Broad Ligaments-The Rectouterine Pouch (pouch of Douglas) and Disease-

Broad Ligaments

The broad ligaments are two-layered folds of peritoneum that extend across the pelvic cavity from the lateral margins of the uterus to the lateral pelvic walls. Superiorly, the two layers are continuous and form the upper free edge. Inferiorly, at the base of the ligament, the layers separate to cover the pelvic floor. The ovary is attached to the posterior layer by the mesovarium. The part of the broad ligament that lies lateral to the attachment of the mesovarium forms the suspensory ligament of the ovary. The part of the broad ligament between the uterine tube and the mesovarium is called the mesosalpinx. At the base of the broad ligament, the uterine artery crosses the ureter. Each broad ligament contains the following:

■■ The uterine tube in its upper free border

■■ The round ligament of the ovary and the round ligament of the uterus. They represent the remains of the gubernaculum.

■■ The uterine and ovarian blood vessels, lymph vessels, and nerves

■■ The epoophoron, a vestigial structure that lies in the broad ligament above the attachment of the mesovarium. It represents the remains of the mesonephros .

■■ The paroöphoron, also a vestigial structure that lies in the broad ligament just lateral to the uterus. It is a mesonephric remnant .

 

The Rectouterine Pouch (pouch of Douglas) and Disease

Since the rectouterine pouch (pouch of Douglas) is the most dependent part of the entire peritoneal cavity (when the patient is in the standing position), it frequently becomes the site for the accumulation of blood (from a ruptured ectopic pregnancy) or pus (from a ruptured pelvic appendicitis or in gonococcal peritonitis). Because the pouch lies directly behind the posterior fornix of the vagina, it is commonly violated by misguided nonsterile instruments, which pierce the wall of the posterior fornix in a failed attempt at an illegal abortion. Pelvic peritonitis, often with fatal consequences, is the almost certain result.

A needle may be passed into the pouch through the posterior fornix in the procedure known as culdocentesis. Surgically, the pouch may be entered in posterior colpotomy. The interior of the female pelvic peritoneal cavity may be viewed for evidence of disease through an endoscope; the instrument is introduced through a small colpotomy incision.