The uterus, adnexa, superior bladder, and upper rectum are peritonealized. These structures attach to the pelvis and to one another via a variety of peritoneal reflections and vascular and fibrous ligaments and pedicles.

• Pelvic organs:

  • Reproductive organs: uterus, fallopian tubes, ovaries

  • Rectum: separated from the uterus by the posterior cul-de-sac, or Pouch of Douglas

  • Urinary system:

    • Bladder: shares a common peritoneal lining with the lower uterine segment and cervix

    • Ureters: Common sites for injury during gynecologic procedures:

      • Near the pelvic brim when the ovarian vessels are divided for oophorectomy

      • Along the peritoneum during retroperitoneal pelvic dissection

      • At the cardinal ligament during transection of the uterine arteries, where the ureter crosses under the uterine vasculature (“water under the bridge”)

      • At the lateral angles of the vaginal cuff closure

• Vascular pedicles:

  • Ovarian vessels: branch from the aorta (right ovarian vein drains to IVC and left ovarian vein to the left renal vein) and supply the adnexa

  • Uterine vessels: branch medially from internal iliac vessels and course toward then along the uterus

  • Parametrial/vaginal vessels: branches of the internal iliac arteries that course through the parametria

• Ligaments and peritoneal reflections:

  • Utero-ovarian ligament: connects ovaries to uterus

  • Mesosalpinx: peritoneal reflection that suspends the fallopian tube and contains mesosalpingeal vessels

  • Round ligament: extends from the bilateral uterine cornua and courses through the deep inguinal ring

  • Broad ligament: peritoneal reflection attaching the uterus to the round ligament, adnexa, and sidewall

  • Cardinal ligament: the connection between the lower uterine segment/cervix and pelvic sidewall

  • Uterosacral ligament: connects the base of the cervix to the sacrum