Suspensory Ligament

The suspensory ligament of the ovary, also called the infundibulopelvic ligament, is a fold of peritoneum extending from the superior or tubal pole of the ovary toward the lateral wall of the pelvis. It forms an important neurovascular connection between the ovary and the posterior abdominal and lateral pelvic regions.

The suspensory ligament is particularly important because it transmits the ovarian artery, ovarian vein, lymphatic vessels, and autonomic nerves to and from the ovary. These structures travel within connective tissue enclosed by the peritoneal fold.

The suspensory ligament should not be confused with the ovarian ligament, which connects the ovary to the uterus. The suspensory ligament extends laterally toward the pelvic wall, whereas the ovarian ligament extends medially toward the uterine horn.

Location

The suspensory ligament lies within the female pelvis between the ovary and the lateral pelvic wall. It is associated with the superior and lateral aspect of the ovary and is continuous with the peritoneal folds surrounding the adnexa.

Its position places it near the lateral end of the uterine tube and the lateral margin of the broad ligament.

Structure

The suspensory ligament is a peritoneal fold containing connective tissue and the principal neurovascular structures supplying the ovary.

Unlike a dense fibrous ligament whose main function is mechanical stabilization, the suspensory ligament serves primarily as a supporting peritoneal fold and a conduit for vessels, lymphatics, and nerves.

Attachments

Medially, the suspensory ligament is attached to the region of the superior pole of the ovary. Laterally, it extends toward and blends with the peritoneum of the lateral pelvic wall.

This arrangement suspends the lateral aspect of the ovary while providing a pathway through which the ovarian neurovascular structures reach it.

Superior Pole of the Ovary

The superior pole of the ovary is also called the tubal pole because of its close relationship to the uterine tube.

The suspensory ligament approaches this pole from the lateral pelvic wall, carrying the ovarian vessels toward the ovarian hilum.

Lateral Pelvic Attachment

The lateral end of the suspensory ligament becomes continuous with the peritoneum covering the lateral pelvic wall.

At this location, the ovarian vessels cross the pelvic brim and enter the suspensory ligament as they approach the ovary.

Contents

The principal structures transmitted within the suspensory ligament include:

• Ovarian artery
• Ovarian vein and venous plexus
• Ovarian lymphatic vessels
• Autonomic nerve fibers
• Connective tissue

These structures collectively form the principal vascular, lymphatic, and neural connection between the ovary and the posterior abdominal region.

Ovarian Artery

The ovarian artery usually arises directly from the abdominal aorta inferior to the renal arteries. It descends retroperitoneally along the posterior abdominal wall before crossing the pelvic brim.

After entering the pelvis, the artery travels within the suspensory ligament toward the ovary. It gives branches to the ovary and uterine tube and participates in anastomoses with branches of the uterine artery.

Course of the Ovarian Artery

From its aortic origin, the ovarian artery descends over the posterior abdominal wall. It crosses anterior to structures associated with the posterior abdominal and pelvic regions before entering the suspensory ligament.

Within the ligament, it approaches the ovarian hilum and divides into branches supplying the ovary and adjacent reproductive structures.

Ovarian Veins

Venous blood from the ovary initially drains into a venous network associated with the ovarian hilum. These vessels unite to form the ovarian vein, which travels within the suspensory ligament.

The ovarian veins then ascend from the pelvis along the posterior abdominal wall.

Right Ovarian Vein

The right ovarian vein generally drains directly into the inferior vena cava.

This differs from the drainage pattern on the left side and is an important example of asymmetrical venous anatomy within the abdomen.

Left Ovarian Vein

The left ovarian vein generally drains into the left renal vein rather than directly into the inferior vena cava.

The difference between right and left ovarian venous drainage is clinically relevant in pelvic venous disorders and interpretation of abdominal and pelvic imaging.

Ovarian Lymphatics

The lymphatic drainage of the ovary follows its embryological vascular supply. Lymphatic vessels leave the ovary and travel within the suspensory ligament alongside the ovarian vessels.

They then ascend toward the posterior abdominal wall and drain primarily into lumbar lymph nodes, also called lateral aortic or para-aortic nodes.

Why Ovarian Lymph Drains Superiorly

The relatively high lymphatic drainage of the ovary reflects its embryological origin in the posterior abdominal region. During development, the ovaries descend into the pelvis but retain vascular and lymphatic connections with the abdominal region from which they originated.

This explains why ovarian lymph does not primarily drain to superficial inguinal lymph nodes despite the ovary's adult pelvic location.

Nerve Supply

Autonomic nerve fibers reach the ovary by traveling along the ovarian vessels and through the suspensory ligament.

These fibers arise from autonomic plexuses associated with the abdominal aorta and ovarian vascular pathways and include sympathetic and visceral afferent fibers.

Relationship to the Broad Ligament

The suspensory ligament is continuous with the peritoneal folds associated with the broad ligament of the uterus. It extends laterally from the adnexal region toward the pelvic wall.

Although closely related, the broad ligament and suspensory ligament are anatomically distinguishable. The broad ligament extends broadly between the uterus and pelvic walls, whereas the suspensory ligament specifically carries the ovarian neurovascular structures toward the ovary.

Relationship to the Mesovarium

The mesovarium is a short peritoneal fold connecting the anterior border of the ovary to the posterior layer of the broad ligament.

The suspensory ligament approaches the ovary from the lateral pelvic wall, while the mesovarium connects the ovary with the broad ligament. Neurovascular structures reaching the ovary through the suspensory ligament continue toward the ovarian hilum.

Relationship to the Uterine Tube

The suspensory ligament lies near the lateral end of the uterine tube, particularly the infundibulum and fimbriae.

Branches of the ovarian artery traveling within the ligament contribute to the vascular supply of the uterine tube and anastomose with tubal branches derived from the uterine artery.

Relationship to the Ovarian Ligament

The ovarian ligament extends from the medial pole of the ovary to the lateral aspect of the uterus near the uterine horn.

The suspensory ligament extends in the opposite direction, from the superior or lateral region of the ovary toward the lateral pelvic wall.

Ovarian Attachments

Structure	Connection	Principal Significance
Mesovarium	Ovary to broad ligament	Attaches ovarian hilum to broad ligament
Ovarian ligament	Ovary to uterus	Maintains medial connection to uterus
Suspensory ligament	Ovary to lateral pelvic wall	Transmits ovarian vessels, lymphatics, and nerves

Relationship to the Ureter

The ureter is an important structure near the suspensory ligament and ovarian vessels. As the ovarian vessels enter the pelvis, their relationship to the ureter must be recognized during surgical procedures.

The ureter generally passes posterior to the ovarian vessels near the pelvic brim. This relationship makes identification of the ureter particularly important before the suspensory ligament is surgically divided.

Relationship to the External Iliac Vessels

The suspensory ligament is associated with the lateral pelvic wall near major iliac vessels. The exact spatial relationships vary with ovarian position and individual pelvic anatomy.

Knowledge of these relationships is important during pelvic surgery because the ligament may need to be isolated and divided close to major retroperitoneal structures.

Ovarian Hilum

The ovarian hilum is located along the anterior border of the ovary where vessels, nerves, and lymphatics enter and leave the organ.

The mesovarium attaches in this region, and neurovascular structures carried toward the ovary through the suspensory ligament ultimately reach the hilum.

Function

The suspensory ligament has two closely related functions. It helps maintain the anatomical relationship of the ovary to the lateral pelvic wall and provides a protected pathway for the ovarian neurovascular structures.

Its role as a vascular pedicle is particularly important anatomically and surgically.

Vascular Pedicle of the Ovary

The suspensory ligament is often considered the principal vascular pedicle of the ovary because it contains the ovarian artery and vein.

When the ovary is surgically removed, these vessels must be securely controlled before the ligament is divided.

Embryological Basis

The anatomy of the suspensory ligament reflects the developmental descent of the ovary from the posterior abdominal region into the pelvis.

The ovary retains vascular, lymphatic, and neural connections extending toward the upper posterior abdominal region. These structures reach the adult ovary through the suspensory ligament.

Development of the Ovary

The ovaries initially develop high on the posterior abdominal wall. During fetal development, they descend into the pelvis.

Their final position is influenced by development of the uterus and the gubernaculum, but their principal arteries continue to arise directly from the abdominal aorta.

Relationship to the Gubernaculum

The suspensory ligament should not be confused embryologically with the ovarian ligament or round ligament of the uterus.

The ovarian ligament and round ligament are derived from the gubernaculum. The suspensory ligament instead represents a peritoneal fold associated with the ovarian neurovascular pedicle.

Suspensory Ligament versus Ovarian Ligament

Feature	Suspensory Ligament	Ovarian Ligament
Connection	Ovary to lateral pelvic wall	Ovary to uterus
Structure	Peritoneal fold containing neurovascular structures	Fibromuscular cord
Major contents	Ovarian vessels, lymphatics, and nerves	No comparable major vascular pedicle
Embryological relationship	Associated with ovarian neurovascular pedicle	Derived from gubernaculum
Direction from ovary	Lateral and superior	Medial toward uterus

Suspensory Ligament versus Mesovarium

Feature	Suspensory Ligament	Mesovarium
Connection	Ovary to lateral pelvic wall	Ovary to broad ligament
Main significance	Carries ovarian neurovascular pedicle	Attaches ovary at its hilum
Relationship to ovary	Approaches superior/lateral pole	Attaches along anterior border

Suspensory Ligament versus Broad Ligament

Feature	Suspensory Ligament	Broad Ligament
Extent	Ovary toward lateral pelvic wall	Uterus toward lateral pelvic wall
Main association	Ovary	Uterus, uterine tube, and ovary
Important contents	Ovarian vessels, lymphatics, nerves	Multiple reproductive structures and neurovascular pathways
Primary significance	Ovarian neurovascular conduit	Pelvic peritoneal organization

Ovarian Torsion

Ovarian torsion occurs when the ovary rotates around its supporting structures and vascular pedicle. The suspensory ligament and ovarian ligament may participate in the axis around which torsion occurs.

Twisting can initially compromise venous and lymphatic drainage and, with increasing torsion, impair arterial blood flow to the ovary.

Vascular Effects of Ovarian Torsion

Because veins have thinner walls and lower intravascular pressure than arteries, venous outflow is often compromised before arterial inflow during torsion.

This can lead to ovarian congestion, edema, enlargement, hemorrhage, and eventually ischemic injury if the torsion persists.

Suspensory Ligament in Oophorectomy

During an oophorectomy, the suspensory ligament is a critical surgical structure because it contains the ovarian vessels.

The ligament must be isolated and its vessels controlled before division to prevent significant hemorrhage.

Suspensory Ligament in Salpingo-Oophorectomy

During salpingo-oophorectomy, removal of the ovary and uterine tube requires management of the ovarian vascular pedicle within the suspensory ligament.

The surgeon must identify nearby retroperitoneal structures, particularly the ureter, before securing and dividing the ligament.

Ureteric Injury

The proximity of the ureter to the ovarian vessels and suspensory ligament creates a risk of ureteric injury during pelvic surgery.

Direct visualization or reliable identification of the ureter's course is therefore important before ligating the ovarian vascular pedicle.

Hemorrhage

Because the suspensory ligament contains the ovarian artery and vein, injury to the ligament can result in substantial bleeding.

Hemorrhage can occur during trauma, surgery, or disruption of the ovarian vascular pedicle.

Ovarian Vein Thrombosis

Ovarian vein thrombosis is a vascular disorder involving thrombosis of the ovarian vein. It is particularly associated with pregnancy and the postpartum period, although it can occur in other clinical settings.

Because the ovarian vein travels through the suspensory ligament before ascending into the abdomen, knowledge of this pathway assists in understanding the anatomical distribution of the condition.

Pelvic Congestion

Dilation and incompetence of ovarian veins can contribute to pelvic venous congestion. The ovarian venous pathways passing through the suspensory ligament connect the pelvic venous circulation with major abdominal veins.

The asymmetric drainage of the right and left ovarian veins can influence patterns of venous dilation and collateral circulation.

Ovarian Malignancy and Lymphatic Spread

The lymphatic vessels of the ovary accompany the ovarian vessels through the suspensory ligament toward the lumbar lymph nodes.

This pathway is important in understanding the lymphatic spread of ovarian malignancy and the distribution of regional lymph node involvement.

Imaging Appearance

On cross-sectional imaging, the ovarian vessels can help identify the course of the suspensory ligament between the ovary and lateral pelvic or posterior abdominal region.

Tracing these vessels can also assist in determining the origin of an adnexal mass and distinguishing ovarian structures from adjacent pelvic organs.

Surgical Anatomy

The suspensory ligament is one of the most important landmarks during surgery involving the ovary. The ovarian vessels must be identified, controlled, and divided safely when removal of the ovary is required.

The relationship between the ligament, ureter, iliac vessels, uterine tube, ovary, and pelvic sidewall should be understood before the ovarian pedicle is manipulated.

Relationship to the Pelvic Brim

The ovarian vessels descend from the posterior abdominal wall and cross into the pelvis near the pelvic brim. From this region they enter the suspensory ligament and travel toward the ovary.

This transition marks the connection between the abdominal origin of the ovarian vasculature and the pelvic position of the adult ovary.

Relationship to the Infundibulum

The lateral end of the uterine tube expands into the infundibulum, which lies near the superior pole of the ovary and suspensory ligament.

This close anatomical relationship places the ovarian vascular pedicle near the fimbrial end of the uterine tube.

Relationship to the Fimbriae

The fimbriae extend from the infundibulum toward the ovary. One particularly long fimbria, the ovarian fimbria, is attached to the ovary.

The suspensory ligament lies nearby but remains a distinct structure whose principal importance is transmission of the ovarian neurovascular pedicle.

Relationship to the Ovarian Fossa

The ovary commonly occupies the ovarian fossa on the lateral pelvic wall. The suspensory ligament extends from the superior region of the ovary toward the pelvic wall above this area.

The ovarian fossa is related to important vascular, neural, and ureteric structures, contributing to the surgical importance of this region.

Mobility of the Ovary

The ovary has a degree of physiological mobility because its attachments do not rigidly fix it to the pelvic wall.

The mesovarium, ovarian ligament, and suspensory ligament collectively maintain its anatomical relationships while permitting some movement. Excessive mobility or enlargement can contribute to susceptibility to torsion.

Changes During Pregnancy

Pregnancy produces substantial changes in the position and vascularity of the reproductive organs. Enlargement of the uterus can alter the position of the ovaries and associated peritoneal folds.

Ovarian and pelvic vessels may also become more prominent because of increased reproductive blood flow.

Key Anatomical Relationships

• The suspensory ligament connects the region of the ovary to the lateral pelvic wall.
• It is also called the infundibulopelvic ligament.
• It is a peritoneal fold containing connective tissue and neurovascular structures.
• It carries the ovarian artery and ovarian vein.
• Ovarian lymphatic vessels travel through it toward lumbar lymph nodes.
• Autonomic nerves accompany the ovarian vessels within it.
• It is continuous with peritoneal folds near the lateral margin of the broad ligament.
• It is distinct from the ovarian ligament, which connects the ovary to the uterus.
• It is distinct from the mesovarium, which attaches the ovary to the broad ligament.
• The ureter is an important nearby structure during surgical division of the ligament.
• The ligament forms the principal vascular pedicle of the ovary.

Clinical Importance

The suspensory ligament is particularly important in gynecological surgery because it contains the main ovarian vascular pedicle. Procedures involving removal of the ovary require secure control of the ovarian artery and vein before the ligament is divided.

The ureter lies close to the ovarian vascular pathway near the pelvic brim and pelvic sidewall. Failure to identify this relationship can result in ureteric injury during oophorectomy or salpingo-oophorectomy.

The suspensory ligament is also involved in the anatomy of ovarian torsion. Rotation of the ovary and its supporting structures can compromise vessels within the ligament, initially obstructing venous drainage and eventually reducing arterial perfusion. The resulting congestion and ischemia can threaten ovarian viability.

Because ovarian lymphatics travel through the suspensory ligament toward para-aortic lymph nodes, the ligament also provides an important anatomical pathway for understanding lymphatic drainage and patterns of spread from ovarian malignancies.

Functional Importance

The suspensory ligament maintains the neurovascular connection between the ovary and the abdominal and pelvic walls. Its ovarian artery supplies oxygenated blood, its veins provide venous drainage, its lymphatics carry lymph toward abdominal nodes, and its nerves provide autonomic and visceral sensory connections.

Its anatomy reflects the developmental history of the ovary. Although the adult ovary lies within the pelvis, its vessels arise from and return toward structures in the posterior abdomen because the gonad originally developed at a much higher level.

Understanding the suspensory ligament provides a foundation for studying ovarian anatomy, ovarian blood supply, ovarian lymphatic drainage, the broad ligament, ovarian ligament, mesovarium, uterine tube, ovarian torsion, oophorectomy, pelvic surgical anatomy, and the developmental descent of the ovary.