A 40-year-old woman presents to the emergency department with excruciating pain in her right lower quadrant. She reports experiencing intermittent pain in the same area for the past few months, but the severity of the pain has significantly increased over the past 24 hours. On physical examination, her abdomen is tender to palpation in the right lower quadrant. Ultrasound reveals a large, complex cystic mass in her right ovary. Surgery is recommended, and the surgeon plans to approach the mass via the posterior cul-de-sac. The surgeon must be mindful to avoid injury to which of the following structures during this procedure?
B) Inferior vena cava
D) Common iliac arteries
E) Sigmoid colon
The ureters are retroperitoneal structures that pass in close proximity to the ovaries, uterus, and posterior cul-de-sac (also known as the pouch of Douglas), making them particularly vulnerable to injury during gynecological surgeries. The ureters course from the renal pelvis, over the pelvic brim and under the ovarian vessels, and then along the lateral wall of the pelvis towards the bladder. Therefore, any procedure involving the female reproductive tract requires careful dissection and constant awareness of the location of the ureters to avoid inadvertent injury. The inferior vena cava (Choice B), aorta (Choice C), common iliac arteries (Choice D), and sigmoid colon (Choice E) are not as directly threatened in this surgical approach as the ureters.