The anterior leaf of the broad ligament forms the roof of the paravesical space, blending with the bladder peritoneum medially and the parietal peritoneum laterally. The space is composed of connective tissue and fat. The bladder occupies the medial border, and the obturator internus muscle forms the lateral border. The posterior limit of the space is formed by the cardinal ligament, and the floor is composed of the levator ani muscle. The anterior leaf of the broad ligament should be opened at the midportion of the round ligament (Fig. 3). The incision extends laterally to expose the pelvic vessels and medially to reflect the bladder peritoneum. The space is entered on the lateral side of the obliterated hypogastric artery, and blunt dissection is carried to the level of the levator ani muscle.
The pararectal space lies beneath the pelvic peritoneum. Its borders include the cardinal ligament anterolaterally and the uterosacral ligament medially. The sacrum forms the posteromedial margin of the space and the ureter is attached to the peritoneum, forming the roof of the space.
(Fig 3).Schematic sectional drawing of the pelvis shows the firm connective tissue and the paraspaces (Amreich). The bladder, cervix, and rectum are surrounded by a connective tissue covering. The Mackenrodt ligament extends from the lateral cervix to the lateral abdominal pelvic wall. The vesicouterine ligament originating from the anterior edge of the Mackenrodt ligament leads to the covering of the bladder on the posterior side. The sagittal rectum column spreads both to the connective tissue of the rectum and to the sacral vertebrae closely nestled against the back of the Mackenrodt ligament and lateral pelvic wall. Between the firm connective tissue bundles there is loose connective tissue (paraspaces). (From Von Peham H, Amreich JA: Gynaekologische operaaonslehre, Berlin, 1930, S Karger.)
The hypogastric artery and vein are located in the pararectal space, and entry should be cautious, with medial displacement of the ureter and its attached peritoneum. Surgical entry is accomplished by cephalad extension of the previous incision for the paravesical space along the lateral border of the infundibulopelvic ligament.