 To examine the autonomic nerves in the pelvis, we will use a specimen which has been transversed section and the right hip bone has been removed. The retroperitoneal and pelvic structures are continuous. Viewing the pelvis from the side, note the levator ante and sacrospinus ligament. The levator ante is sandwiched by lower and upper fasciae of the pelvic diaphragm. By stripping the fasciae from the levator ante and then reflecting the upper fasciae, we can see the prostate and the fascial attachment. Posteriorly, we see the level at which the fasciae attaches to the rectum. Above the levator ante and encircled by the pubic symphysis and sacroplexus, we see a rich venous plexus. Vessels run in the groove between the bladder and prostate, as well as between the prostate and rectum. By removal of the venous plexus, we are able to view the nerve plexus and arteries. The nerves and arteries are intermingled. In the actual dissection, first we identify the arteries. The arteries of the urogenital organs originate from the internal iliac artery. The superior and inferior vesicle arteries, as well as the middle rectal artery, will be seen in the next actual dissection. In the specimen, the inferior vesicle artery originates from the angle between the umbilical artery and the inferior gluteal artery. First we identify the arteries. We see the external and internal iliac arteries, the ilio lumbar artery, the superior gluteal artery, as well as the inferior gluteal artery. Moving downwards, we see the internal pudendal artery, which runs below the levator ante. And ascending, we see the umbilical artery and finally the superior vesicle arteries. Here, the inferior vesicle artery has a rather high origin. The middle rectal artery originates from the inferior gluteal artery and then passes through the pelvic plexus to distribute to the anterior edge of the levator ante and the lower rectum. In this scheme, the yellow represents sympathetic contribution and the dark green parasympathetic. The yellow-green pelvic plexus consists of dark green pelvic splenchnic nerves and yellowish hypogastric and sacral splenchnic nerves. The major sympathetic components originate from the lumbar splenchnic nerves and descend. In the following actual dissection, we demonstrate that the major sympathetic hypogastric nerve and pelvic splenchnic nerves unite to form the pelvic plexus. Now we will follow the superior hypogastric plexus to the right lumbar splenchnic nerve and trace upwards. The right lumbar splenchnic nerve passes beneath the inferior vena cava to reach the lumbar sympathetic trunk. By removal of the inferior vena cava, the whole course of the right lumbar splenchnic nerve can be viewed. By directly viewing the pelvic plexus, we zoom in on the sacral plexus and nerve to the obturator internus. From the lower part of the sacral plexus, the pudendal nerve originates. From this nerve, the dorsal nerve of the penis can be traced. The levator ante is reflected and the nerve of this muscle is identified on the upper surface. Now you can clearly see the pelvic plexus and the right hypogastric nerve as it descends to enter the plexus. Here are the pelvic splenchnic nerves from S3 and S4. The pelvic plexus is formed just outside the seminal vesicle, rectum, and bladder. Looking at the upper branches from the plexus, we see those reaching the ureter and bladder. The lower branches distribute to the neck of the bladder and prostate. Finally, the lower most branches run in the groove between the prostate and rectum to reach the anterior edge of the levator ante. Due to its position, this levator ante edge seems to play an important role to support the prostate. A thin branch passes between the pubic symphysis and levator ante to reach the penis. It is the cavernous nerve of the penis. Similar to the actual operation view from above and from cranial, in the center near the aortic bifurcation, we trace the lumbar splenchnic nerve, the major sympathetic component, to reach the superior hypogastric plexus. Descending along the right hypogastric nerve, we reach the pelvic plexus. Shifting the pelvic plexus anteriorly, you can clearly see the pelvic splenchnic nerves which make up the parasympathetic component. Note, it is lower and lateral to the hypogastric nerve. By reflection of the ductus deferens, we see the corresponding nerve. Here we see the upper branches of the pelvic plexus which reach the ureter and bladder. The lower branches of the plexus distribute to the neck of the bladder and prostate. Finally, the lower most branches are seen. Some supply the anterior edge of the levator ante. This nerve is a cavernous nerve of the penis. Note, the nerve of the levator ante can be seen on its upper surface. Here, the bladder, prostate, and penis have been median sectioned. Then, the rectum and vertebral column were likewise median sectioned. The left and right halves were divided, but the autonomic nerve connections remain intact. We see the hypogastric nerve and the pelvic splenchnic nerves unite to form the pelvic plexus. Numerous branches are sent to the urinary and genital organs. However, the rectal branches are rather few. The inferior mesentery artery continues to the superior rectal artery, and the nerve plexus surrounding these arteries has communicating branches with the hypogastric nerve. Some parasympathetic branches of the pelvic plexus ascend via these connections to distribute to the descending colon and sigmoid colon. The composition and distribution of the pelvic plexus have been demonstrated. The lymphatic pathways of the rectum are divided into ascending and lateral pathways. The ascending pathway runs along the superior rectal artery and inferior mesentery artery to reach the paraeortic node chain. The lateral pathway runs via the iliac lymph node chain to reach the paraeortic node chain. In this video, we demonstrate the lymph node chain along the iliac arteries. Lymphatics which reach the aorta intermingle with rich nerve plexuses. The right hip bone has been removed, and the right testis is seen. Ascending lymphatics from the testis run alongside the testicular vessels and reach the aorta. The lymph vessels spread out, some reaching the aortic bifurcation, while others reach the level of the left renal vein. In front of the inferior vena cava and along the testicular vein, several large nodes are seen. The surface of the aorta comes into view, as well as the aortic bifurcation, the common iliac external and internal iliac arteries. Then we reach the inguinal region. Just below the inguinal ligament lie the inguinal lymph nodes. From these nodes, lymph vessels ascend along the medial side of the external iliac artery and reach the angle between the external and internal iliac arteries. Also, from the inguinal nodes, we trace an ascending pathway along the lateral side of the external and common iliac arteries, which reaches the aortic and cable region. Now, moving past the urogenital organs, in close proximity, we find the obturator nerve and vessels. Tracing these obturator structures, we find they reach the inter-iliac angle and are closely related to lymphatics. Tracing lymphatics from the internal organs, we find they follow along their corresponding vessels for a distance and then independently run to cross the obturator nerve and vessels and reach the inter-iliac region. Some lymphatics ascend medial to the common iliac artery to reach nodes of the aortic bifurcation in front of the left common iliac vein. These lymphatics are intertwined and closely related to the superior hypogastric plexus. Then, they ascend along the aorta. Lymphatics surrounding the inferior mesentery artery also drain into the para-aortic node chain. Here, with the mesosigmoid stripped, we can see the inferior mesentery artery gives off several sigmoid arteries and continues as the superior rectal artery. Note the lymphatic vessels running alongside these arteries. They converge at the origin of the inferior mesentery artery. In front of the aortic bifurcation, you can see the superior hypogastric plexus and many communications with the inferior mesentery nerve plexus. Now, we will examine the left side to determine if a similar arrangement is found. The ureter is shifted. We widen the inter-iliac area by separating the structures. From this inter-iliac area, tracing the lymphatics distally, we reach the inguinal nodes. Again, following the ascending lymphatics along the external iliac artery, we find the lymphatics actually wind around the external iliac artery. Lateral ascending lymphatics of the common iliac artery connect with the lymphatic chain lateral to the aorta. Some ascending lymphatics cross over the internal iliac artery and run in the groove of the left common iliac artery and vein and then reach the nodes of the aortic bifurcation. The ascending lymphatics continue to reach the para-aortic node chain. Notice that lymph nodes are situated deep to the superior hypogastric plexus in the bifurcation angle. The iliac and para-aortic lymph node chains have been demonstrated. To demonstrate the pelvic fasciae, first we view the visceral fasciae of the retroperitoneal space. Here the cecum and transverse colon are lifted and we note the right colic flexure. From the right colic flexure, we strip the fusion fasciae of the digestive organs. The forceps indicates the inferior vena cava. Reaching the hepatic veins, they are now cut in order to separate the liver from the inferior vena cava. With the liver shifted leftward, we view the origin of the ciliac trunk and superior mesenteric artery, appearing as a single mass. By cutting these two arteries, the digestive organs on the right side of the left colic flexure can be removed. Here is the right renal fasciae, including the testicular vessels. By reflecting the renal fasciae, including the ureter, to the left, we note the division between the renal fasciae and the fascial sheath surrounding the iliac arteries. In order to understand the relationship of this fasciae to the other pelvic structures, a scheme will be shown. Looking at the pelvic structural arrangement, the connective tissues converge towards the organs, blood vessels, and nerves to form intra-palvic fasciae. The internal iliac artery and its visceral branches are shown. For fascial consideration, also note the obliterated umbilical artery and the obturator artery. Lateral ligaments surround the visceral arteries and nerves. Note the fasciae includes the obliterated umbilical artery. Also, around the major autonomic nerves, fasciae are formed. The renal fascia, as shown in the above specimen, continues as the fascia surrounding the hypogastric nerve. Now, back to the renal fasciae and tracing to the pelvis, we shift the fasciae to the left and note the peritoneum over the bladder. On the lower left, the forceps indicates the external iliac artery and just above the internal iliac artery. The umbilical artery is included within the vesical hypogastric fasciae. This unique fasciae is like a wall with the umbilical artery running inside the top and the bottom of the wall reaches the pelvic floor. By pulling the external iliac artery, we can more clearly see the internal iliac artery and the fasciae between these two arteries. It is within this fasciae that the inter-iliac lymph nodes are situated. We will now return to the vesical hypogastric fasciae. Looking at the lateral surface of the vesical hypogastric fasciae, we dissect within it and find a venous plexus as well as nerves. Here, lifting the descending colon and its mesentery, we identify the inferior mesentery artery. A finger can be inserted behind both renal fasciae. Therefore, at the level of the aortic bifurcation, these fasciae can be separated from the aorta and inferior vena cava. Returning the right renal fasciae, we note a bundle-like structure crossing above the finger. Upon dissection, we find it is the superior hypogastric plexus. Thus, this renal fasciae sheet not only includes the ureter, but also the hypogastric plexus and nerves. Now we trace the ureter downward to the bladder. We note it crosses the ductus deferens. Just medial to the ureter lies the terminal portion of the hypogastric nerve. Checking its course, we see the lumbar splenchnic nerves, the superior hypogastric plexus, and the right hypogastric nerve. Then, at this level, this so-called renal fasciae may be considered as the ureteral hypogastric fasciae. By inserting a finger, we can lift this fasciae and separate it from the fasciae covering the sacrum. Upon removal of the ureteral hypogastric fasciae, we find numerous band-like structures converge and form the pelvic plexus. Here again is the vesicle hypogastric fasciae. We will trace downward along its inner surface to reach the pelvic plexus. Note this vesicle hypogastric fasciae serves as a landmark layer and is useful to identify the pelvic plexus. Here, with the rectum and its peritoneum pulled to the left, we can identify the lateral ligament of the rectum. The cut inferior mesenteric artery is reflected together with the sigmoic colon, revealing the superior rectal artery. We will trace towards the pelvis. With the rectum strongly pulled leftward, we see the contents of its lateral ligament, including the pelvic plexus and the hypogastric nerve. Not only from lateral, but also from behind, vessels from the front of the sacrum are seen. This may be considered as the posterior ligament of the rectum. The forceps indicate the lateral ligament of the bladder and prostate. Now, as viewed from above, as in an actual operation, we lift the sigmoic colon and rectum to the front to observe the posterior lateral surface of the rectum. The bladder is median section and pulled lateral word, revealing the lateral ligament of the rectum and then the pelvic plexus. With the bladder lifted, you can see the hypogastric nerve entering the pelvic plexus. Here are the pelvic splenchnic nerves, lateral and lower to the hypogastric nerve. Thus, there is a clear space between the hypogastric nerve and the pelvic splenchnic nerves. Viewing these nerves laterally and close up, we insert a finger between the hypogastric nerve and the pelvic splenchnic nerves. The tip of the finger reaches the inferior margin of the pelvic splenchnic nerves. By cutting the umbilical artery, we clearly view the hypogastric nerve and the pelvic splenchnic nerves. The fascial arrangement in the pelvis has been demonstrated.