The most harmful and enduring anatomical error in all of western medicine was made 500 years ago by an anatomist and artist by the name of Andreas Vesalius. For reasons that remain unknown, Vesalius drew the human pelvis with a 90º backward rotation. It's never been corrected and is used by the medical community today as a basis of understanding human anatomy.
The fact that the error was made so long ago is not surprising. What is disgraceful however, is that the mistake was never corrected.
Reasons why the position of the pelvis remains misrepresented to this day are less mysterious, as virtually all pelvic and hip surgeries are based on this age-old anatomical misconception. The error has been compounded over the centuries, so that now the practices of gynecology, urology, and orthopedics are far too invested in their wrong view of pelvic orientation to ever make the correction.
How could the gynecologist suddenly admit that all “pelvic floor” surgeries are misconceived because in reality there is no pelvic floor? How could the urologist possibly acknowledge that the exceedingly high failure rates associated with incontinence procedures are due to profound anatomical error? Or the orthopedist confess that all “3D” CT scans of the hip are rotated into the Vesalius position by software programs?
Understand that the medical system has had ample time to rectify the mistake. J.W. Davies pointed out in 1955 that the misconception of human pelvic position has serious implications for gynecologic surgery.
Veterinarians Stromberg and Williams asked the question in 1983, “Why isn’t this being corrected?” In 1996, urogynecologists Linda Brubaker and Theodore Saclarides published a textbook titled, The Female Pelvic Floor, in which they reproduced the original Davies drawings to inform pelvic surgeons that the pelvis is not positioned like a bowl. For if it were in the bowl position, the pubic bones would dislocate with every step. The human pelvis is positioned like a ring on its edge with the pubic bones underneath the body like straps of a saddle.
The key conceptual change in realizing the true position of the pelvis within the standing body is that we do not have a muscular pelvic floor underneath the torso. Rather, we have a pelvic wall at the back of the body. The pelvic organs are positioned at right angles to their channels and are supported by the true bony pelvic floor (pubic bones), and the lower abdominal wall.
This conceptual shift has huge implications for women. When women believe they have a hole in the bottom of a “floor", they automatically think they have to squeeze to make the vagina smaller, tighter, and stronger so their organs don’t fall out. This is a misconception, as the vagina folds down into a flat, airless space when the body is properly weight-loaded from above.
Surgeries for pelvic organ prolapse and urinary incontinence are built upon an incorrect understanding of the anatomy of the female pelvis. Gynecology and urology see the vagina as like a tree trunk, holding the uterus and ovaries up above. This too leads to the misunderstanding that the vagina must be made stronger, tighter, and smaller through prolapse surgery.
Pelvic surgeons used to tell women that scar tissue created by vaginal wall “repairs” would act as a barricade to prevent the bladder or rectum from bulging into the vaginal space. A century of surgical failure led to the development of polypropylene mesh “walls” implanted between vagina and bladder, and vagina and rectum. More than 2 million women in the United States have been implanted with transvaginal mesh over the past 2 decades. The devastating truth is that these surgeries don’t work because they are built upon a foundational anatomical misconception. In reality the vagina is a flattened tube running back to front, which protects itself by flattening under the forces of intraabdominal pressure.
As many countries work to outlaw transvaginal mesh, other dangerous devices and procedures are being rushed to market to treat prolapse and incontinence. All prolapse and incontinence surgeries are based on incorrect anatomical understanding. One such procedure is the NeuGuide operation that permanently implants a metal alloy material into the sacrospinous ligament, and then attaches the device to the back wall of the cervix with long permanent sutures. This is believed to “elevate the uterus to its normal or non-prolapsed position", a concept that is mistaken. In reality, the sacrospinous ligament is at the back of the body, while the uterus is at the front. The vagina forms a natural axis from its opening at the back, toward the uterus at the front.
Affixing the cervix to the sacrospinous ligament ultimately results in prolapse of both the uterus and bladder because these organs are being constantly pulled toward the back of the body. No long-term data exist for the NeuGuide operation. However, sacrospinous ligament fixation of the post-hysterectomy vagina has been studied extensively over the past three decades. After amputation from the cervix, the vagina is rarely long enough to stretch to both sacrospinous ligaments, so is sutured to one side of the pelvis or the other. The surgery is associated with many serious side effects, not the least of which is new-onset or worsening bladder prolapse, and was largely abandoned in favor of sacrocolpopexy. However, like all surgeries for prolapse and incontinence, sacrospinous ligament fixation was recycled when the newer operation failed as well.
Polypropylene mesh is a disaster when implanted into the vaginal walls. However, the critical point that must be understood is that no matter what the material - bovine, porcine, or any other biological or synthetic tissue - implanting mesh to “strengthen” the vaginal walls is simply a wrong concept.
You may have noticed that inguinal hernias run in families. Researchers say yes, there is a genetic component to the risk of developing an inguinal hernia.
At the annual meeting of the American Association of Gynecologic Laparoscopists (AAGL), two leading urogynecologists debated the use of pelvic mesh versus native tissue repair in surgery.
In this Mesh News Desk podcast, Dr. Donald Ostergard talks about how to find a doctor to do pure tissue repair rather than use polypropylene mesh, tests, and treatments for SUI.