A Guided Tour of Pelvic Anatomy and Endometriosis

When patients read their surgical pathology reports or view their operative photos, the medical terminology can feel like a foreign language. Words like “peritoneal sidewall,” “uterosacral ligament,” and “rectovaginal cul-de-sac” often leave patients confused about where their endometriosis actually was and why it caused so much pain.

In this guided surgical video, Dr. Andrea Vidali, assisted by Dr. Osbert Fernandez, takes you on a visual tour of the female pelvis inside the operating room. By understanding this anatomy, you can better understand your disease, your symptoms, and the goals of excision surgery.

The Major Landmarks of the Pelvis

To orient the viewer, the video begins at the bifurcation of the large blood vessels, specifically where the aorta meets the right iliac artery.

• The Uterus, Ovaries, and Tubes: During the tour, the right ovary is shown appearing white, shiny, and glistening right next to the fallopian tube. The uterus is elevated by a surgical instrument to improve visibility; in its normal state, it would rest lower down inside the pelvic cavity.

• The Bladder and Abdominal Wall: The bladder is located in the front of the pelvis, appearing slightly greenish in this video due to a Foley catheter. The round ligaments can be seen extending toward the abdominal wall.

• The Rectum and Bowel: The rectum is positioned at the back of the pelvis. Above this area, the bowel transitions into the sigmoid colon and further up into the right colon. The appendix is also clearly visible in the surgical field.

Endometriosis “Hotspots”

Endometriosis does not just affect the uterus and ovaries. It frequently invades the surrounding structural support systems and adjacent organs.

1. The Peritoneal Sidewall and the Ureter

• The peritoneal sidewall is a highly significant anatomical area because endometriosis has a tendency to live there.

• Running along this sidewall is the ureter, the vital tube connecting the kidney to the bladder, which can be seen moving, or “vermiculating,” in the video.

• When endometriosis causes scar tissue to form in this specific area, surgeons must perform a delicate procedure called “ureterolysis” to carefully free the ureter.

2. The Uterosacral Ligaments

• The right and left uterosacral ligaments act as support structures, extending from the neck of the uterus all the way back to the promontory of the sacrum.

• If there is disease located on the uterosacral ligaments, it can put tension directly on the muscle.

• Because nerves run inside this area under the peritoneum, disease in this location has a tendency to affect those nerves, which is a major driver of pelvic pain.

3. The Rectovaginal Area

• The rectovaginal area is the specific space where the rectum meets the back part of the vagina.

• In the video, Dr. Vidali uses an instrument in the vagina to demonstrate this spatial relationship and points out visible endometriosis in the rectal area that requires surgical treatment.

Beyond Endometriosis: Comprehensive Pelvic Care

A skilled excision surgeon examines the entire pelvic environment, including the parametrium (the deeper tissue inside the broad ligament) and the psoas muscle, which helps lift the leg.

Because the entire pelvic cavity is evaluated, surgeons sometimes find other anatomical issues. For example, during this anatomical tour, Dr. Vidali points out an incidental finding: a small inguinal hernia where the round ligament enters the open inguinal canal.

Understanding your pelvic anatomy is the first step to advocating for your care. When you know where the uterosacral ligaments and the peritoneal sidewalls are, you can better understand why your pain manifests the way it does—and why a high-volume, multidisciplinary excision team is required to treat it safely.