a very important clinical tie-in there's a condition called ovarian torsion and in this condition the ovary twists around the ligament there by squeezing the contents that are within the ligament and what contents are those the ovarian artery and the ovarian vein therefore ovarian torsion will decrease blood flow to the ovary and will cause ovarian ischemia to help you remember that the suspensory ligament connects to the end of the ovary to suspend it to the abdominal wall I use the phrase suspend the end suspend at the end let me explain what I mean by this let's say here are the ovaries and here are our lines depicting the abdominal wall and right here are the ends of the ovaries these are the lateral ends of the ovaries what connects to these lateral ends of the ovaries these suspensory ligaments these suspensory ligaments connect the ovaries to the lateral abdominal wall so you could say they suspend the ovaries by connecting to their lateral ends so suspend the end again here's the end of the ovary and they ligament connect it to the wall is the suspensory ligament suspend at the end so now we just talked about ovarian torsion and how this can lead to ovarian ischemia resulting from blockage of the ovarian artery the last important idea to know about the suspensory ligament is that the ureter passes posteriorly and inferiorly and this is important because during surgical removal of the ovary the surgeon needs to be mindful of how close the ligament is to the ureter so the surgeon is trying to ligate the suspensory ligament in an oophorectomy but he or she may accidentally damage the ureter because of how close it is remember it passes just posterior lis and inferiorly to the ligament right here we have the ureter and it travels down to the bladder we have one on each side and if the surgeon is trying to remove the ovary he or she will light the ovarian artery in vain and in so doing he or she can accidentally ligate the order which can be devastating now that we've discussed the IP or suspensory ligament let's talk about the uterus sacral ligaments these connect the uterus to the sacrum and this allows for support of the uterus we can see the uterus right here and we have the posterior surface right here and the sacrum over here in this uterus sacral ligament will connect the two offering uterine support this ligament is really important because if it's damaged this can lead to pelvic organ prolapse and what is pelvic organ prolapse pelvic organ prolapse occurs when there's loss of supporting structures like the ligament we just discussed and when it's not there to support then pelvic organs will herniate into the vaginal wall and this loss of support often occurs in older women who have had multiple vaginal deliveries or prolonged deliveries so in this way delivering babies actually weakens these supporting structures and we just talked about the uterus sacral ligament but there are others you should be aware of for example the transverse cervical ligament and the levator Ani muscles those are all important supporting structures this image depicts the various types of pelvic organ prolapse look at this top left image labeled the syste cell and we can see the bladder right here notice how the bladder is protruding backwards posteriorly into the vaginal wall you can imagine this process could lead to some urinary symptoms and we will discuss these symptoms in a moment now let's look at the top right image rectus eel we can see the rectum right here and we can see how its protruding anteriorly into the vaginal wall now look at the bottom enter a seal we can see this arrow which is pressing downward into the vaginal wall this indicates the intestines the point is that weakness to supporting structures in the pelvis most importantly the uterus allows for prolapse of nearby organs into the vaginal wall so now that we've discussed the uterus sacral ligaments and how important it is for uterine support and without it we can get pelvic organ prolapse let's do a question to apply what you've learned so far a 67 year old female presents for a routine physical exam the physician examines the pelvis and notes that the posterior vaginal wall appears to bulge especially when the patient coughs what structure is more likely damaged the uterus sacral ligaments or the suspensory ligaments hopefully you notice that this patient has pelvic organ prolapse and we know that because the posterior vaginal wall appears to bulge when the patient coughs of the two ligaments listed which one is responsible for supporting uterus that would be the uterus sacral ligaments once again going back to this slide we can see that the three supporting structures you need to be familiar with are the uterus sacral ligaments transverse cervical ligaments which is also called the Cardinal ligament and the levator Ani muscles on the left image we can see the uterus sacral ligament now let's look at the right image although not shown the transverse cervical ligament would be found here and we will discuss this ligament later in this lecture on the previous slide we also mentioned the levator Ani muscles and how they offer support now these muscles are not a ligament so we will not discuss these in this lecture however in the next lecture we discuss the pelvic floor and at that time we will discuss the levator Ani muscles and briefly revisit the idea of pelvic organ prolapse so the take-home point if one or more of these structures are weak patients can experience a form of pelvic organ prolapse as we discussed before with this image now let's talk about the round ligament the round ligament connects the uterine horn to the labia majora right here is what we would call the uterine horn you can see it over here as well and notice we have the round ligament labeled over here on the left and it starts here at the horn and then it continues outward and going back to our table the round ligament travels through the inguinal canal and we discussed the inguinal canal in the GI anatomy chapter and in that chapter we introduce this image we can see the inguinal canal right here and in males this conducts the spermatic cord but in females the inguinal canal conducts the round ligament so if there's an inguinal hernia that travels through the inguinal canal the intestines will travel with the round ligament and end up going to the labia majora which is where the round ligament extends to so for the round ligament just remember that it travels through the inguinal canal and connects to the labia majora and this means that in direct inguinal hernias will protrude through the inguinal canal which is the path of the round ligament in this sagittal image is perhaps the best one to represent the round ligament which you can see late right here you can see how it attaches to the uterine horn up here although you can't appreciate that it is the uterine horn just know that it's in this region as we just discussed and then it will reach down to the labia majora labeled here now let's talk about the ovarian ligament this will connect the ovary to the uterus there isn't anything really special you need to know about the ovarian ligament I only include the ligament on this table because it can be often mistaken for other ligaments for example the suspensory ligament so let's make sure you don't make the same mistake so here's the uterus again and notice this ligament goes from the uterus to the ovary right here the ovarian ligament from the uterus to the ovary don't confuse this with the suspensory ligament over here which connects the lateral portion of the uterus to the lateral wall and again I like to use the phrase suspend the end so that I can easily remember that it's the suspensory ligament that attaches to the end of the ovary and connects it to the lateral pelvic wall suspending it suspend the end now let's do a question a 49 year old female is diagnosed with stage 1 left-sided ovarian cancer during the surgery several ligaments are transected to remove the ovary immediately upon removal of the ovary the surgeon see profuse hemorrhage from one of the transected ligaments the surgeon promptly begins to tie off the involved vessels what vessels and ligament is he targeting hopefully you thought of the ovarian artery and veins what ligament contains these that would be the suspensory ligament also called the infundibulum pelvic ligament or IP ligament recall from the table that the suspensory ligament contains the ovarian artery and vein and it's like ated during oophorectomy and going back to this image we can clearly see that the suspensory ligament conducts the ovarian artery and vein so when you want to remove the ovary you're gonna cut this ligament which means you're going to ligate these vessels now let's talk about the transverse cervical or Cardinal ligament this ligament is important because it conducts the uterine artery and the vein the transverse cervical agreement will attach for this lateral side of the uterus at the level of the cervix and attach it to the lateral pelvic wall and if you picture the transverse cervical ligament in this area then it's much easier to understand that it contains the uterine artery and vein as well as the ureter which you can see right here and labeled up at the top right and since it conducts the uterine artery and the uterine vein this transverse cervical ligament is very important clinically because if there's a hemorrhage of the uterus let's say in a postpartum women these arteries can targeted to stop the bleeding so the physician needs to get through the transverse cervical ligament to get to these arteries these arteries can also be ligated during a hysterectomy so don't forget the transverse cervical ligament also known as the Cardinal ligament and since this Cardinal ligament contains the ureter that means that during ligation of the uterine artery and vein there can actually be damage to the ureter just like we discussed up here with the IP ligament when you like ate the ligament in or for ectomy you can damage the ureter another important clinical tie-in is that the transverse cervical ligament is actually important for uterine support that means that if there's damage or weakness of the Cardinal ligament the patient can experience pelvic organ prolapse recall from this slide regarding pelvic organ prolapse that the important supporting structures for the uterus include the uterus a colon which we already discussed and the transverse cervical ligament or Cardinal ligament which we just introduced and since you can use the term transverse cervical or Cardinal ligament I can find that this can be a little bit confusing for me I think it's easiest to remember that it's the transverse cervical eggman I like this title because it has cervical in the title which reminds me that it connects the uterus to the pelvic wall at the level of the cervix or you can just remember Cardinal ligament starts with a cc4 cervix either way just remember that this ligament the transverse cervical agreement connects the uterus at the level of the cervix and it supports it by connecting it to the lateral pelvic wall the last ligament to discuss is the broad ligament and really it's just a fold of the peritoneum and since it's a fold of the peritoneum it's actually musin Terry and Mees and Terry is discussed in great detail in section 1 of the gastrointestinal anatomy chapter and these folds of the peritoneum can be divided into three portions the measles Sal Pink's which involves the fallopian tubes the muse ovarian which involves the ovaries and the mezzo metrium which involves the uterine body we can see these three portions right here Meisel Sal Pink's muse ovarian and mezzo metrium now pausing for just a moment let's focus on the uterine artery and vein we discussed how these are within the transverse cervical ligament but if you're looking at the broad ligament it looks like the uterine artery and vein actually passed through part of the broad ligament and that's true they actually do pass through the broad ligament so let's make this simple we have the broad ligament up here and we have the transverse cervical ligament down below and with this approach you can imagine that the uterine artery in vein travel through here and they can also extend into the broad ligament now this Anatomy can be very confusing but don't let it be just think of the broad ligament above conducting the uterine artery in vain just think of the transverse cervical ligament below near the cervix and conducting the uterine artery in vain and above that we have the broad ligament which contains the extensions of the uterine artery in vain okay so now let's just focus again on the broad ligament notice how the prefix in each word is mezzo and this will help you remember that the mesentery is what's covering here mezzo Sal Pink's for uterine tube or fallopian tube means ovarium for musin Terry covering the ovary and mezzo metrium for mesentery covering the uterus so the final point regarding the broad ligament is that it can be transected during hysterectomy which I guess goes without saying imagine if you have to remove the uterus right here you're gonna end up transecting the broad ligament now let's do one last question to apply what you learned a 33 year old female with endometriosis undergoes elective hysterectomy during the surgery the physician identifies the ureters on both sides of the uterus she avoids ureter damage until she like eights the uterine artery on the right side what ligament was she likely transecting at the time of ureter damage with respect to the uterine artery did the surgeon transect too far anteriorly or posterior Li so we are told that the uterine artery was damaged at the same time as the ureter and what ligament contains both the uterine artery and the ureter that would be the Cardinal ligament or transverse cervical ligament now for the second part of the question with respect to the uterine artery did the surgeon transect too far anteriorly or posterior Li well we know that the ureter passes behind the uterine artery in vain so if you have the transverse cervical ligament right here and we see that the uterine artery was damaged you can clearly see on the image that the ureter labeled up at the top passes posterior Li to these vessels so the surgeon likely transected too far posterior Li going back to the table looking at the Cardinal ligament we can see that the uterine artery and vein is supposed to be ligated during hysterectomy but with that that can accidentally be damage to the ureter so an answer to our question the surgeon likely transected too far posterior Li and that concludes a section