While the insertion of a TOT is a relatively simple procedure, removal of all the mesh requires a complex and delicate dissection around the obturator foramen. We will review in this movie the pelvic anatomy importance in placement and removal of a trans-obturator sling. The bony structures of the pelvis are seen. The sacro-spinous ligament extends from the sacrum to the ischial spine. The obturator internus and externus originate from the obturator foramen and obturator membrane. They insert onto the trochanter of the femur. The pelvic musculature is seen, including the coccygeus, pubococcygeus, ileococcygeus, and obturator internus muscles. A perineal view of the pelvic musculature is seen. The bulbospongiosus muscle, the perineal membrane, the ischiocavernosus muscle, the transverse perineal muscle, the pubococcygeus muscle, the ileococcygeus muscle, the external anal sphincter. For TOT removal, an incision is made lateral to the labia and obturator ring. The subcutaneous tissue and adductor fascia are seen. The adductor fascia is opened, revealing the adductor longus and gracilis muscles. The cadaveric dissection of the groin musculature is seen. The adductor longus and gracilis muscles are seen attached to the pubis. Retraction of the adductor longus and gracilis muscles uncovers the adductor brevis and external obturator muscles. A curved needle passer traverses the obturator foramen a few centimeters from the obturator nerve and vessels. The anatomy is again seen in these illustrations. The adductor longus and gracilis muscles are seen in blue. The adductor longus and gracilis muscles have been removed, exposing the external obturator, adductor brevis, and adductor magnus muscles. Removal of the external obturator exposes the obturator membrane and pedicle. Removal of the obturator membrane reveals the obturator internus. The iliococcidious muscle, seen in blue, inserts in a condensation of the internal obturator fascia. Infected or inflamed mesh traversing the muscles and nerves affecting the hip and pelvis may result in hip, pelvic, and leg pain. The obturator nerve and vessels enter at the superior lateral aspect of the obturator foramen. Here is the pelvic view of the nerves involved in trans-obturator surgery. It includes the ilial inguinal, the genital branch of the genitofemoral, the pudendal, and the obturator nerves. A perineal view of the pelvis depicts the areas of superficial nerve distribution important in obturator sting placement and removal. Again we see the ilial inguinal nerve, the genital branch of the genitofemoral nerve, the obturator nerve, and the pudendal nerve. The perineal nerve and the perineal branch of the femorocutaneous nerve can also be affected. Deep knowledge of the anatomy of the obturator fossa is essential in the surgical removal of obturator mesh.

pelvic anatomy

trans-obturator slings

TOT placement

TOT removal

obturator fossa