Precise Neurovascular Anatomy For Radical Hysterectomy: Shingo Fujii Kentaro Sekiyama

Shingo Fujii
Kentaro Sekiyama
Precise Neurovascular
Anatomy for Radical
Hysterectomy
123
Precise Neurovascular Anatomy
for Radical Hysterectomy
Shingo Fujii • Kentaro Sekiyama
Precise Neurovascular
Anatomy for Radical
Hysterectomy
Shingo Fujii Kentaro Sekiyama
Department of Gynecology and Obstetrics Department of Obstetrics and Gynecology
Kyoto University Kitano Hospital
Kyoto Kita-ku
Japan Osaka
Japan
ISBN 978-981-13-8097-6 ISBN 978-981-13-8098-3 (eBook)

https://doi.org/10.1007/978-981-13-8098-3
© Springer Nature Singapore Pte Ltd. 2020

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Preface
Since Ernst Wertheim reported the first systematic data on radical hysterectomy in 1911,
radical hysterectomy has been considered the most interesting and challenging operation in
gynecologic surgery. Naturally, many surgeons have endeavored to improve on Wertheim’s
radical hysterectomy. Among them, the most pioneering modifications might be by Latzko
in 1919 and by Okabayashi in 1921. Okabayashi’s radical hysterectomy became popular by
1930 and has been performed as a standard technique for the treatment of Stage Ib and IIb
cervical cancer patients in Japan. In contrast, radical hysterectomy was not popular in
Western countries until 1954, when Meigs established radical hysterectomy as a safe and
effective treatment modality for the cervical cancer patient with early invasive lesion.
In order to accomplish a safe radical hysterectomy, knowledge of the precise anatomical
female pelvis is essential. Many advances in our understanding of anatomy have been neces-
sary for further development of techniques in radical hysterectomy. Until recently, the exact
anatomy of the bilateral cardinal and the vesicouterine ligaments in the retroperitoneal space
at the level of the uterine cervix and upper vagina was a black box for many years. Moreover,
quality of life after radical hysterectomy, particularly the bladder function, has been pursued
by many doctors under the name of nerve-sparing radical hysterectomy, and the precise neuro-
vascular anatomical knowledge of the pelvic cavity has been elucidated.
This book is focused on the detailed neurovascular anatomy during the open-abdominal radi-
cal hysterectomy. Color illustrations are used as much as possible to depict each surgical step
during a radical hysterectomy. For the introduction of radical hysterectomy, illustrated figures
from the early twentieth century describe each original surgical step of Okabayashi’s radical
hysterectomy. This is followed by a step-by-step guide to radical hysterectomy without nerve-
sparing, illustrating the precise neurovascular anatomy of the retroperitoneal space of the uter-
ine cervix and upper vagina (the cardinal ligament and the vesicouterine ligament). The last
chapter of the book is focused on nerve-sparing radical hysterectomy, illustrating the detailed
anatomical relationship between the vascular system of the vesicouterine ligament and the nerve
plane of the inferior hypogastric plexus formed by the hypogastric nerve, the pelvic splanchnic
nerve, the uterine branch, and the bladder branch. Five video disks are provided, with these
titles: (1) Radical Hysterectomy, performed by Okabayashi himself; (2) Nerve-Sparing Radical
Hysterectomy, by Shingo Fujii; (3) Mibayashi’s Original Super-radical Hysterectomy; (4)–(5)
Live Surgical Videos of Step-by-Step Nerve-Sparing Radical Hysterectomy, by Shingo Fujii.
With the benefit of magnified views during laparoscopic surgery, surgeons have a greater
appreciation of the clear anatomy of the blood vessels in the connective tissues in the female
pelvis. Laparoscopy is now well established in the surgical management of gynecological
malignancies, with laparoscopic and robotic approaches becoming commonplace in radical
hysterectomy. A sound understanding of the neurovascular anatomy is a necessity for emerging
gynecological oncology surgeons for open-abdominal and laparoscopic radical hysterectomy.
We hope the book will be a helpful and valuable addition for surgeons who would like to
brush up their surgical skills to perform a safe and comprehensive radical hysterectomy.
Kyoto, Japan Shingo Fujii

Osaka, Japan Kentaro Sekiyama
v
Acknowledgments
I would like to acknowledge Kenji Takakura, M.D., Noriomi Matsumura, M.D., Toshihiro
Higuchi, M.D., Sigeo Yura, M.D., Masaki Mandai, M.D., Tsukasa Baba, M.D., Shinya
Yoshioka, M.D., Kentaro Sekiyama, and colleagues of the Department of Gynecology and
Obstetrics at Kyoto University for their sincere support during the clarification of the precise
anatomy of the vesicouterine ligament and the inferior hypogastric plexus.
Kentaro Sekiyama and I would like to express our gratitude to Dr. Ranjit Manchanda,
Clinical Senior Lecturer and Consultant Gynecological Oncologist, Barts Cancer Institute,
Queen Mary University of London, and his associate Dr. Dhivya Chandrasekaran for editing
this textbook.
Shingo Fujii
vii
Contents
1 Brief History of Surgical Treatment for Cervical Cancer�� 1

1.1 Cervical Amputation and Simple Total Hysterectomy�� 1
1.2 Extended Hysterectomy with Lymph Node Resection as a Radical
Approach for Cervical Cancer Patients �� 2
1.3 Modification of Wertheim’s Radical Hysterectomy
with Pelvic Lymphadenectomy �� 3
1.4 Situation of Radical Hysterectomy in Mid-Twentieth Century�� 4
1.5 Recent Novel Findings and Methods on Radical Hysterectomy�� 5
1.6 Super-Radical Hysterectomy�� 6
1.7 Notes�� 8
1.7.1 Surgical Novel Concepts and Anatomical
Findings on Radical Hysterectomy�� 8
1.7.2 History of Radical Hysterectomy in Western Countries and in Japan�� 9
References�� 10
2 Classification of Radical Hysterectomy �� 11
2.1 Piver–Rutledge–Smith’s Classification (1974)�� 11
2.2 Querler & Morrow’s Classification (2008) �� 12
2.3 Classification of Radical Hysterectomy
and Corresponding Surgical Treatment Modalities �� 13
References�� 14
3 Concept of the Original Okabayashi’s Radical Hysterectomy�� 15
3.1 Principles of Okabayashi’s Radical Hysterectomy�� 15
4 Atlas of the Original Okabayashi’s Transabdominal Radical Hysterectomy�� 19
4.1 Surgical Steps of Original Okabayashi’s Radical Hysterectomy�� 19
4.1.1 Opening of the Abdominal Cavity�� 19
4.1.2 Exposure of the Pelvic Cavity�� 19
4.1.3 Visual and Manual Examination of the Spread
of the Disease and Judgment of Operability�� 19
4.1.4 Traction of the Uterus �� 19
4.2 Illustrated Surgical Steps of Original Okabayashi’s
Radical Hysterectomy �� 20
4.2.1 Ligation and Division of the Round Ligament to Reveal
the Connective Tissue of the Broad Ligament�� 20
4.2.2 Ligation and Division of the Ovarian Ligament (Propria Ovarii)
and the Fallopian Tube for the Preservation of the Ovary�� 21
4.2.3 Isolation, Ligation, and Division of the Uterine Artery�� 22
4.2.4 Separation of the Ureter from the Dorsal Peritoneal
Layer of the Broad Ligament�� 23
4.2.5 The Same Procedures on the Opposite Side �� 23
4.2.6 Separation of the Peritoneal Layer of the Pouch of Douglas�� 24
ix
x Contents
4.2.7 Development of the Retrovaginal Space and Dissection

of the Uterosacral Ligament �� 25
4.2.8 Further Division of the Uterosacral Ligament and the
Development of Okabayashi’s Pararectal Space�� 26
4.2.9 Further Development of the Pararectal Space�� 31
4.2.10 Development of the Paravesical Space and Separation
of the Connective Tissue of the Base of the Cardinal Ligament�� 32
4.2.11 Clamp the Cardinal Ligament�� 33
4.2.12 Dissection of the Cardinal Ligament�� 35
4.2.13 The Procedures on the Opposite Side�� 35
4.2.14 Separation of the Peritoneum Between the Urinary
Bladder and the Uterus �� 36
4.2.15 Separation of the Connective Tissue Between the Urinary
Bladder and the Ventral-Side of the Cervical Fascia
(the Vesicocervical Space) �� 37
4.2.16 Separation of the Anterior (Ventral) Leaf
of the Vesicouterine Ligament (Left Side) �� 38
4.2.17 Clamp and Dissect the Anterior (Ventral)
Leaf of the Vesicouterine Ligament�� 39
4.2.18 Separation of the Posterior (Dorsal) Leaf of the
Vesicouterine Ligament and the Paravaginal Space �� 40
4.2.19 Separation of the Posterior (Dorsal) Leaf of the Vesicouterine
Ligament Through the Paravaginal Space�� 41
4.2.20 Division of the Posterior (Dorsal) Leaf of the
Vesicouterine Ligament from the Paracolpium�� 42
4.2.21 The Same Procedures on the Opposite Side�� 42
4.2.22 Treatment of the Rectovaginal Ligament �� 43
4.2.23 A Figure of the Both Cut-Ends of the Cardinal Ligament,
the Uterosacral Ligaments, and the Rectovaginal Ligaments�� 44
4.2.24 Ligation and Dissection of the Paracolpium�� 45
4.2.25 A View of the Pelvic Cavity After the Removal of the Uterus
and Lymphadenectomy and Closure of the Abdominal Cavity�� 47
5 Novel Points of Okabayashi’s Radical Hysterectomy�� 49
5.1 Novel Points of the Okabayashi’s Radical Hysterectomy �� 49
5.1.1 Clarification of the Anatomy of the Paravaginal Space
Between the Posterior (Dorsal) Leaf of the Vesicouterine
Ligament and the Paracolpium�� 49
5.1.2 Clarification of the Anatomy of the Posterior (Dorsal)
6 Step-by-Step Radical Hysterectomy with Pelvic
Lymphadenectomy (Without Nerve-Sparing) �� 55
6.1 Surgical Process of the Step-by-Step Radical Hysterectomy�� 55
6.1.1 Open the Abdominal Cavity �� 55
6.1.2 Exposure of the Pelvic Cavity�� 55
6.1.3 Visual and Manual Examination of the Spread
of the Disease and Operability �� 55
6.1.4 Traction of the Uterus�� 55
6.1.5 Ligation and Division of the Round Ligament�� 56
6.1.6 Ligation and Division of the Suspensory Ligament of the
Ovary (Ovarian Vessels) �� 57
6.1.7 Confirmation of the Ureter �� 58
6.1.8 Isolation of the Ureter�� 59
Contents xi
6.1.9 Application of a Vessel Tape for a Marker of the Ureter�� 60

6.1.10 Tentative Development of the Pararectal Space �� 61
6.1.11 Definition of the Pararectal Space�� 62
6.1.12 The Ureter and the Hypogastric Nerve Are
on the Same Connective Tissue Plane�� 64
6.1.13 Division of the Peritoneum at Pouch of Douglas �� 65
6.1.14 Separation of the Peritoneum of the Vesicouterine Pouch �� 66
6.2 Pelvic Lymphadenectomy �� 67
6.2.1 Lymph Nodes in the Pelvis�� 67
6.2.2 Exposure of the Adipose Tissue in the Supra-Inguinal Area�� 68
6.2.3 Exposure of the Iliopsoas Muscle�� 69
6.2.4 Separation of the External Supra-Inguinal Nodes
from the Ventral Surface of the External Iliac Artery�� 70
6.2.5 Tentative Development of the Paravesical Space �� 71
6.2.6 Separation of the Connective Tissue Between the
External Iliac Artery and Iliopsoas Muscle�� 72
6.2.7 Separation of the Uterine Side Connective Tissue
of the External Iliac Artery and Vein�� 73
6.2.8 Lymphadenectomy of the External Iliac Nodes of the Uterine Side�� 74
6.2.9 Separation of the Connective Tissue Between the Iliopsoas Muscle
and the External Iliac Vessels Toward the Pelvic Floor�� 75
6.2.10 Dissection of the External Iliac Nodes �� 76
6.2.11 Separation of the Connective Tissue on the Internal Iliac Artery�� 77
6.2.12 Confirmation of the Obturator Nerve in the Obturator Fossa�� 78
6.2.13 Lymphadenectomy of the Obturator Fossa�� 79
6.2.14 Lymphadenectomy of the Obturator Fossa �� 80
6.2.15 Lymphadenectomy of the Obturator Fossa �� 81
6.2.16 En Bloc Removal of the Lymph Nodes in the Obturator Fossa �� 82
6.2.17 Lymphadenectomy for the Dorsal Side of the Obturator Nerve�� 83
6.2.18 Confirmation of the Base of the Cardinal Ligament�� 85
6.2.19 The Lymphadenectomy of the Common Iliac Nodes �� 86
6.2.20 Lymphadenectomy of the Sacral Nodes�� 88
6.2.21 Removal of the Common Iliac Nodes�� 89
6.2.22 A View of the Pelvic Cavity After the Pelvic Lymphadenectomy �� 90
6.3 Treatment of the Cardinal Ligament�� 91
6.3.1 A View of the Pelvis After the Lymphadenectomy�� 91
6.3.2 Separation of the Loose Connective Tissue Between
the Uterine Artery and the Superior Vesical Artery�� 92
6.3.3 Development of the Paravesical Space and Confirmation
of the Uterine Artery�� 93
6.3.4 Definition of the Cardinal Ligament�� 94
6.3.5 Isolation and Division of the Uterine Artery�� 95
6.3.6 Separation of the Superficial Uterine Vein �� 96
6.3.7 Clamp, Divide, and Ligate the Superficial Uterine Vein �� 97
6.3.8 Separation of the Deep Uterine Vein�� 98
6.3.9 Clamp, Divide, and Ligate the Deep Uterine Vein �� 99
6.3.10 Confirmation and Division of the Pelvic Splanchnic Nerve �� 100
6.4 Development of the Rectovaginal Space and Division
of the Uterosacral Ligament�� 101
6.4.1 Separation and Division of the Peritoneum of the Douglas’ Pouch�� 101
6.4.2 Development of the Rectovaginal Space�� 102
6.4.3 Division of the Uterosacral Ligament�� 103
xii Contents
6.4.4 Further Division of the Uterosacral Ligament and Development

of the Okabayashi’s Pararectal Space�� 104
6.4.5 Development of the Pararectal Space�� 105
6.5 Separation of the Urinary Bladder and the Vesicouterine Ligament �� 106
6.5.1 Separation of the Urinary Bladder from the Cervical Fascia �� 106
6.5.2 Anatomy of the Vesicouterine Ligament�� 107
6.5.3 Anatomy of the Anterior (Ventral) Leaf of the Vesicouterine
Ligament�� 108
6.5.4 Anatomy of the Posterior(Dorsal) Leaf of the Vesicouterine
Ligament�� 109
6.5.5 Cross-Sectional Pelvic View of the Blood Vessels
in the Vesicouterine Ligament with Each Surgical Step�� 110
6.5.6 Lateral(Right) Side View of the Treatment
of the Anterior (Ventral) Leaf of the Vesicouterine
Ligament with Each Surgical Step �� 115
6.5.7 Step-by-Step Separation of the Anterior (Ventral)
6.6 Treatment of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament �� 124
6.6.1 Step-by-Step Separation of the Posterior (Dorsal) Leaf
of the Vesicouterine Ligament�� 124
6.6.2 Division of the Rectovaginal Ligament�� 132
6.6.3 Further Division of the Rectovaginal Ligament �� 134
6.6.4 Division of the Paracolpium (Vaginal Blood Vessels)�� 135
6.6.5 Incision to the Vaginal Wall�� 136
6.6.6 Amputation of the Vaginal Wall and Closure of the Vaginal Cuff�� 137
6.6.7 Partial Suture to the Pelvic Peritoneum and Insertion
of Drains into the Retroperitoneal Space �� 138
6.6.8 Closure of the Abdominal Cavity�� 139
References�� 140
7 What Is Nerve-Sparing Radical Hysterectomy? �� 141
7.1 Severe Bladder Dysfunction/Colorectal Motility Disorders
Are Common Complications of Radical Hysterectomy�� 141
7.1.1 Nerve Supply to the Uterus, Rectum, and Urinary Bladder�� 142
7.1.2 Locations of Nerve Damages During Radical Hysterectomy�� 143
7.1.3 Efforts on Nerve-Sparing Radical Hysterectomy�� 144
7.1.4 Principle of Nerve-Sparing Radical Hysterectomy�� 145
7.1.5 The Description of Anatomy for Nerve-Sparing
Radical Hysterectomy�� 146
7.1.6 Indication of Nerve-Sparing Radical Hysterectomy�� 147
References�� 148
8 Step-by-Step Nerve-Sparing Radical Hysterectomy with Pelvic
Lymphadenectomy�� 149
8.1 The Surgical Process of the Step-by-Step Nerve-Sparing
Radical Hysterectomy Is Listed in the Following Pages �� 149
8.2 The Following Are Described in Chap. 6�� 149
8.3 Contents in Chap. 8 �� 149
8.4 Treatment of the Cardinal Ligament�� 150
8.4.1 A View of Pelvis After the Lymphadenectomy�� 150
8.4.2 Separation of the Loose Connective Tissue Between the
Uterine Artery and Superior Vesical Artery�� 151
8.4.3 Development of the Paravesical Space and Confirmation
of the Uterine Artery�� 152
Contents xiii
8.4.4 Confirmation of the Cardinal Ligament �� 153

8.4.5 Isolation and Division of the Uterine Artery�� 154
8.4.6 Separation of the Superficial Uterine Vein �� 155
8.4.7 Clamping and Division of the Superficial Uterine Vein �� 156
8.4.8 Separation of the Deep Uterine Vein�� 157
8.4.9 Division of the Deep Uterine Vein Reveals the
Pelvic Splanchnic Nerve�� 158
8.5 Treatment of the Hypogastric Nerve �� 159
8.5.1 Isolation of the Hypogastric Nerve�� 159
8.5.2 Apply a Vessel Tape to the Isolated Hypogastric Nerve�� 160
8.5.3 Separation of the Ureter from the Connective Tissue
Plane and Application of a Vessel Tape to the Isolated Ureter �� 161
8.6 Development of the Rectovaginal Space and Division
of the Uterosacral Ligament�� 162
8.6.1 Separation and Division of the Peritoneum of the Douglas’ Pouch�� 162
8.6.2 Development of the Rectovaginal Space�� 163
8.6.3 Division of the Uterosacral Ligament�� 164
8.7 Separation of the Urinary Bladder and Anatomy
of the Vesicouterine Ligament �� 165
8.7.1 Separation of the Urinary Bladder from the Cervical Fascia �� 165
8.7.2 Anatomy of the Vesicouterine Ligament�� 166
8.7.3 Anatomy of the Anterior (Ventral) Leaf of the Vesicouterine
Ligament�� 167
8.7.4 Anatomy of the Posterior (Dorsal) Leaf of the Vesicouterine
Ligament�� 168
8.7.5 Skeletonized View of the Blood Vessels and the Ureter
in the Vesicouterine Ligament�� 169
8.8 Treatment of the Anterior(Ventral) Leaf of the Vesicouterine Ligament�� 170
8.8.1 Isolation of the Ureteral Branch of the Uterine Artery�� 170
8.8.2 Division of the Ureteral Branch of the Uterine Artery �� 171
8.8.3 Separation of the Superficial Uterine Vein from the
Ureter and Isolation of the Superior Vesical Vein�� 172
8.8.4 Division of the Superior Vesical Vein�� 173
8.8.5 Complete Separation of the Uterine Side of the Uterine Artery
and the Superficial Uterine Vein from the Ventral Side of the Ureter�� 174
8.8.6 Separation of the Anterior (Ventral) Leaf of the
Vesicouterine Ligament�� 175
8.8.7 Isolation and Division of the Cervicovesical Vessels �� 176
8.9 Treatment of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament �� 177
8.9.1 Mobilize the Ureter to the Symphysis Side and Confirm the
Posterior (Dorsal) Leaf of the Vesicouterine Ligament�� 177
8.9.2 Isolation of a Vein Connecting the Ureter with the Cervix�� 178
8.9.3 Division of a Vein Connecting the Ureter with the Cervix�� 180
8.9.4 Separation of the Cut-End of the Deep Uterine Vein
from the Pelvic Splanchnic Nerve�� 182
8.9.5 Importance of the Removal of the Adipose Tissues in the
Posterior (Dorsal) Leaf of the Vesicouterine Ligament�� 184
8.9.6 Clamp and Divide the Middle Vesical Vein�� 185
8.9.7 Clamp and Divide the Inferior Vesical Vein �� 187
8.10 Confirmation of the Inferior Hypogastric Plexus (IHP)�� 189
8.11 The Concept of the Pelvic Nerve Plane�� 191
8.12 Separation of the Rectovaginal Ligament �� 192
8.13 Separation of the Bladder Branch from the Paracolpium �� 193
xiv Contents
8.14 Separation of the Uterine Branch from the IHP�� 195

8.15 Division of the Uterine Branch �� 197
8.16 Separation of the Rectovaginal Ligament Preserving T-Shaped Nerve Plane�� 199
8.17 Clamp of the Paracolpium�� 201
8.18 Ligation and Division of the Paracolpium�� 203
8.19 Incise the Vaginal Wall for Amputation of the Vagina�� 205
8.20 Removal of the Uterus Preserving T-Shaped Nerve Plane�� 206
8.21 Closure of the Vaginal Cuff�� 207
8.22 Partial Suture to the Pelvic Peritoneum and Insertion of Drains
into the Retroperitoneal Space�� 207
8.23 Closure of the Abdominal Cavity�� 207
8.24 Management After Nerve-Sparing Radical Hysterectomy �� 207
Brief History of Surgical Treatment
for Cervical Cancer 1
1.1 Cervical Amputation and Simple Total Hysterectomy (Figure 1.1)
Cervical cancer that was visible from the vagina enabled the total hysterectomy was developed either transabdominally
vaginal resection of the lesion in the prolapsed uterus. The (Freund 1878 January) and transvaginally (Czerny 1978
amputation of the cervix of the prolapsed uterus for the surgi- August) for the treatment of cervical cancer. Nevertheless, the
cal treatment of cervical cancer started in the early seven- outcome of these surgical treatments was still very poor.
teenth century. However, due to the poor outcomes following Consequently, wider resection of the paracervical tissues (the
local excision, clinicians began to postulate that removal of uterine supportive tissues), termed the radical approach
the uterus may be necessary for the treatment of invasive cer- (extended hysterectomy) was introduced for the treatment of
vical cancer. By the end of the nineteenth century, simple cervical cancer.
Figure 1.1 History of

Cervical amputation of prolapsed uterus
surgical treatment for cervical
cancer
End of 17th Century
Cervical amputation of normal positioned uterus
Osiander (1801)
Extended hysterectomy
Total abdominal hysterectomy with lymphadenectomy
Freund (1878, January)
Vaginal hysterectomy
Czerny (1878, August)
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© Springer Nature Singapore Pte Ltd. 2020 1

S. Fujii, K. Sekiyama, Precise Neurovascular Anatomy for Radical Hysterectomy,
https://doi.org/10.1007/978-981-13-8098-3_1
2 1 Brief History of Surgical Treatment for Cervical Cancer
1.2 xtended Hysterectomy with Lymph Node Resection as a Radical Approach for Cervical

E
Cancer Patients (Figure 1.2)
In 1895, JG Clark [1] reported the surgery of wider In 1898, Ernst Wertheim in Vienna developed a novel pro-
resection of the paracervical tissues with the uterus, cedure of total hysterectomy; removal of the uterus with the
(with bougie insertion into the ureters) as a novel cervi- parametrium, longer vaginal cuff, and lymph nodes. Then, he
cal cancer surgery in Johns Hospital Bulletin (USA). reported his improved technique and pathological findings of
Each of the 12 surgeries performed by Clark et al. dif- the removed uterus and lymph nodes with the prognosis of
fered slightly. In some cases the lymph nodes were 500 cervical cancer patients in 1911 [2]. Since then,
removed, and in others the parametrium and a vaginal Wertheim’s method was accepted as the “radical hysterec-
cuff were removed. This is considered as the first report tomy” and it became a representative method of radical hys-
of radical hysterectomy. terectomy in Western countries.
Figure 1.2 Introduction of

Clark (1895)
extended hysterectomy
Extended hysterectomy Radical vaginal hysterectomy

with lymphadenectomy
Schauta (1908)
Wertheim (1898)
Wertheim started a new chapter in surgical treatment for cervical cancer

following the report of 500 cases of transabdominal extended hysterectomy
in 1911.
Wertheim’s method became the standard “radical hysterectomy” in Western

Countries.
1.3 Modification of Wertheim’s Radical Hysterectomy with Pelvic Lymphadenectomy 3
1.3 odification of Wertheim’s Radical Hysterectomy with Pelvic Lymphadenectomy

M
(Figure 1.3)
After the Wertheim’s publication, many doctors attempted to nique at the meeting of the Japanese Gynecological Association
modify the techniques of Wertheim’s radical hysterectomy. in 1917. Moreover, Takayama’s student, Hidekazu Okabayashi
Two novel surgical approaches were reported from Europe published the novel radical hysterectomy in 1921 [5].
and East-Asia. In 1919, Wilhelm Latzko [3] published novel Okabayashi’s surgery opens the paravesical space and para-
and more anatomically reasoned radical hysterectomy than rectal space and divides three ligamentous structures: the
that of Wertheim’s. Latzko’s surgery develops the paravesi- uterosacral ligament (retinaculum posterior), cardinal liga-
cal space and the pararectal space and divides three ligamen- ment (retinaculum medial), and paracervical/vaginal tissues
tous structures such as the uterosacral ligament (retinaculum (retinaculum anterior), which is line with that of Latzko’s sur-
posterior), cardinal ligament (retinaculum medial), and para- gery. However, Okabayashi’s radical hysterectomy contained
cervical/vaginal tissues (retinaculum anterior). novel steps on the division of the paracervical/vaginal tissues.
In Japan, Wertheim’s radical hysterectomy was introduced Although the paracervical/vaginal tissues are clamped and
in Kyoto Imperial University. Shohei Takayama [4], Professor divided as a mass in Latzko’s surgery, Okabayashi’s surgery
and Chairman (1906–1921) of the Department of Gynecology separates the paracervical tissues into the vesicouterine liga-
and Obstetrics at Kyoto Imperial University considered that ment (anterior (ventral) leaf and posterior (dorsal) leaf) and
Wertheim’s method was not radical enough for the treatment the blood vessels of the vaginal wall (paracolpium), and
of cervical cancers. Consequently, he endeavored to improve divides independently [5, 6]. In order to get an appropriate
the technique of the Wertheim’s operation to a more radical length of the vaginal cuff, Okabayashi’s surgery was much
removal of the parametrial tissues, and reported his new tech- more extensive than that of Latzko’s surgery.
Figure 1.3 Modification of

Wertheim’s radical Extended hysterectomy Wertheim started a new chapter in surgical treatment for
hysterectomy with lymphadenectomy cervical cancer following the report of 500 cases of
transabdominal extended hysterectomy in 1911.
Wertheim (1898)
Two doctors (Latzko, 1919 and Okabayashi, 1921) believed that Wertheim’s operation
was not radical enough for the treatment of invasive cervical cancers.
Latzko (1919)
Open the paravesical & pararectal space:
Concept of 3 ligamentous structures:
Radical hysterectomy retinaculum anterior, medial and posterior
with Okabayashi (1921)
pelvic lymphadenectomy
Open the paravesical & pararectal space:
Concept of 3 ligamentous structure:
retinaculum anterior, medial and posterior
Novel finding on the posterior(dorsal)-leaf of
vesicouterine ligament
1.4 Situation of Radical Hysterectomy in Mid-Twentieth Century (Figures 1.4 and 1.5)
After the report of Okabayashi’s radical hysterectomy in 1921 the gynecologic surgeries in Japan. Consequently, Okabayashi’s
[5, 6], his surgery was undertaken by the doctors at Kyoto radical hysterectomy was accepted and became the standard
Imperial University, but it gradually spread across Japan. technique for the treatment of cervical cancer patients in Japan.
Particularly, when Kyusaku Ogino (Tokyo Imperial University) In Western countries, Wertheim’s radical hysterectomy had
watched Okabayashi’s radical hysterectomy at Kyoto Imperial been employed for the treatment of cervical cancer in the early
University, he felt that Okabayashi’s method was the most twentieth century. However, surgery was not always safe in
appropriate radical hysterectomy. Then, Ogino introduced that period and radiotherapy gradually became the first-line
Okabayashi’s radical hysterectomy to Tokyo Imperial treatment of cervical cancer. Consequently, Wertheim’s
University. Moreover, Ogino started to improve Okabayashi’s method was not so frequently undertaken until mid-twentieth
radical hysterectomy and his modified technique was suc- century. In 1954, an American gynecologic surgeon, Joe
ceeded by Takashi Kobayashi [7] at Tokyo University. Including Vincent Meigs reported a modified technique of Wertheim’s
Ogino, many doctors such as Kobayashi [7], Masanao Magara radical hysterectomy with en-bloc pelvic lymphadenectomy
[8], Misao Natsume [9], Toshio Fujiwara [10], and Syouichi [12]. The results achieved by Meigs were remarkable;
Sakamoto [11] in Japan tried to improve Okabayashi’s radical almost 90% 5-year survival rate for Stage I disease, and
hysterectomy. Among them, Fujiwara [10] was the first man to more than 60% 5-year survival rate for Stage II disease. Since
introduce liposuction for safe pelvic surgery and lymphadenec- then, radical hysterectomy was revived for the treatment of
tomy in 1983. In Japan, doctors of Obstetrics and Gynecology early cervical cancer in Western countries. The radical hyster-
had been brushing up their surgical skills in order to understand ectomy performed by Meigs was very comparable to Latzko’s
the anatomy of the female pelvic cavity through Okabayashi’s radical hysterectomy. However, Meigs’ radical hysterectomy is
radical hysterectomy as reported. Therefore, Okabayashi’s named as Wertheim–Meigs radical hysterectomy (later Piver
radical hysterectomy is the most esteemed procedure among Type III radical hysterectomy: Chap. 2).
Figure 1.4 Radical
hysterectomy or radiotherapy Extended hysterectomy Wertheim started a new chapter in surgical treatment for
with lymphadenectomy cervical cancer following the report of 500 cases of
transabdominal extended hysterectomy in 1911.
Wertheim (1898)
Radical hysterectomy (RH) with pelvic lymphadenectomy
Latzko (1919) Okabayashi (1921)
Surgery was not always safe in that time period,

and gradually radiotherapy was replacing
surgery as first line therapy. Mainly RH
Western Countries Japan
Figure 1.5 Revival of Radical hysterectomy (RH)

radical hysterectomy Radiation therapy
with pelvic lymphadenectomy
Radical Hysterectomy
(Wertheim’s and Latzko’s surgery)
was revived by Meigs (1954)(USA)
1.5 Recent Novel Findings and Methods on Radical Hysterectomy 5
1.5 Recent Novel Findings and Methods on Radical Hysterectomy
In 1994, Daniel Dargent [13] reported a new transvaginal good outcome of MMR radical hysterectomy reported by
fertility-preserving radical surgery that amputates the cervix Hockel et al. attracted many clinicians. The extensive lymph-
with parametrium for women with early invasive cervical adenectomy performed in this surgery appears to contribute
cancer. The surgery was named as radical trachelectomy to the good surgical outcome. The concept of MMR is under-
[14]. Currently, this surgery is predominantly done either standable, but the anatomy of MMR surgery stays true to the
transvaginally or transabdominally although a laparoscopic original Wertheim’s surgery.
approach has also recently been described. For the early During the technique of radical hysterectomy, the surgeon
invasive cervical cancer patients who wish to retain their fer- usually encounters trouble during the separation of the ureter
tility, radical trachelectomy is a very important surgical tech- from the connective tissues between the cervix and urinary
nique. Recently, however, radical trachelectomy is being bladder. In order to remove the vaginal cuff safely, it is nec-
performed in women with larger tumor volumes than that essary to separate the ureter in the connective tissue that is
primarily indicated. Recurrences and fatal outcomes are called the vesicouterine ligament (anterior (ventral) leaf and
higher with the expansion of indications. An application of posterior (dorsal) leaf). The vesicouterine ligament had been
this surgery to the deeply invaded cervical cancer is still considered as the tissue that bled easily during surgery.
controversial. Moreover, the detailed anatomy of the vesicouterine liga-
In 2003, Hockel et al. [15] introduced a new concept on ment was a black box for more than 90 years. In 2007 Fujii
radical hysterectomy, namely: mesometrial resection (MMR) et al. reported detailed vascular anatomy of the anterior
radical hysterectomy. Under the concept of embryological (ventral) leaf and posterior (dorsal) leaf of the vesicouterine
compartment of the mullerian mesometrium, he performs ligament [16]. We also described the inferior hypogastric
extensive dissection of the uterosacral ligament whilst main- plexus hidden behind the posterior (dorsal) leaf of the vesi-
taining the surgical body of the original Wertheim radical couterine ligament. Moreover, it becomes possible for us to
hysterectomy. This procedure however, appears to entail a isolate the uterine branch from the inferior hypogastric
more extensive pelvic lymphadenectomy. The surgery is plexus. By isolating and dividing the uterine branch alone,
conceptually new, but anatomical resection margin is very well-defined anatomy for the nerve-sparing radical hysterec-
close to the original Wertheim’s radical hysterectomy. The tomy was introduced by Fujii et al. in 2007 [17].
1.6 Super-Radical Hysterectomy
In cases of advanced cancer with lymph node metastasis The above described surgical technique was introduced
adherent to the blood vessels in the cardinal ligament, by Ryuukichi Mibayashi, a successor to Okabayashi at
Okabayashi’s radical hysterectomy is not a suitable surgery Kyoto University, in 1941 as super-radical Hysterectomy
due to the risk of microscopic metastasis being left in the [18]. Current opinion suggests that such cases should be
divided portion of the cardinal ligament. In this situation, we treated with radiation or chemoradiation. However, in
recommend surgery to extirpate the whole base of the cardi- young women with radio-chemo resistant cancer, this type
nal ligament with internal iliac vascular bundle (Figure 1.6). of surgery can save their lives. The same kind of surgery
Both the internal iliac artery and vein are ligated and was introduced by Palfalvi-L and Ungar-L as laterally
divided in this procedure. The internal iliac artery is ligated extended parametrectomy (LEP) in 2003 [19]. Recently,
and divided at the obliterated umbilical artery. The obturator this aggressive surgery is indicated in patients with lymph
artery and vein are ligated and divided before they pass infe- node positive disease, where it has shown good outcomes
riorly to enter the pelvic side wall. The internal iliac vein is without adjuvant radiotherapy [18]. Because super-radical
ligated and divided above the base of the pelvic wall (i.e., hysterectomy and LEP are extirpating the base of the cardi-
inferior gluteal, internal pudendal) exposing the roots of the nal ligament with internal iliac blood vessel systems, Total
sciatic nerve (Figure 1.7). Extirpation of Internal Iliac Blood Vessel System (TEIIBS)
With these steps, the whole base of the cardinal ligament with Cardinal Ligament seems to be a more suitable name
is extirpated along with the internal iliac blood vessels for this surgery.
(Figure 1.8).
Figure 1.6 Anatomy of the

blood vessels in the pelvis
focused on the location of the
internal iliac blood vessel
system (circle of dotted line) obturator artery
external iliac vessels
obturator vein
internal iliac artery
internal iliac vein
cut end of
uterine artery
inferior gluteal vein
deep uterine vein internal pudendal vein

1.6 Super-Radical Hysterectomy 7
Figure 1.7 Sites of ligation

of the internal iliac vessels for
the extirpation of the internal
iliac vessels
ligation of
obturator artery
ligation of
ligation of
obturator vein
ligation of
internal iliac vein
ligation of obliterated
umbilical artery
ligation of
ligation of
deep uterine vein ligation of
internal pudendal vein
Figure 1.8 Extirpated figure

of the internal iliac blood
vessel system
cut end of
obturator artery
cut end of
cut end of
obturator vein
cut end of
internal iliac vein
cut end of obliterated

umbilical artery
cut end of
cut end of
deep uterine vein cut end of
internal pudendal vein
1.7 Notes
1.7.1 Surgical Novel Concepts and Anatomical Findings on Radical Hysterectomy
Figure 1.9 is a list of surgical novel concepts and anatomical

findings on radical hysterectomy.
1895 Clark Abdominal extended (radical) hysterectomy

1898 Wertheim Abdominal extended (radical) hysterectomy
1908 Schauta Vaginal extended (radical) hysterectomy without lymphadenectomy
1911 Wertheim Abdominal extended (radical) hysterectomy. This surgery became a standard of radical hysterectomy
in Western countries
1917 Takayama Modified Wertheim method in Japan and demonstrated his live surgery at the 15th Scientific Meeting
of Japan Society of Gynecology in Kyoto
1919 Latzko Radical hysterectomy: Lymphadenectomy at first, then developing paravesical and pararectal spaces,
divide the cardinal ligament wider than that of Wertheim
1921 Okabayashi Radical hysterectomy: Almost the same type of Latzko’s surgery, but characterized by the separation
of the vesicouterine ligament independently from the paracolpium
1941 Mibayashi Super-radical hysterectomy is the surgery of total extirpation of internal iliac blood vessel system
(TEIIBS) with the cardinal ligament. Laterally extended parametrectomy (LEP) by Palfalvi & Ungar
(2003) is almost the same surgery.
1951 Meigs Reevaluation of Radical Hysterectomy (Wertheim, Latzko) in the USA :Meigs’ radical hysterectomy
is almost the same as that of Latzko’s radical hysterectomy
1961 Kobayashi Pioneer of nerve-sparing radical hysterectomy (pelvic splanchnic nerve)
1994 Dargent Pioneer of fertility-preserving radical surgery: Radical vaginal trachelectomy
2003 Palfalvi & Ungar Laterally extended parametrectomy (LEP) is almost the same as that of Mibayashi’s surgery
2003 Hockel Mesometrial resection (MMR) radical hysterectomy. New concept of radical hysterectomy within the
area of the embryological mesometrial compartment. Surgical margin is almost the same as that of
Wertheim
2007 Fujii Clarification of the detailed anatomy of the vesicouterine ligament for ideal radical hysterectomy
2007 Fujii Clarification of the detailed anatomy of the inferior hypogastric plexus for nerve-sparing radical
hysterectomy
Figure 1.9 Surgical novel concepts and anatomical findings on radical hysterectomy
1.7 Notes 9
1.7.2 History of Radical Hysterectomy in Western Countries and in Japan
Since Wertheim reported his radical hysterectomy in the development of surgical technique on radical hyster-
1911, the technique was modified both in Western coun- ectomy in Western countries and in Japan (Kyoto & Tokyo
tries and in Japan. Figure 1.10 is a chronological chart of University).
Western Countries Japan (Kyoto & Tokyo Univ.)
1911 Wertheim Radical Hysterectomy (RH)
1917 Takayama (1917) Tried to modify Wertheim’s RH

(Kyoto Univ.)
1919 Latzko More radical than Wertheim’s RH
1921 Okabayashi More radical than Wertheim’s RH
(Kyoto Univ.)
Ogino Modification of Okabayashi’s RH
(Tokyo Univ.)
1935 Bonny Reevaluation of Wertheim’s RH
1941 Mibayashi Super-radical hysterectomy (#1)

(Kyoto Univ.)
1954 Meigs RH was revived by Meigs
1961 Kobayashi Pioneer of Nerve-sparing RH

(Tokyo Univ.)
1992 Sakamoto Tokyo method
1994 Dargent Radical trachelectomy (Tokyo Univ.)
2003 Hockel Mesometrial resection on radical
hysterectomy
Palfalvi & Ungar Laterally extended
parametrectomy (#1)
2007 Fujii Open the black-box of vesicouterine

(Kyoto Univ.) ligament and inferior hypogastric
plexus
Figure 1.10 History of radical hysterectomy in Western countries and in Japan (Kyoto & Tokyo Univ.) #1: Total extirpation of the internal iliac
blood vessel system with the cardinal ligament
References 11. Sakamoto S. Radical hysterectomy with pelvic lymphadenectomy—

the Tokyo method. In: Coppleson M, editor. Gynecologic oncology.
2nd ed. Edinburg: Churchill Livingstone; 1992. p. 1257–68.
1. Clark JG. More radical method of performing hysterectomy for 12. Meigs JV. Surgical treatment of cancer of the cervix. New York:
cancer of the uterus. Johns Hopkins Hosp Bull. 1895;6:120–4. Grune & Stration; 1954.
2. Wertheim E. Die erweiterte abdominale Operation bei Carcinoma 13. Dargent D, Brun JL, Roy M, Mathevet P. La trachelectomie élargie:
colli Uteri (auf Grund von 500 Fallen). Berlin: Urban & uné alternative á l'hystérectomie. Radicale dansu traitment des can-
Schwarzenberg; 1911. cers in filtrants. Jobgyn. 1994;2:285–92.
3. Latzko W, Schiffmann WJ. Klinisches und Anatomisches 14. Dargent D, Martin X, Sacchetoni A, Mathevet P. Laparoscopic
zur Radikaloperation des Gebärmutterkrebses. Zbl Gynäkol. vaginal radical trachelectomy: a treatment to preserve the fertility
1919;34:689–705. of cervical carcinoma patients. Cancer. 2000;88:1877–82.
4. Takayama S. Live surgical demonstration of modified Wertheim 15. Höckel M, Horn LC, Hentschel B, Höckel S, Naumann G. Total
method at the 15th Scientific Meeting of Japan Society of mesometrial resection: high resolution nerve-sparing radical hys-
Gynecology in Kyoto; 1917. terectomy based on developmentally defined surgical anatomy. Int
5. Okabayashi H. Radical abdominal hysterectomy for cancer of the J Gynecol Cancer. 2003;13:791–803.
cervix uteri, modification of the Takayama operation. Surg Gynecol 16. Fujii S, Takakura K, Matsumura N, Higuchi T, Yura S, Mandai M,
Obstet. 1921;33:335–41. Baba T. Precise anatomy of the vesico-uterine ligament for radical
6. Okabayashi H. Abdominale systematische Panhysterektomie hysterectomy. Gynecol Oncol. 2007;104:186–91.
fur Karzinoma des Uterus. Jpn J Obstet Gynaecol. 1928;11: 17. Fujii S, Takakura K, Matsumura N, Higuchi T, Yura S, Mandai
136–53. M, Baba T, Yoshioka S. Anatomic identification and functional
7. Kobayashi T. Abdominal radical hysterectomy with pelvic outcomes of the nerve sparing Okabayashi radical hysterectomy.
lymphadenectomy for cancer of the cervix (in Japanese). Tokyo: Gynecol Oncol. 2007;107:4–13.
Nanzando; 1961. 18. Mibayashi R. A surgical film of super-radical hysterectomy

8. Magara M, Iwata H, Senda T. Abdominal radical hysterectomy for presented at the 39th Scientific Meeting of Japan Society of
cancer of the cervix (in Japanese). Tokyo: Nanzando; 1964. Gynecology in Nagoya; 1941 (original film is owned by Kyoto
9. Natsume M. Systemic radical hysterectomy for cancer of the cervix University).
(in Japanese). Tokyo: Nankodo; 1974. 19. Palfalvi L, Ungar L. Laterally extended parametrectomy (LEP), the
10. Fujiwara T. Surgery for cervical cancer (in Japanese). Tokyo:
technique for radical pelvic side wall dissection: feasibility, tech-
Igakushoin; 1983. nique and results. Int J Gynecol Cancer. 2003;13:914–7.
Classification of Radical Hysterectomy
2
In Western countries, since Meigs’ publication on radical hys- hysterectomy (minimum excision of the cardinal ligament
terectomy in 1954 [1], radical hysterectomy was revived as and more excision of the vagina than that of simple total
the standard treatment for early invasive cervical cancer. The hysterectomy), Class II was slight resection of the cardinal
surgical technique of Meigs’ radical hysterectomy contained ligament resembling that of Wertheim’s method. Class III
the isolation and division of the cardinal ligament which is was resection of the cardinal ligament at the level of the
the same as that of Latzko’s surgery or Okabayashi’s surgery. pelvic side wall (Meigs’ surgery was the example of Class
In Japan, by the end of twentieth Century, surgeons met with III surgery). Class IV was characterized by the complete
major bleeding during Okabayashi’s radical hysterectomy. removal of all peri-ureteric tissue and a more extensive exci-
Bleeding could occur at the time of dissection of the cardi- sion of the paravaginal tissues. The class V hysterectomy is
nal ligament at junction with the internal iliac vascular sys- removal of central recurrent cancer involving portions of the
tem, after the development of both pararectal and paravesical distal ureter or bladder.
spaces. The bleeding was usually from the cut-end of the car- This classification became popular, because Class III
dinal ligament of the internal iliac vascular side. Therefore, was considered as a standard radical hysterectomy for
some cases could be finished without any trouble, but other doctors in Western countries. However, it generated the
cases may face heavy bleeding during Okabayashi’s radi- chaotic state of surgical outcomes in cervical cancer treat-
cal hysterectomy. The risk of hemorrhage was hidden in the ment because the classification was used without check-
separation and clamping processes of the anatomically inse- ing the original article. In addition, many different types/
cure tissues. As the results of many efforts by Japanese doc- extent of radical hysterectomy were termed as Class III
tors such as Yoshihiko Yabuki [2–5], recently Okabayashi’s radical hysterectomy. Gradually, majority of the published
radical hysterectomy has proven safer. In order to reduce papers started to use the name of Class III radical hyster-
bleeding during surgery, isolation of each blood vessel in the ectomy for each institution’s radical hysterectomy. The
cardinal ligament has been practiced in Japan and recently submitted manuscript to English journals from Japan also
the risk of hemorrhage has reduced significantly. started to use the terminology of Class III radical hyster-
In order to avoid heavy bleeding from the base of the car- ectomy to the radical hysterectomy done by Okabayashi’s
dinal ligament, partial division of the cardinal ligament was method to get better understanding from the referees of
considered and extended hysterectomy was classified accord- Western countries.
ing to the resection length of the cardinal ligament, in 1974. Differences in surgical margins, lymphadenectomy,
and quality of surgery in each institution created vari-
able surgical outcomes of Class III radical hysterectomy
2.1 Piver–Rutledge–Smith’s Classification across the world. Consequently, the published literature
(1974) [6] accumulated considerable data on surgical outcomes
on Class III radical hysterectomy of varying anatomi-
In 1974, Piver–Rutledge–Smith [6] proposed the classical dissection. This therefore explains the considerable
fication of extended hysterectomy according to the length variation and differences in the data for Class III radical
of cardinal ligament. Class I was extrafascial simple total hysterectomy.

https://doi.org/10.1007/978-981-13-8098-3_2
12 2 Classification of Radical Hysterectomy
2.2 uerler & Morrow’s Classification

Q ligament at the rectum and vesicouterine ligament at the
(2008) [7] bladder and described the complete mobilization of the ure-
ter, and the paracolpos with the corresponding length of
In 2008, Querler & Morrow [7] proposed a new classifi- vagina (15–20 mm from the tumor or the cervix) resected
cation of radical hysterectomy. The title of classification routinely. However, a detailed description on the anatomy
by Piver–Rutledge–Smith was “Five classes of extended of the vesicouterine ligament is lacking in the classifica-
hysterectomy for women with cervical cancer” but the title tion. Radical hysterectomy with nerve-sparing or without
used by Querler & Morrow was “Classification of radi- nerve sparing correspond to Type C1 and C2, respectively.
cal hysterectomy.” Probably, Piver–Rutledge–Smith did The Type C radical hysterectomy corresponds to Latzko–
not intend to classify radical hysterectomy itself but they Meigs’ (Piver–Rutledge–Smith’s Class III) radical hys-
intended to show the surgical margin of each extended terectomy, but in order to perform nerve-sparing radical
hysterectomy depending on the cervical cancer lesion. hysterectomy (Type C1), the anatomy of Okabayashi’s
However, the name of Class III radical hysterectomy radical hysterectomy, particularly the anatomy of the poste-
started to be used independently in each institution as if rior (dorsal) leaf of the vesicouterine ligament is essential.
the Class III radical hysterectomy was the standard for Type C1, nerve-sparing radical hysterectomy, describes the
radical hysterectomy. transection of uterine branch alone from the inferior hypo-
Querler & Morrow’s classification was on radical hyster- gastric plexus and preserves bladder branch, hypogastric
ectomy using alphabets such as Type A, B, C, and D. Type nerve, and pelvic splanchnic nerve with the plexus. It is
A is a simple extrafascial total hysterectomy with minimum not easy to accomplish this using the steps described in
resection of the paracervix. In their classification, the ter- Latzko-Meigs’ or Piver–Rutledge–Smith’s Class III radi-
minology of paracervix is defined to include the cardinal cal hysterectomy because they do not separate the posterior
ligament (Mackenrodt’s ligament), parametrium, or para- (dorsal) leaf of the vesicouterine ligament. Without care-
colpium. This seems to again introduce ambiguity in the ful separation of the posterior (dorsal) leaf of the vesico-
surgical margin by using a word with a wide range of mean- uterine ligament, identification of the complete structure of
ings. In addition, they are also included a simple extrafascial the inferior hypogastric plexus and transecting the uterine
total hysterectomy with less than 10 mm vaginal resection branch in isolation is difficult. Therefore, Type C1 surgery
in the classification of radical hysterectomy with the name should be based on the Okabayashi’s nerve-sparing radical
of Type A. hysterectomy. In 2011, Cibula-D, Querler, Morrow et al.
Type B is the surgery where the ureter is unroofed and in 2011 [8], published a paper entitled “New classifica-
rolled laterally, permitting transection of the paracervix at tion system of radical hysterectomy: Emphasis on a three-
the level of the ureteric tunnel. This surgery does neither dimensional anatomic template for parametrial resection.”
resect the cardinal ligament nor the deep uterine vein. Type B This described the dissection in Type C1 where the ureter
is almost the same as that of the original Wertheim’s surgery. is unroofed, dissected from the cervix and from the para-
This surgery is rather a semi-radical hysterectomy. Querler & metria, but only partially from the ventral parametria. This
Morrow’s classified Type B into two subtypes such as Type anatomical description similarly does not allow easy iden-
B1 or Type B2 depend on whether or not lymphadenectomy tification of the inferior hypogastric plexus and transection
is performed. Type B2 surgery is the most common type of of uterine branch in isolation. We recommend the use of
radical hysterectomy in Western countries. consistent anatomical description on nerve-sparing radical
Type C involves a transection of the paracervix at the hysterectomy for the better understanding of surgeons.
junction with internal iliac vascular system. This entails the Type D is laterally extended resection. This category
transection of the cardinal ligament with the deep uterine includes a super radical hysterectomy by Mibayashi in 1941
vein at the junction of the internal iliac vein; both Latzko– [9] or laterally extended parametrectomy (LEP) (Palifavi,
Meigs’ and Okabayashi’s radical hysterectomy described Ungar [10]) or laterally extended endopelvic resection
this step. Type C involves the transection of the uterosacral (LEER) (Hockel [11]).
2.3 Classification of Radical Hysterectomy and Corresponding Surgical Treatment Modalities 13
2.3 lassification of Radical Hysterectomy and Corresponding Surgical

C
Treatment Modalities
As shown in the Figure 2.1, each alphabetical category of Recently, some institutions have reported that the sur-
Querler & Morrow’s Classification corresponds to the exist- gical outcomes following high quality radical hysterec-
ing surgical modalities for the different stage of cervical tomy or more extensive radical hysterectomy can achieve
cancer (Figure 2.1). If we can reach a consensus on radical greater than 90% 5 year survival rate in patients with
hysterectomy, the various classifications using classes or let- FIGO IB2 disease (Nam et al. [12, 13]) or invasive cervi-
ters will become redundant. cal cancer lesion having positive lymph node metastasis
A recent trend in surgical treatment of cervical cancer has without giving any adjuvant radiotherapy, respectively
been to reduce the surgical margins (less invasive) in order (Ungar et al. [14]). In order for this to become a wider
to achieve better quality of life following surgery. However, trend, it is imperative to have knowledge of precise pelvic
in order to accomplish a less invasive approach with reduced anatomy to accomplish the most appropriate surgery for
surgical margins, it is very important for us to have the skill each patient.
and anatomical knowledge to accomplish the surgery of
extended surgical margins.
Figure 2.1 Relationship Classification of radical hysterectomy

between the classification and and corresponding surgical treatment modalities
surgical treatment modalities
for cervical cancer. TEIIBS
Classification Classification Surgical treatment modalities for cervical cancer
Total extirpation of the Piver et al 1974 Querler/Morrow (2008)
internal iliac blood vessel
system with the cardinal Conization
ligament
Type 1 Type A Extra-fascial simple total hysterectomy
Type II-III Type B Extended simple total hysterectomy or

Semi-Radical hysterectomy
Radical Trachelectomy
Type C1 Radical hysterectomy with Nerve-sparing
Type III? Type C2 Radical hysterectomy (Latzko’s or Meigs’ surgery)

Okabayashi’s radical hysterectomy (not equal)
Type D1 Laterally extended parametrectomy(LEP) (Mibayashi:
su per-rasical hysterectomy (TEIIBS))
D2 D1 + adjacent fascial or muscular structure: laterally
extended endopelvic resection(LEEP)
Pelvic Exenteration
14 2 Classification of Radical Hysterectomy
References anatomical template for parametrial resection. Gynecol Oncol.

2011;122:264–8.
9. Mibayashi R. A surgical film of super-radical hysterectomy
1. Meigs JV. Surgical treatment of cancer of the cervix. New York:
presented at the 39th Scientific Meeting of Japan Society of
Grune & Stration; 1954.
Gynecology in Nagoya; 1941 (original film is owned by Kyoto
2. Yabuki Y, Sasaki H, Hatakeyama N, Murakami G. Discrepancies
University).
between classic anatomy and gynecologic surgery on pelvic con-
10. Palfalvi L, Ungar L. Laterally extended parametrectomy (LEP), the
nective tissue structure: harmonization of those concepts by collab-
technique for radical pelvic side wall dissection: feasibility, tech-
orative cadaver dissection. Am J Obstet Gynecol. 2005;193:7–15.
nique and results. Int J Gynecol Cancer. 2003;13:914–7.
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11. Hockel M, Horn LC, Einenkel J. (Laterally) extended endopelvic
S. Dissection of the cardinal ligament in radical hysterectomy for
resection: surgical treatment of locally advanced and recurrent can-
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cer of the uterine cervix and vagina based on ontogenetic anatomy.
Gynecol. 1991;164:7–14.
Gynecol Oncol. 2012;127:297–302.
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12. Park JY, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH. Laparoscopic
proposal for radical hysterectomy. Gynecol Oncol. 1996;62:370–8.
versus open radical hysterectomy in patients with stage IB2 and
5. Yabuki Y, Asamoto A, Hoshiba T, Nishimoto H, Nishikawa Y,
IIA2 cervical cancer. J Surg Oncol. 2013;108(1):63–9.
Nakajima T. Radical hysterectomy: an anatomic evaluation of para-
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metrial dissection. Gynecol Oncol. 2000;77:155–63.
Lee JW, Kim BG, Bae DS, Huh SJ, Nam JH. Comparison of out-
6. Piver MS, Rutledge F, Smith JP. Five classes of extended hys-
comes between radical hysterectomy followed by tailored adjuvant
terectomy for women with cervical cancer. Obstet Gynecol.
therapy versus primary chemoradiation therapy in IB2 and IIA2
1974;44:265–72.
cervical cancer. J Gynecol Oncol. 2012;23:226–34.
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Lancet Oncol. 2008;9:297–303.
ment of lymph node metastases in stage IB cervical cancer. The lat-
8. Cibula D, Abu-Rustam NR, Benedetti-Panici P, Kohler C,
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Raspagliesi F, Querleu D, Morrow CP. New classification sys-
a 5 year follow-up. Gynecol Oncol. 2011;123:337–41.
tem of radical hysterectomy: emphasis on a three-dimensional
Concept of the Original Okabayashi’s
Radical Hysterectomy 3
3.1 rinciples of Okabayashi’s Radical

P Okabayashi independently divided the paracolpium (vaginal
Hysterectomy blood vessels).
After separation of the urinary bladder from the cervical/
This surgery is designed for the treatment of invasive cervi- vaginal fascia, the vesicouterine ligament surrounding the
cal cancer. The principle is the removal of the whole uterus ureter is revealed between the sidewall of the cervix/vagina
with enough length of vaginal cuff dissecting the most distal and the paravesical space. We call the ventral side of the ure-
portion of the uterine supportive tissues (Figures 3.1, 3.2, ter as the anterior (ventral)-leaf of the vesicouterine ligament
and 3.3). Surgically, Okabayashi developed three major sup- and the dorsal side as the posterior (dorsal)-leaf of the vesi-
portive tissue bundles between the uterus and the pelvic wall. couterine ligament. By the complete separation of each leaf
The concept of the three supportive tissues was introduced of the vesicouterine ligament, the ureter and the urinary blad-
by Latzko in 1919. Okabayashi also developed anterior, mid- der can be separated from the cervix/upper vagina as much
dle, and posterior supportive tissues (Figure 3.4). The ante- as one wishes. In addition, this procedure allows us to iden-
rior (ventral) supportive tissue is composed of the anterior tify the paracolpium (vaginal blood vessels and the connec-
(ventral) and posterior (dorsal) leaves of the vesicouterine tive tissue). The dissection level of the paracolpium depends
ligament. The middle supportive tissue includes the cardinal on the level of disease and the length of the lateral vaginal
ligament and pelvic splanchnic nerve. The posterior (dorsal) cuff. Moreover, dissection of the rectovaginal ligament
supportive tissue contains the uterosacral ligament, hypogas- enables the surgeon to decide the appropriate vaginal cuff
tric nerve, and rectovaginal ligament. The cardinal ligament length of the dorsal vagina (Figure 3.5). In addition to the
is visualized by the development of the pararectal space and division of the distal portion of the three major supportive
the paravesical space. For the removal of the uterus, tissues, pelvic lymph nodes are systematically removed.

https://doi.org/10.1007/978-981-13-8098-3_3
16 3 Concept of the Original Okabayashi’s Radical Hysterectomy
Figure 3.1 Sagittal section Cutting line of simple total hysterectomy

view of the pelvic cavity is
showing the different cutting
line of the vagina of simple
total hysterectomy and radical
hysterectomy
bladder
rectum
bladder trigone
vagina Cutting line of radical hysterectomy
Figure 3.2 Ventral side view

of the uterus, vagina, and their ovary
fallopian tube
associated supportive
ligaments, showing the ventral side of
resection line of the uterine uterine corpus
supportive tissues (the
anterior (ventral) leaf of the
vesicouterine ligament, the
cardinal ligament) and the
vagina at radical hysterectomy
round lig.
anterior (ventral)
leaf of broad lig.
uterine artery
ureter anterior (ventral) leaf

of vesicouterine lig.
Cutting line of radical hysterectomy vagina Cardinal lig.

3.1 Principles of Okabayashi’s Radical Hysterectomy 17
Figure 3.3 Dorsal side view ovarian lig.

of the uterus, vagina, and the
uterosacral ligament showing dorsal side of
the resection line of the uterine corpus
uterosacral ligament and the
vagina at radical hysterectomy
suspensory lig. of ovary

posterior (dorsal) (ovarian vessels)
leaf of broad lig.
uterine artery Cutting line of radical hysterectomy
ureter
uterosacral lig.
vagina
Figure 3.4 A cross-sectional

Cross section view of the 3 pelvic supportive tissue
view of the pelvic cavity is
showing three (anterior
Anterior (ventral) supportive tissue
(ventral), middle, and
posterior (dorsal)) pelvic vesicouterine ligament (anterior
supportive tissues and their bladder (ventral) and posterior (dorsal))
cutting line at radical
hysterectomy
ureter paravesical
space
vesicovaginal Middle supportive tissue

space
cardinal ligament
pelvic splanchnic nerve
cervix
rectovaginal
space pararectal
rectum space
Posterior (dorsal) supportive tissue

uterosacral ligament
hypogastric nerve
rectovaginal ligament
18 3 Concept of the Original Okabayashi’s Radical Hysterectomy
Figure 3.5 A lateral side

Division of the each ligament and its blood vessels
view of the resection line of
the anterior (ventral) and
posterior (dorsal) leaf of the
vesicouterine, the cardinal, anterior (ventral) leaf of
and the uterosacral ligaments. cervicovesical uterosacral ligament and
Major blood vessels are vessels rectovaginal ligament
shown in each ligament and
the paracolpium
superior vesical vein
vesical veins uterine artery
superficial uterine
posterior (dorsal) leaf of vein
cardinal ligament
paracolpium
deep uterine vein
Atlas of the Original Okabayashi’s
Transabdominal Radical Hysterectomy 4
4.1 urgical Steps of Original

S 4.1.3 V
isual and Manual Examination
Okabayashi’s Radical Hysterectomy of the Spread of the Disease
and Judgment of Operability
4.1.1 Opening of the Abdominal Cavity
The peritoneal surface of the pelvic cavity is inspected. The
The abdomen is opened by a midline incision which should uterus and surrounding organs are examined to determine the
be made a sufficient length to secure free exposure of the extent of disease and the operability of the case. Bimanually,
operative field. (This usually extends from the symphysis to examination of the cervical lesion and surrounding tissues
above the umbilicus.) determines whether there is invasion outside of the cervix.
Mobility of the uterus from the surrounding organs and pel-
vic wall is the most important determinant of operability.
4.1.2 Exposure of the Pelvic Cavity
After examination of the upper abdominal cavity, the intes- 4.1.4 Traction of the Uterus
tine is packed out of the pelvis with large abdominal towels
moistened with saline water and the uterus and both ovaries/ The uterus is held on traction by a stout tenaculum on the
fallopian tubes are exposed in the pelvic cavity. fundus (Figure 4.1).

https://doi.org/10.1007/978-981-13-8098-3_4
20 4 Atlas of the Original Okabayashi’s Transabdominal Radical Hysterectomy
4.2 Illustrated Surgical Steps of Original Okabayashi’s Radical Hysterectomy
4.2.1 L
igation and Division of the Round Ligament to Reveal the Connective Tissue of the Broad
Ligament (Figure 4.1)
The uterus is drawn cranial (upward) left, then the right the peritoneum is separated and incised toward the urinary
round ligament becomes tense. The ligament is picked up bladder. Then, the peritoneum of the cranial side is separated
and the uterine side is clamped by Kocher forceps. The pel- and incised to open the retroperitoneal space of the broad
vic side is ligated. The round ligament is divided between the ligament. This will expose the loose connective tissue within
Kocher forceps and ligature. Then, picking up the perito- the retroperitoneal space.
neum on the cut edge of the foot side of the broad ligament,
connective tissue of broad lig.
uterus bladder
cut-end of
round lig.
cut-end of ovarian lig.

and fallopian tube
peritoneum of broad lig.
rectum
and fallopian tube
Figure 4.1 Ligation and division of the round ligament to reveal the connective tissue of the broad ligament
4.2 Illustrated Surgical Steps of Original Okabayashi’s Radical Hysterectomy 21
4.2.2 L
igation and Division of the Ovarian Ligament (Propria Ovarii) and the Fallopian Tube
for the Preservation of the Ovary (Figure 4.2)
With the uterus held over to the pelvic sidewall, long Kocher between the long Kocher forceps and the ligature, a dissec-
forceps are placed to clamp the uterine side of the ovarian tion is made. (In case there is need to remove the ovary and
ligament and the fallopian tube. The ovarian side of the ovar- the fallopian tube, the suspensory ligament of ovary (ovarian
ian ligament and the fallopian tube is ligated, and then vessels) is isolated, doubly ligated, and divided.)
uterus bladder
cut-end of
round lig.
cut-end of ovalian lig.

and fallopian tube
main trunk of
uterine artery
rectum
and fallopian tube
Figure 4.2 Ligation and division of the ovarian ligament (propria ovarii) and the fallopian tube for the preservation of the ovary
4.2.3 Isolation, Ligation, and Division of the Uterine Artery (Figure 4.3)
Gradual separation of the loose connective tissue in the ret- of the uterine artery is tied first, close to the origin from the
roperitoneal space reveals the main trunk of the uterine artery internal iliac artery and second, near the uterus, and divided
and its junction with the internal iliac artery. The main trunk between the two ligatures.
Figure 4.3 Isolation,
ligation, and division of the
uterine artery
cut-end of
round lig.
main trunk of
uterine artery
ureter
and fallopian tube
4.2.4 Separation of the Ureter from the Dorsal Peritoneal Layer of the Broad Ligament (Figure 4.4)
The ureter running along the dorsal peritoneal layer of the surrounding the ureter including the feeding blood vessels
broad ligament is isolated. Kocher forceps are placed on the are separated and isolated from the retroperitoneal side of the
leading edge of the dorsal peritoneal layer and held cranially broad ligament using scissors. It is better to separate and
on traction, and the loose connective tissue of the retroperi- trace the ureter as close as possible to the uterine side of the
toneal side of the broad ligament is separated. Then, the peri- cut-end of the uterine artery.
staltic ureter sheath becomes visible. The connective tissues
Figure 4.4 Separation of the

ureter from the dorsal cut end of
peritoneal layer of the broad main trunk of
ligament uterine artery
posterior (dorsal) leaf

of broad lig.
ureter
4.2.5 T
he Same Procedures on the Opposite
Side
The same procedures Sects. 4.2.1–4.2.4 are performed on the

opposite side.
4.2.6 Separation of the Peritoneal Layer of the Pouch of Douglas (Figure 4.5)
The uterus is tilted toward the pubic arch and the rectum with sides of the broad ligament. With the uterus held over to the
its peritoneal surface is stretched with the hand toward the pubic arch and the rectum stretched toward the cranial por-
cranial side. Then, the peritoneum between the uterus and tion with hand, a loose connective tissue layer appears
the rectum is lifted from the bottom of the pouch of Douglas. between the rectum and the cervix/vagina. This is the land-
The incision is made on the lifted-up peritoneum and carried mark of the rectovaginal space. After the connective tissue of
with scissors across the dorsal side (back) of the cervix. The the rectovaginal space is separated, the rectum is gently freed
step connects the exposed retroperitoneal spaces on both from the cervical/vaginal wall.

peritoneal layer of the Pouch
of Douglas
uterosacral lig.
rectum
Douglas’ pouch
4.2.7 D
evelopment of the Retrovaginal Space and Dissection of the Uterosacral Ligament
(Figure 4.6)
If there is no infection-related adhesion or tumor invasion, can occur if the dissection is close to the rectal wall. By this
the loose connective tissue layer between the rectum and cer- procedure, the bilateral thick connective tissue bundles
vical fascia is easily separated and can develop the rectovagi- (uterosacral ligament) become clear between the rectovagi-
nal space. Pressing the tips of scissors against the cervical nal space and the retroperitoneal space of the broad ligament.
fascia, the rectum is bluntly detached from the cervix/upper The uterosacral ligament on either side is stretched forward
part of the vagina. This separation should be carried in the and dissected at the base of the rectal sidewall.
correct plane, to avoid the risk of injury to the rectum, which
Figure 4.6 Development of

the retrovaginal space and
dissection of the uterosacral
ligament
uterosacral lig.
rectovaginal
space
4.2.8 F
urther Division of the Uterosacral Ligament and the Development of Okabayashi’s
Pararectal Space (Figure 4.7)
Further division of the uterosacral ligament with connective sues between the rectal wall and the connective tissue layer
tissue of the rectal sidewall toward the base of the pelvis usu- in which the ureter is included. This is an entrance of the
ally reveals a space filled with cobweb-like connective tis- Okabayashi’s pararectal space.
Figure 4.7 Further division

of the uterosacral ligament
and the development of
Okabayashi’s pararectal space
cut-end of uterosacral lig.

hypogastric nerve
rectovaginal
space
(Notes) Definition of the Spaces Developed During called Latzko’s pararectal space (Figure 4.8).
Radical Hysterectomy Therefore, the pararectal space developed by the
1. Rectovaginal space (Loose connective tissue Okabayashi’s approach is usually wider and deeper
between the rectum and cervical/vaginal fascia) than that of the Latzko’s approach. Consequently,
After the separation of the peritoneum in the pouch the extended Okabayashi’s pararectal space (origi-
of Douglas, the loose connective tissue along the nal Okabayashi’s pararectal space + Latzko’s para-
dorsal center of the cervical fascia is easily sepa- rectal space) (Figure 4.8) is surrounded by the rectal
rated from the rectum. This is the entrance of the sidewall (uterine side), the internal iliac blood ves-
rectovaginal space. sels (pelvic sidewall), the sacral bone (cranial side),
2. Latzko’s pararectal space and Okabayashi’s and blood vessels and connective tissue of the car-
pararectal space dinal ligament (inguinal side). The pararectal space
The pararectal space can be defined as a loose con- is filled with the loose connective tissues to the base
nective tissue space surrounded by the rectal side- of the pelvis. In order to perform nerve-sparing
wall (uterine side), the internal iliac blood vessels radical hysterectomy, it is not necessary to develop
(pelvic sidewall), the sacral bone (cranial side), and the Okabayashi’s pararectal space, and the Latzko’s
blood vessels and connective tissue of the cardinal pararectal space is enough (Chapter 8).
ligament (inguinal side). 3. Paravesical space
There are two types of surgical approaches for Separation of the connective tissue between the
the development of the pararectal space. One obliterated umbilical artery and the external iliac
approach is the separation of the connective tissue vein at 2–3 cm cranial to the pubic bone reveals a
between the rectum/ureter and the internal iliac cobweb-like loose connective tissue structure. The
artery/vein by retracting medially the rectal side- loose connective tissue that is deep into the base of
wall with the ureter. Then a space filled with the pelvis is separated. This is the paravesical space
cobweb-like connective tissues is revealed. This is a surrounded by the obliterated umbilical artery (uri-
space called as Latzko’s pararectal space nary bladder side), rectal/vaginal wall (rectal side),
(Figures 4.8 and 4.9). Another approach is from the external iliac vein (inguinal side), public bone (foot
division of the uterosacral ligament and separating side), and the connective tissue of the cardinal liga-
the connective tissue of the rectal sidewall toward ment (cranial side) (Figures 4.8 and 4.9). The most
the base of the pelvis (Figure 4.10a, b). Then dorsal part of the cardinal ligament is composed of
another space filled with cobweb-like connective loose connective tissue. By penetrating the dorsal
tissues is revealed (Figure 4.10a, b). This is a space side of the cardinal ligament with scissors, the para-
called as Okabayashi’s pararectal space vesical space and the pararectal space are
(Figures 4.8 and 4.10a, b). Okabayashi’s pararectal connected.
space is a space between the rectal sidewall and the 4 . Vesicocervical/vaginal space
pelvic-side connective tissue layer in which the ure- At the center of the dorsal wall of the urinary blad-
ter and hypogastric nerve reside (Figure 4.10a, b). der and the ventral cervical fascia/vaginal wall is
The ureter and the hypogastric nerve are in the composed with a loose connective tissue, and easily
same connective tissue plane, and the hypogastric separated by the cranial level of the trigone of the
nerve runs 2–3 cm dorsal to the ureter. Because urinary bladder. This is the vesicocervical/vaginal
Okabayashi’s pararectal space is developed very space (Figure 4.8). By picking up the urinary blad-
close to the rectum, the pelvic side connective tis- der with the covering peritoneum, the hollow loose
sue plane becomes an obstacle for the expansion of connective tissue is appreciated between the dorsal
Okabayashi’s pararectal space. After isolation and side of the urinary bladder and ventral side of the
retraction of the ureter toward the pelvic sidewall, it cervical fascia at the center of both organs. Press the
becomes necessary to sacrifice the hypogastric tip of scissors on the cervical fascia and push down
nerve. In order to increase the mobility of the toward the hollow, then the bladder is easily sepa-
uterus, Okabayashi preferred to open the space rated from central wall of the cervical/upper vaginal
from the uterosacral ligament. In Particular, the fascia by the cranial level of the trigone of the uri-
mobility of the uterus is increased by the division of nary bladder, and the connective tissue bundle (the
the hypogastric nerve, and the Okabayashi’s para- vesicouterine ligament) is formed on each lateral
rectal space is extended laterally toward the space side of the cervix.
Cross section view of the surgical spaces

vesico- vesicouterine
cervical/vaginal bladder ligament (anterior
space (ventral) and
posterior (dorsal))
ureter
paravesical
space
Middle supportive tissue
cardinal ligament
pelvic splanchnic
nerve
cervix
rectovaginal
space
Latzko’s Latzko’s
pararectal pararectal
space space
rectum
Okabayashi’s
uterosacral ligament pararectal
hypogastric nerve space
Figure 4.8 Cross-sectional view of the pelvis at the level of cervix showing major three supportive tissues and their corresponding ligaments
Figure 4.9 Location of

Latzko’s pararectal space and
paravesical space during
surgery paravesical space
obliterated umbilical artery
external iliac
Latzko’s
artery/vein
pararectal
space
rectum
internal iliac
ureter artery/vein
The surgical spaces created between these supportive tissues Figure 4.10a is showing the entrance of Okabayashi’s
and between the pelvic organs are also illustrated. The paravesical space between the rectum and the hypogastric
difference of the Latzko’s pararectal space and Okabayashi’s nerve, Figure 4.10b is showing the location of Okabayashi’s
pararectal space is also illustrated. pararectal space as a photo during surgery.
a Okabayashi’s pararectal space b
uterus
pelvic
splanchnic
nerve
ureter
Douglas’ pouch
rectum
hypogastric nerve
Figure 4.10 Okabayashi’s pararectal space

4.2.9 Further Development of the Pararectal Space (Figure 4.11)
Okabayashi’s pararectal space is very close to the rectum, and side) and, blood vessels and connective tissue of the cardinal
hence, during the opening processes of the space the hypogas- ligament (inguinal side). The pararectal space is filled with the
tric nerve is usually divided and the space is extended toward loose connective tissues to the base of the pelvis. The develop-
Latzko’s pararectal space. The boundaries of the pararectal ment of the pararectal space can be achieved using fingers
space include the rectal sidewall (uterine side), the internal inserted between the rectum and the internal iliac artery/vein.
iliac blood vessels (pelvic sidewall), the sacral bone (cranial The direction of insertion is toward the pelvic axis.
Figure 4.11 Further
development of the pararectal
space
pararectal space
cardinal lig.
ureter
cut-end of cut-ends of
uterosacral lig. hypogastric nerve
4.2.10 Development of the Paravesical Space and Separation of the Connective Tissue of the Base

of the Cardinal Ligament (Figures 4.8, 4.9, and 4.12)
Separation of the connective tissue between the obliterated vaginal wall (rectal side), external iliac vein (inguinal
umbilical artery and the external iliac vein at a point side), public bone (foot side), and the connective tissue of
2–3 cm cranial to the pubic bone reveals a cobweb-like the cardinal ligament (cranial side). The most dorsal part
loose connective tissue structure. Separate the loose con- of the cardinal ligament is composed of loose connective
nective tissue deep into the base of the pelvis. This is the tissue. By penetrating the dorsal side of the cardinal liga-
paravesical space, the boundaries of which include the ment with scissors, the paravesical space and the pararec-
obliterated umbilical artery (urinary bladder side), rectal/ tal space are connected.

the paravesical space and
separation of the connective
tissue of the base of the
cardinal ligament
cut-ends of
hypogastric nerve cardinal lig.
ureter
deep uterine vein

4.2.11 Clamp the Cardinal Ligament (Figure 4.13)
The connective tissue of the cardinal ligament is separated to ment. A long Pean forceps is placed close to the pelvic
make it as narrow as possible. The deep uterine vein and the sidewall (see the following Notes) and another forceps is
pelvic splanchnic nerve usually Iie within the cardinal liga- placed to the uterine side of the cardinal ligament.
Figure 4.13 Clamp the

cardinal ligament
cut-ends of
hypogastric nerve cardinal lig.
ureter
deep uterine vein

Notes: The term pelvic sidewall is very confusing. clamping the internal iliac vein itself including the
Surgical anatomy of the pelvic sidewall means the drain- inflow of the deep uterine vein. Dividing the cardinal
ing site of the deep uterine vein into the internal iliac ligament close to the pelvic sidewall can lead to terrible
vein. The procedure of Okabayashi’s original approach bleeding from the internal iliac vein itself, which is
to the cardinal ligament usually clamps both the deep often very difficult to control. In order to avoid this mis-
uterine vein and the pelvic splanchnic nerve. However, take, it is better to perform pelvic lymphadenectomy
it is not recommended to clamp the cardinal ligament first. Then the base of the cardinal ligament becomes
too close to the pelvic sidewall. If the clamp is placed well defined and the inflow of the deep uterine vein into
too close to the pelvic sidewall, there is a possibility of the internal iliac vein is better exposed (Figure 4.14).
Figure 4.14 Surgical
anatomy of the pelvic
sidewall means the draining Pelvic Sidewall
sites of the deep uterine vein cut-ends of
into the internal iliac vein uterine artery
cut-ends of
superficial
uterine vein
deep uterine vein

4.2.12 Dissection of the Cardinal Ligament (Figure 4.15)
The base of the cardinal ligament is divided between the two ment. Okabayashi described that now the muscles of the pelvic
clamps, near the forceps on the pelvic side. The pelvic side floor are seen and the rectum is laid bare. (Notes: The divided
forceps is replaced with a suture ligation and the uterine side cardinal ligament usually contains the superficial uterine vein,
forceps is left for a marker of the cut-end of the cardinal liga- the deep uterine vein, and the pelvic splanchnic nerve.)
Figure 4.15 Dissection of

the cardinal ligament
cut end of cardinal lig

(deep uterine vein/
pelvic splanchnic nerve)
cut-end of
hypogastric nerve
4.2.13 The Procedures on the Opposite Side
The same procedures Sects. 4.2.6–4.2.12 are performed on

the opposite side.
4.2.14 Separation of the Peritoneum Between the Urinary Bladder and the Uterus (Figure 4.16)
In order to stretch the vesicouterine fold of peritoneum, the separate the peritoneum easily without any damage to the
uterus is drawn toward the cranial side. The peritoneum of urinary bladder, is divided across the ventral side of the cer-
the bladder side is lifted with forceps. The peritoneum, just vix. Separation of the peritoneum too close to either the uri-
1–2 cm inferior to the vesicouterine fold where scissors can nary bladder or vesicouterine fold can lead to bleeding.
Figure 4.16 Separation of

the peritoneum between the
urinary bladder and the uterus vesicouterine fold
bladder
uterine cut end of cardinal lig.

artery
cut end of
uterine artery
ureter
4.2.15 Separation of the Connective Tissue Between the Urinary Bladder and the Ventral-Side

of the Cervical Fascia (the Vesicocervical Space) (Figure 4.17)
By picking up the urinary bladder along with its peritoneum bladder easily from the central wall of the cervical/upper
in an up-and-down motion, the hollow of the loose connec- vaginal fascia. Inferiorly, the trigone of the urinary bladder
tive tissue is formed between the dorsal side of the urinary (vesicocervical space) and the connective tissue bundle (ves-
bladder and ventral side of the cervical fascia at the midline icouterine ligament) are formed on each lateral side of the
of both organs. Press the tip of scissors on the cervical fascia cervix.
and push down toward the hollow in order to separate the

the connective tissue between
the urinary bladder and the fascia of uterine cervix
ventral side of the cervical
fascia (the vesicocervical anterior (ventral) leaf
bladder of vesicouterine
space)
ligament
ureter
cut-end of
cardinal lig.
cut-end of
uterine artery
cut-end of
cardinal lig.
4.2.16 Separation of the Anterior (Ventral) Leaf of the Vesicouterine Ligament (Left Side)

(Figure 4.18)
The uterus is drawn cranially right. The cut-end of the uter- nel to be enlarged and the ventral side of the connective tis-
ine artery on the uterine side is lifted with forceps and the sues covering the ureter is separated through the tunnel.
connective tissue between the ureter and the uterine artery is (Notes: If this step does not produce the desired result, the
carefully separated. The entrance of the ureter tunnel now trigone side connective tissue of the anterior (ventral) leaf of
comes into view. The curved scissors with the concave side the vesicouterine ligament should be opened. From the tri-
pointing dorsally are insinuated into the tunnel and the ureter gone side of the anterior (ventral) leaf of the vesicouterine
is pressed dorsal side with it. This movement allows the tun- ligament, the ureter can be shelled out.)

the anterior (ventral) leaf of
the vesicouterine ligament
(left side)
cut-end of
uterine artery
anterior (ventral) leaf

ureter
ureter tunnel
cut-end of cardinal lig.

4.2.17 Clamp and Dissect the Anterior (Ventral) Leaf of the Vesicouterine Ligament (Figure 4.19)
Protecting the ureter with the scissors, place two forceps made with scissors between the two forceps. The forceps
on the anterior (ventral) leaf of the vesicouterine ligament are replaced by ligatures.
along the course of the insinuated scissors. Incision is
Figure 4.19 Clamping and anterior (ventral) leaf of vesicouterine lig.

dissection of the anterior
(ventral) leaf of the cut-end of uterine artery
ureter
cut-end of cardinal lig. ureter tunnel

4.2.18 Separation of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament and the Paravaginal

Space (Figure 4.20)
By the separation of the connective tissues in the anterior able varies in different cases, but it should certainly be no
(ventral) leaf of the vesicouterine ligament, the ureter is less than 1.5–2 cm below the lowest level/extent of tumor
completely freed of its attachment to the posterior (dorsal) visualized. The insertion of a broad L-shaped retractor to
leaf of the vesicouterine ligament. Consequently, the ureter reflect the bladder above the line of the separation is very
is separated from the surface of the posterior (dorsal) leaf of useful. Then, try to find a space in the posterior (dorsal) leaf
the vesicouterine ligament and shifted inferiorly. Following of the vesicouterine ligament named as “a paravaginal space”
this, the urinary bladder with the ureter is separated from the by Okabayashi. The entrance to the paravaginal space is
cervix/upper vagina. The extent to which dissection is desir- marked using a circle line.
Figure 4.20 Separation of entrance of paravaginal space

the posterior (dorsal) leaf of
cut-ends of anterior
the vesicouterine ligament bladder
(ventral) leaf of
and the paravaginal space
vesicouterine lig.
ureter
posterior (dorsal) leaf of

vesicouterine lig.
ureter
cut-end of
cardinal lig.
cut-end of
uterine artery
4.2.19 Separation of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament Through

the Paravaginal Space (Figure 4.21)
Draw the uterus cranially, and give tension to the cut-end of the posterior (dorsal) leaf of the vesicouterine ligament and
the cardinal ligament laterally and to the L-shaped retractor the paracolpium (vaginal vessels). The curved scissors insin-
holding the bladder with ureter toward the foot side, then the uated into this area is rather easily penetrated into the para-
connective tissue of the posterior (dorsal) leaf of the vesico- vesical space and recognized as a paravaginal space. (Notes:
uterine ligament becomes tense. At a level 2–3 cm cranial If the curved scissors are not insinuated appropriately into
from the insertion of the ureter into the bladder, there exists the paravesical space, a large amount of bleeding can occur
a loose connective tissue area (paravaginal space) between at this stage.)

paravaginal space cut-ends of anterior
through the paravaginal space
(ventral) leaf of
vesicouterine lig.

vesicouterine lig.
cut-end of
uterine artery
ureter
cut-end of
cardinal lig.
rectum
4.2.20 Division of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament from the Paracolpium

(Figure 4.22)
Giving tension to the cut-end of the cardinal ligament, two the vesicouterine ligament from the vaginal vessels (paracol-
straight long pressure forceps are inserted along the line of pium). Moreover, the urinary bladder with the ureter becomes
the scissors. Place one toward the bladder side and the other free from the vaginal wall. Therefore, by separating the con-
toward the uterine side of the posterior (dorsal) leaf of the nective tissue between the vaginal wall and the bladder, the
vesicouterine ligament. Then divide and ligate between the urinary bladder with ureter is separated from the vaginal wall
two forceps. This step separates the posterior (dorsal) leaf of for whatever length one wishes.
Figure 4.22 Division of the

posterior (dorsal) leaf of the cut-ends of anterior
vesicouterine ligament from (ventral) leaf of
the paracolpium paravaginal space vesicouterine lig.
(white arrow)
posterior (dorsal) leaf of cut-end of

vesicouterine lig. uterine artery
ureter
cut-end of
cardinal lig.
rectum
4.2.21 The Same Procedures on the Opposite

Side
The same procedures Sects. 4.2.14–4.2.20 are performed on

the opposite side.
4.2.22 Treatment of the Rectovaginal Ligament (Figure 4.23)
The uterosacral ligament is already divided bilaterally, and stitch to the rectovaginal ligament is appreciated. However, it
only the connective tissue bundles are recognized bilaterally is not necessary to ligate the rectovaginal ligament because
between the vagina and the rectum. Draw the uterus to the the use of electrocautery, such as monopolar or bipolar
ventral/pubic bone side and stretch the rectum toward cranial instruments, is usually enough for the division of the recto-
portion with hand, then the connective tissue bundles become vaginal ligament. By the division of the rectovaginal liga-
clear between the rectum and vagina. These are the recto- ment, the dorsal side of the vaginal wall becomes free.
vaginal ligaments. Okabayashi tried to ligate and divide the Therefore, the length of the vaginal cuff can now be selected
rectovaginal ligaments. Therefore, in this illustration the and tailored to be as long as one wishes.
Figure 4.23 Treatment of

the rectovaginal ligament
cut-end of
cardinal lig.
cut-end of
hypogastric nerve
ureter
cut-ends of
uterosacral lig.
vagina
rectovaginal lig.
rectum
4.2.23 A Figure of the Both Cut-Ends of the Cardinal Ligament, the Uterosacral Ligaments,

and the Rectovaginal Ligaments (Figure 4.24)
The pelvic view from the cranial side of the pelvis is demon- nal ligament. Now, the uterus is connected only with the bilat-
strating both cut-ends of the cardinal ligament, the uterosacral eral vaginal blood vessels (paracolpium) and the vaginal wall.
ligament including the hypogastric nerve, and the rectovagi- Next step is ligation and division of the paracolpium.
Figure 4.24 A figure of the

both cut-ends of the cardinal
ligament, the uterosacral
ligaments, and the
rectovaginal ligaments
cut-ends of
hypogastric nerve
cut-end of cut-ends of
cardinal lig. uterosacral lig.
ureter
rectum
cut-ends of rectovaginal lig.
4.2.24 Ligation and Dissection of the Paracolpium (Figure 4.25)
The uterus with its surrounding tissues such as cut-ends of pium) is connected with the vagina and is ready to be ligated.
the cardinal ligament and the vesicouterine ligament are The paracolpium is ligated where we wish to amputate the
appreciated. Now only the lateral vaginal tissue (the paracol- vaginal wall.
Figure 4.25 Ligation and

dissection of the paracolpium cut-end of anterior
(ventral) leaf of
vesicouterine lig.
paracolpium
cut-ends of posterior
(dorsal) leaf of
vesicouterine lig.
cut-end of
cardinal lig.
cut-end of
uterine artery
4.2.24.1 Division of the Vagina and Extirpation of the Uterus (Figure 4.26)

The vaginal wall is divided. Now the uterus is attached only face of the vaginal wall. After this, the vaginal wall is divided
with the vaginal wall. A hot Paquelin cautery (Okabayashi’s completely around. The bleeding parts of the cut edge of the
original description) or a monopolar device is used to open vaginal wall are grasped with forceps and the forceps are
the vaginal cavity. Then, a piece of gauze is pushed into the replaced by ligatures. Then, the ventral side and dorsal side
opened vaginal cavity in order to expel the discharge from of the vaginal stump are closed with suture material.
the uterus. Tincture of iodine is painted over the inner sur-

vagina and extirpation of the cut-end of anterior
uterus (ventral) leaf of cut-ends of paracolpium
vesicouterine lig.
cut-end of anterior
(ventral) leaf of
vesicouterine lig.
cut-ends of posterior
(dorsal) leaf of
vesicouterine lig.
cut-end of
uterine artery
cut-end of
cardinal lig.
4.2.25 A View of the Pelvic Cavity After the Removal of the Uterus and Lymphadenectomy

and Closure of the Abdominal Cavity (Figure 4.27)
Okabayashi usually performed pelvic lymphadenectomy adenectomy, readers can refer to the procedure of pelvic
after the removal of the uterus. However, the procedure of lymphadenectomy described in Chap. 6.
lymphadenectomy is not clearly described in his atlas. In the Following closure of the ventral abdominal peritoneum and
atlas of original Okabayashi’s radical hysterectomy, only a the fascia, interrupted skin suture is undertaken. Using a vaginal
view of the pelvic cavity after the division of the vagina speculum, the packed gauze is removed from the vagina and the
(Figure 4.27) is illustrated. On the detail of the pelvic lymph- vaginal stump suture is checked. The surgery is now finished.
Figure 4.27 A view of the

pelvic cavity after the removal
of the uterus and
cut-end of anterior cut-ends of
lymphadenectomy
(ventral) leaf of paracolpium
vesicouterine lig.
ureter
vagina
rectum
Novel Points of Okabayashi’s Radical
Hysterectomy 5
5.1 Novel Points of the Okabayashi’s Radical Hysterectomy
5.1.1 C
larification of the Anatomy of the Paravaginal Space Between the Posterior (Dorsal) Leaf
of the Vesicouterine Ligament and the Paracolpium
In the tissue of the paracervix, Okabayashi found a loose into the space, the paracervix is separated into the posterior
connective tissue space. The space is named as Okabayashi’s (dorsal) leaf of the vesicouterine ligament and the vaginal
paravaginal space (Figure 5.1a, b). By insinuation of scissors blood vessels (paracolpium).
a b
Okabayashi’s paravaginal space

Direction of Okabayashi’s paravaginal
space
cut end of anterior
(ventral) leaf of
vesicouterine lig. cut end of vein
bladder connecting ureter
trigone and cervix.
ureter
vagina
cervix
posterior (dorsal) ureter

leaf of
vesicouterine lig.
uterine cut end of cardinal lig.

artery (cut end of deep
uterine vein and pelvic vesical veins in the
splanchnic nerve) posterior leaf of the
vesicouterine lig.
Figure 5.1 Anatomical location of Okabayashi’s paravaginal space. of the posterior (dorsal) leaf of the vesicouterine ligament from the lat-
(a) Anatomical location of the entrance of Okabayashi’s paravaginal eral side of the cervix, the location of the paravaginal space is illustrated
space (a yellow color area surrounded by a blue line) in the posterior as a yellow band with two black arrow heads
(dorsal) leaf of the vesicouterine ligament. (b) In the skeletonized view

https://doi.org/10.1007/978-981-13-8098-3_5
50 5 Novel Points of Okabayashi’s Radical Hysterectomy
Recently, our clarification of the posterior (dorsal) leaf of bladder run in the posterior leaf of the vesicouterine ligament
the vesicouterine ligament revealed that at least two to three and drain into the deep uterine vein in the cardinal ligament
venous blood vessels from the dorsal side of the urinary (Figures 5.1b and 5.2a, b).
a b
Line of paravaginal space

Line of paravaginal space cut end of anterior
(ventral) leaf of
vesicouterine lig.
posterior cut end of uterine artery

(dorsal) leaf of
vesicouterine lig
cut end of deep
vesical veins uterine vein
vesical veins

cut end of deep
uterine vein
cut end of cardinal lig.

cut end of pelvic
splanchnic nerve
Figure 5.2 Lateral view of the venous blood vessels in the posterior cating the direction of insinuation. (b) Using two Kocher forceps, the
(dorsal) leaf of the vesicouterine ligament. (a) Insinuation of scissors posterior (dorsal) leaf of the vesicouterine ligament is clamped through
into Okabayashi’s paravaginal space. Two dotted arrow lines are indi- Okabayashi’s paravaginal space
5.1 Novel Points of the Okabayashi’s Radical Hysterectomy 51
The separation and division of the posterior (dorsal) leaf vaginal wall (with the vaginal vein that also drains into the
of the vesicouterine ligament enables the urinary bladder deep uterine vein). It resembles the picture of an open book
with ureter to be completely free from the cervix and the (Figure 5.3a, b).
a b
Paravaginal space between paracolpium and

Bladder is completely separated
posterior (dorsal) leaf of the vesicouterine lig.
from the vaginal wall
paracolpium vagina
cut end of paracolpium

superficial
uterine vein bladder
cut end of inferior
vesical vein.
cut end of deep

uterine vein Open a book
cut end of middle

vesical vein ureter
Figure 5.3 The result of the division of the posterior (dorsal) leaf of The relationship between the urinary bladder with the ureter and the
the vesicouterine ligament. (a) The relationship between the divided vaginal tissues with the paracolpium. As if we open a book, the uri-
blood vessels in the posterior (dorsal) leaf of the vesicouterine liga- nary bladder with the ureter is completely separated from the vaginal
ment and the vaginal blood vessels of the paracolpium (a yellow dot- tissues with the paracolpium
ted arrow line is indicating the direction to the paravaginal space). (b)
52 5 Novel Points of Okabayashi’s Radical Hysterectomy
Then, by the separation of the trigone portion of the ligated and divided where the surgeon wishes to amputate
urinary bladder from the vaginal wall, we can select the (Figure 5.4a). The uterus is removed with any length of
level at which the vagina is divided. Consequently, the the vaginal cuff deemed appropriate for the extent of dis-
vaginal blood vessels (paracolpium) are independently ease (Figure 5.4b).
a b
Separation of ureter paracolpium Division of paracolpium and vaginal incision

and bladder from
paracolpium cut end of anterior vaginal incision
cut end of posterior (ventral) leaf of
(dorsal) leaf of vesicouterine lig. cut end of
vesicouterine lig. paracolpium
cut end of posterior

cut end of (dorsal) leaf of
cardinal lig. cut end of deep cut end of
vesicouterine lig. cardinal lig.
uterine vein
Figure 5.4 The treatment of the paracolpium and the division of the is ligated. (b) By the division of the blood vessels in the paracolpium,
vaginal wall. (a) The vaginal blood vessels (paracolpium) have a con- the uterus is connected only with the vagina. The incision to the vagina
nection with the deep uterine vein (cardinal ligament). The paracolpium is made with enough vaginal cuff for the treatment of cervical cancer
5.1 Novel Points of the Okabayashi’s Radical Hysterectomy 53
5.1.2 Clarification of the Anatomy of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament
A novel point of Okabayashi’s radical hysterectomy is the blood vessels and can select the length of vaginal cuff deemed
independent separation and division of the posterior (dorsal) appropriate for each case (Figure 5.5c). This is the most
leaf of the vesicouterine ligament and the paracolpium. In sophisticated section of Okabayashi’s radical hysterectomy.
Wertheim’s or Meigs’ operation (Piver et al. Class III), the Through Okabayashi’s radical hysterectomy, we learnt
posterior (dorsal) leaf of the vesicouterine ligament is treated the following anatomical truths:
as a mass of the parametrial tissues with the vaginal blood
vessels (the paracolpium) under the name of the paracervix. 1. The venous blood vessels from the urinary bladder are
During the process of the removal of the uterus with the vagi- running in the posterior (dorsal) leaf of the vesicouterine
nal cuff, all other types of radical hysterectomies have to ligament and they drain into the deep uterine vein in the
divide tissues in conjunction with venous blood vessels from cardinal ligament.
the urinary bladder and the vagina together as a mass 2. The venous drainage from the vaginal wall is running
(Figure 5.5a, b). However, only Okabayashi’s radical hyster- parallel with the vaginal wall and drains into the deep
ectomy divides the vesical veins separating from the vaginal uterine vein in the cardinal ligament.
Different cutting line of the paracervix

a b c
parametrium posterior (dorsal) leaf
(paracervix) parametrium of vesicouterine ligament paracolpium
(paracervix)
Wertheim’s Method Meigs’ Method Okabayashi’s method

(Piver et al Type III)
cardinal ligament cardinal ligament

(deep uterine vein) (deep uterine vein)
Figure 5.5 Different cutting lines (two-directional arrow lines) of the paracervix among three different radical hysterectomies such as Wertheim’s
method (a), Meigs’ method (Piver et al. Type III) (b) and Okabayashi’s method (c)
Step-by-Step Radical Hysterectomy
with Pelvic Lymphadenectomy 6
(Without Nerve-Sparing)
6.1 Surgical Process of the Step-by-Step Radical Hysterectomy
6.1.1 Open the Abdominal Cavity
6.1.2 Exposure of the Pelvic Cavity
6.1.3 Visual and Manual Examination of the Spread of the Disease and Operability
6.1.4 Traction of the Uterus (Figure 6.1)
Long Kocher forceps are placed close to the bilateral uterine fallopian tubes. The Kocher forceps are tied by a ribbon to
body including the round ovarian ligaments as well as the use as a uterine retractor.
Figure 6.1 Traction of the uterus using two long Kocher forceps
Kocher forceps for traction of uterus

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56 6 Step-by-Step Radical Hysterectomy with Pelvic Lymphadenectomy (Without Nerve-Sparing)
6.1.5 Ligation and Division of the Round Ligament (Figure 6.2)
The uterus is drawn cranially left, then the right round liga- ligatures. Then an incision to the anterior peritoneal layer of
ment becomes tense. The ligament is picked up and two liga- the broad ligament is made toward the urinary bladder and
tures, one to the uterine side and the other to the inguinal cranially toward the common iliac artery to expose the loose
side, are placed on the round ligament through the broad connective tissue in the broad ligament (the retroperitoneal
ligament. The round ligament is divided between the two connective tissue).
Figure 6.2 Ligation and

division of the round ligament cut-end of
and the direction of the bladder round ligament
separation of the peritoneum cut-end of
of the broad ligament (blue round ligament
arrow line) connective tissue
of broad ligament
uterus
peritoneum of broad ligament
rectum
Direction of division of broad ligament peritoneum

6.1 Surgical Process of the Step-by-Step Radical Hysterectomy 57
6.1.6 Ligation and Division of the Suspensory Ligament of the Ovary (Ovarian Vessels) (Figure 6.3)
With the uterus held over to the left side, long Kocher for- divided. (For the preservation of the ovary and the fallo-
ceps are already placed to clamp the uterine side of the ovar- pian tube, ovarian side of the ovarian ligament and fallopian
ian ligament and fallopian tube. The suspensory ligament of tube is ligated, then dissected between the long Kocher for-
the ovary (ovarian vessels) is isolated, doubly ligated, and ceps and the ligature.)
Figure 6.3 Ligation and cut-end of round ligament

bladder
division of the suspensory
ligament of the ovary (ovarian cut-end of
vessels). The retroperitoneal round ligament
space beneath the broad
ligament is widely separated
uterus
connective tissue
of broad ligament
rectum
cut end of suspensory ligament of ovary

(ovarian vessels)
6.1.7 Confirmation of the Ureter (Figure 6.4)
Usually, in the connective tissue of the dorsal side of the ureter. Manually, firmly press the tubular structure between
cut-end of the suspensory ligament of the ovary, a long the thumb and middle finger, which should lead to the tubu-
tubular structure can be appreciated running toward the uri- lar structure slipping from your fingers with a “snapping
nary bladder. Tapping the tubular structure stimulates a ver- sensation.” The snapping sensation is characteristics of the
miculation movement. This is a characteristic feature of the ureter.
a b
manually firmly press tubular structure tubular structure slipping from fingers
between thumb and middle finger with a snapping sensation
Figure 6.4 Manual confirmation of the ureter with fingers using structure. (b) Press firmly the tubular structure with two fingers, then
thumb and middle fingers. (a) Putting the connective tissues of the the ureter usually slips between the fingers and creates a snap sound
broad ligament between thumb and middle fingers, search the tubular (snapping sensation)
6.1.8 Isolation of the Ureter (Figure 6.5)
The ureter running along the posterior peritoneal layer of the isolate from the surrounding connective tissue, when approached
broad ligament is separated from the connective tissue of the as cranially at the level of the common iliac artery and caudally
retroperitoneal side of the peritoneum. The ureter is easier to at the level where the ureter crosses the uterine artery.
Figure 6.5 Isolation of the cut-end of round lig.

bladder
ureter. The ureter is isolated
from the loose connective
cut-end of
tissues beneath the rectal side
round lig.
of the broad ligament
peritoneum
uterus
vessel tape
rectum
ureter
cut end of suspensory lig. of ovary
(ovarian vessels)
6.1.9 Application of a Vessel Tape for a Marker of the Ureter (Figure 6.6)
A vessel tape is applied to act as a marker of the isolated tunities to divide or damage the ureter as a result of a careless
ureter. It is very important to maintain the ureter with a mistake during surgery. The marker of the vessel tape can
marker during a radical hysterectomy. There are many oppor- help to avoid injuries to the ureter.
Figure 6.6 Application of a

bladder cut-end of round lig.
vessel tape for a marker of the
ureter
cut-end of
round lig.
uterus
rectum
ureter
vessel tape
6.1.10 Tentative Development of the Pararectal Space (Figure 6.7)
Between the posterior peritoneal layer and internal iliac vein/ the pelvic floor along the pelvis axis between the rectum and
artery, the retroperitoneal connective tissue is dissected. This the internal iliac artery/vein. This is the loose connective tissue
allows the loose connective tissue to be easily separated toward of the pararectal space (Latzko’s pararectal space).
Figure 6.7 Tentative cut-end of round lig.

development of the pararectal bladder
space (Latzko)
cut-end of
round lig.
uterus
rectum
pararectal space
vessel tape (Latzko)
6.1.11 Definition of the Pararectal Space (Figures 6.8 and 6.9)
The pararectal space is a space surrounded by rectal side- space can be undertaken by inserting fingers into the loose
wall (uterine side), internal iliac blood vessels (pelvic side- connective tissue between the rectum and the internal iliac
wall), sacral bone (cranial side), and blood vessels and artery/vein. The direction of insertion is toward the pelvic
connective tissue of cardinal ligament (inguinal side). The axis. Separation of the connective tissue between the inter-
pararectal space is filled with the loose connective tissue to nal iliac artery and the ureter reveals a space called as
the base of the pelvis. The development of the pararectal Latzko’s pararectal space.
a b
paravesical space
cardinal ligament
uterine artery
Latzko’s
pararectal internal iliac
space artery/vein
ureter
Figure 6.8 Definition of the pararectal space. (a) The relationship between the rectal sidewall with the ureter and the internal iliac artery/
among the paravesical space, the cardinal ligament and the pararectal vein. On the rectal sidewall of the pararectal space the hypogastric
space (Latzko). (b) A surgical photo of the developed pararectal space nerve accompanied by a small blood vessel is appreciated
a b
Entrance of Okabayashi’s pararectal space
uterus pelvic
splanchnic
nerve
ureter
Douglas’ pouch
rectum
hypogastric nerve
Figure 6.9 Anatomical location of Okabayashi’s pararectal space. (a) just between the rectal sidewall and the connective tissue plane that
An oval-shaped orange circle filled with yellow color on the uterosacral includes the ureter and the hypogastric nerve. This connective tissue
ligament is the landmark of the entrance of Okabayashi’s pararectal plane resides between Okabayashi’s pararectal and Latzko’s pararectal
space. (b) A surgical photo of Okabayashi’s pararectal space developed space
In contrast, Okabayashi opened the pararectal space by the open the space from the uterosacral ligament. Between Latzko’s
division of the uterosacral ligament and usually divided the and Okabayashi’s pararectal space, the hypogastric nerve is
hypogastric nerve. Therefore, Okabayashi’s pararectal space appreciated parallel to the ureter as shown in Figure 6.8b. In
is developed just close to the rectal sidewall retracting the iso- order to extend Okabayashi’s pararectal space toward Latzko’s
lated ureter to the pelvic sidewall (Figure 6.9a, b). In order to pararectal space, it is necessary to divide the hypogastric nerve,
increase the mobility of the uterus, Okabayashi preferred to which in turn increases the mobility of the uterus.
6.1.12 The Ureter and the Hypogastric Nerve Are on the Same Connective Tissue Plane (Figure 6.10)
As shown in the photos during surgery (Figure 6.10a, b), if sion of the connective tissue plane with the hypogastric nerve
the two spaces are developed separately, the connective tis- can expand Okabayashi’s pararectal space to reach Latzko’s
sue plane containing the ureter is created between pararectal space. The expanded pararectal space is very wide
Okabayashi’s pararectal space and Latzko’s pararectal space. and deep. When performing nerve-sparing radical hyster-
The hypogastric nerve runs at a level 2–4 cm dorsal to the ectomy, the development of Latzko’s pararectal space is
ureter in the same connective tissue plane. Usually, the ureter enough and development of the Okabayashi’s pararectal
is already isolated from the connective tissue plane. The divi- space is not required.
a b
Figure 6.10 Anatomical relationship between Okabayashi’s pararec- rectional arrow). (b) Okabayashi’s pararectal space is medially devel-
tal space and Latzko’s pararectal space. (a) On the rectal sidewall of oped between the rectum and the connective tissue plane of the ureter
Latzko’s pararectal space, the ureter and the hypogastric nerve are and hypogastric nerve that was the rectal sidewall of Latzko’s pararectal
appreciated on the same connective tissue plane (a dotted line with bidi- space
6.1.13 Division of the Peritoneum at Pouch of Douglas (Figure 6.11)
The uterus is drawn toward the pubic arch and the rectum incision is made on the elevated peritoneum and extended
with its peritoneal surface is stretched with the hand toward with scissors across the dorsal side (back) of the cervix. This
the cranial side. The peritoneum between the uterus and the step connects the retroperitoneal spaces of the broad liga-
rectum is lifted from the base of the Pouch of Douglas. The ment on both sides.
Figure 6.11 Division of the peritoneum of the Douglas’ pouch uterosacral lig.
uterus
Douglas’
pouch
ureter
rectum hypogastric
nerve
6.1.14 Separation of the Peritoneum of the Vesicouterine Pouch (Figure 6.12)
The peritoneum is divided across the ventral side of the cer- can insinuate and divide the peritoneum easily without any
vix, just 1–2 cm below the vesicouterine fold where scissors damage to the urinary bladder.
vesicouterine fold
bladder
connective
uterine
tissue of
artery
broad ligament
uterine
artery
ureter
Figure 6.12 Separation of the peritoneum of the vesicouterine pouch

6.2 Pelvic Lymphadenectomy 67
6.2 Pelvic Lymphadenectomy
6.2.1 Lymph Nodes in the Pelvis (Figure 6.13)
Major lymph nodes in the pelvic cavity are illustrated in pelvic lymph nodes, we undertake paraaortic lymphade-
the Figure 6.13. We usually start the dissection of lymph nectomy above the bifurcation of the aorta either till the
nodes from the supra-inguinal area and finish cranially by level of the inferior mesenteric artery or till the level of
the common iliac area. If we find positive nodes in the the renal vein.
Figure 6.13 Lymph nodes in

the pelvis
sacral node
common iliac node
internal iliac node
uterus
obturator node
external iliac node
urinary bladder
parametrial node
(node of cardinal lig.)
internal suprainguinal node
6.2.2 Exposure of the Adipose Tissue in the Supra-Inguinal Area (Figure 6.14)
The adipose tissues are distributed in the retroperitoneal sectional view of the retroperitoneal structures in the pelvis at
space of the pelvis on the external iliac/internal iliac/common the level of a two-directional arrow drawn in the Figure 6.14b.
iliac vessels as shown in Figure 6.14a. Including the incised A dotted arrow line in Figure 6.14b shows the separation
abdominal wall and the cut-end of the round ligament, a point of connective tissue from the iliopsoas muscle. In the
retractor is applied to the abdominal wall on the inguinal side. following illustrations of cross-sectional view of lymphade-
Then, the retractor is pulled caudally, to expose the adipose nectomy, the dotted arrow line indicates the separation line of
tissue of the supra-inguinal area. Figure 6.14b shows a cross- the connective tissue from muscle, blood vessels, or nerve.
a b
traction
genitofemoral nerve
cross-section line
ureter
iliopsoas muscle
obturator nerve
rectum
obturator vessels
cut end of internal iliac

ovarian vessels hypogastric nerve vessels
pararectal space
(Latzko)
Figure 6.14 Exposure of the adipose tissues in the supra-inguinal at the level of a two-directional arrow (cross-sectional line) drawn in
area. (a) Exposed retroperitoneal adipose tissues of the broad ligament. Figure 6.14a. A dotted arrow line indicates the separation point of the
(b) A cross-sectional view of the retroperitoneal structures in the pelvis connective tissue from the iliopsoas muscle
6.2.3 Exposure of the Iliopsoas Muscle (Figure 6.15)
By retracting the incised abdominal wall laterally from ventral surface of the external iliac artery (Figure 6.15a).
the supra-inguinal region to the region of the common The genitofemoral nerve runs parallel to the external iliac
iliac artery, the ventral side of the iliopsoas muscle is artery. Usually, the genitofemoral nerve is preserved. A
revealed. The connective tissue with adipose tissue is dis- dotted arrow line in Figure 6.15b indicates the direction of
sected from the surface of the iliopsoas muscle toward the separation of the adipose tissue on the external iliac artery.
a traction b
separation of adipose
tissue on iliopsoas muscle
direction of separation
iliopsoas muscle
obturator
iliopsoas muscle nerve
external iliac
artery
internal iliac
vessels
genitofemoral nerve
Figure 6.15 Exposure of the iliopsoas muscle. (a) Four small arrows lines are showing direction of the separation of the adipose tissues
on the iliopsoas muscle are indicating the direction of the separation of toward the external iliac artery
the adipose tissues toward the external iliac artery. (b) Two dotted arrow
6.2.4 S
eparation of the External Supra-Inguinal Nodes from the Ventral Surface of the External
Iliac Artery (Figure 6.16)
Retraction of the abdominal wall of the supra-inguinal area artery. Avoiding a deep circumflex iliac vein, the adipose tis-
distally (arrow in Figure 6.16a) exposes the adipose tissue of sue with lymph nodes is dissected up from the ventral sur-
the supra-inguinal region. Picking up the adipose tissue on face of the external iliac artery. A dotted arrow line in
the external iliac artery, the adipose tissue including supra- Figure 6.16b indicates the direction of separation that reaches
inguinal node is separated from the ventral surface of the to the ventral surface of the external iliac vein. Paying atten-
external iliac artery. In the supra-inguinal region, usually the tion to the deep circumflex iliac vein, the adipose tissues
deep circumflex iliac vein runs across the external iliac with the external supra-inguinal nodes are removed.
a b
traction
external suprainguinal node
deep circumflex iliac vein direction of separation
external iliac
vein
iliopsoas muscle
genitofemoral nerve
Figure 6.16 Separation of the external supra-inguinal nodes from the face of the external iliac artery. (b) A dotted arrow line indicates the
ventral surface of the external iliac artery. (a) By the traction of the direction of separation of the adipose tissues that reaches to the ventral
abdominal wall of the supra-inguinal area distally (arrow), the adipose surface of the external iliac vein
tissue including supra-inguinal nodes is separated from the ventral sur-
6.2.5 Tentative Development of the Paravesical Space (Figure 6.17)
By the separation of the connective tissue between the oblit- public bone (caudal side), the connective tissue of the cardi-
erated umbilical artery and the external iliac vein at a point nal ligament (cranial side), and pelvic floor (dorsal side). In
2–3 cm cranial to the pubic bone, the cobweb-like loose con- the base of the pelvis, a yellow-white string running from the
nective tissue becomes visible. This is the entrance of the foramen obturatum is appreciated. This is the obturator
paravesical space. The paravesical space is surrounded by nerve. The obturator nerve can be traced along the dorsal
the obliterated umbilical artery (urinary bladder side), rectal/ side of external iliac vein by the lateral side of the common
vaginal wall (rectal side), external iliac vein (inguinal side), iliac vein.
Figure 6.17 Tentative obliterated umbilical

development of the paravesical space
artery obturator nerve
paravesical space
deep circumflex iliac vein
external iliac vein
external iliac artery
iliopsoas muscle
6.2.6 S
eparation of the Connective Tissue Between the External Iliac Artery and Iliopsoas Muscle
(Figure 6.18)
The connective tissue surrounding the external iliac artery is sheath on the surface of the external iliac artery is dissected.
separated by insertion of a small retractor and medial trac- This procedure opens the space between the iliopsoas mus-
tion of the external iliac artery as shown in Figure 6.18. cle and external iliac vessels. It is possible to continue the
Giving tension to the connective tissue between the external dissection along the medial surface of the iliopsoas muscle
iliac artery and iliopsoas muscle, the loose connective tissue deep into the obturator fossa.
Figure 6.18 Separation of the connective tissue between the

external iliac artery and iliopsoas muscle
external iliac
vein
separation of
from iliopsoas muscle
iliopsoas muscle
genitofemoral nerve
6.2.7 S
eparation of the Uterine Side Connective Tissue of the External Iliac Artery and Vein
(Figure 6.19)
The dissection proceeds toward the medial side of the exter-

nal iliac artery and continues to the sheath of the medial side
of the external iliac vein.
Figure 6.19 Separation of the uterine side connective tissue of

the external iliac artery and vein
external iliac
node
external iliac
artery
iliopsoas muscle
obturator nerve
genitofemoral
nerve
6.2.8 Lymphadenectomy of the External Iliac Nodes of the Uterine Side (Figure 6.20)
Picking up the adipose tissue on the medial side, the external and vein. The direction of the separation is illustrated using a
iliac lymph nodes are dissected from the external iliac artery dotted arrow line in Figure 6.20b.
a b
obturator nerve
external iliac node
genitofemoral nerve
external iliac node
external iliac vein
Figure 6.20 Lymphadenectomy of the external iliac nodes of the uterine side. (a) Picking up the adipose tissue on the medial side, the external
iliac lymph nodes are dissected from the external iliac artery and vein. (b) A dotted arrow line is the direction of the separation
6.2.9 S
eparation of the Connective Tissue Between the Iliopsoas Muscle and the External Iliac
Vessels Toward the Pelvic Floor (Figure 6.21)
The ventral side of the adipose tissue on the iliopsoas muscle muscle (Figure 6.21a). The scissors are advanced dorsally
is already removed. The connective tissue of the external into the obturator fossa. Moreover, the dissection should be
iliac artery side is picked up and scissors are advanced into extended deep enough to reach the base of the pelvic wall as
the connective tissue along the medial side of the iliopsoas shown in Figure 6.21b using a dotted arrow line.
a b
genitofemoral nerve
external iliac vein
external iliac node
genitofemoral
nerve
iliopsoas muscle
separation of
from iliopsoas muscle
obturator vessels obturator nerve

iliopsoas muscle
Figure 6.21 Separation of the connective tissue between the iliopsoas connective tissue along the medial side of the iliopsoas muscle. (b) A
muscle and the external iliac vessels. (a) The connective tissue of the dotted arrow line is the direction of the scissors dorsally into the obtura-
external iliac artery side is picked up and scissors are advanced into the tor fossa deep enough to reach the base of the pelvic sidewall
6.2.10 Dissection of the External Iliac Nodes (Figure 6.22)
Drawing the external iliac artery medially by a small retractor, with adipose tissue including the external iliac lymph nodes is
the loose connective tissue sheath on the external iliac vein is separated from the external iliac vein (Figure 6.22b). The sep-
separated toward the dorsal surface of the external iliac vein arated adipose tissues with lymph nodes are reflected medially
(Figure 6.22a). During this step, the connective tissue sheath to the obturator fossa or can be dissected at this point.
a b
deep cicumflex iliac vein
elevation of iliopsoas muscle

external iliac vein
iliopsoas muscle
external iliac node
external iliac node
Figure 6.22 Dissection of the external iliac nodes. (a) Drawing the surface of the external iliac vein. (b) The connective tissue sheath with
external iliac artery medially by a small retractor, the loose connective adipose tissue including the external iliac lymph nodes is separated
tissue sheath on the external iliac vein is separated toward the dorsal from the external iliac vein as illustrated using a dotted arrow line
6.2.11 Separation of the Connective Tissue on the Internal Iliac Artery (Figure 6.23)
The same kind of dissection is extended to both cranial side and connective tissues are separated from the ventral side of
and caudal side of the external iliac vein. The adipose tis- the internal iliac artery (Figure 6.23b). The uterine artery
sues with external iliac lymph nodes are separated from the and the obturator arteries often branch from the internal
external iliac vein and are collected in the obturator fossa iliac artery. In order to avoid injuries to these arteries, it is
(Figure 6.23a). Once the common iliac artery is identified, better to start dissection from the ventral surface of the
the internal iliac artery is found medially and the adipose internal iliac artery.
a b
pararectal space obturator nerve
(Latzko)
deep circumflex vein
iliopsoas muscle
external iliac vein
unroofing of internal
iliac artery
ureter
ureter rectum
external iliac node
Figure 6.23 Separation of the connective tissue on the internal iliac obturator fossa. (b) Once the internal iliac artery is found medially, the
artery. (a) The dissection is extended to both cranial side and caudal adipose and connective tissues are separated from the ventral side of the
side of the external iliac vein. The adipose tissues with external iliac internal iliac artery as illustrated using a dotted arrow line
nodes are separated from the external iliac vein and are collected in the
6.2.12 Confirmation of the Obturator Nerve in the Obturator Fossa (Figure 6.24)
In the dorsal level of the external iliac vein, we usually becomes a landmark of the obturator fossa (Figure 6.24a). As
appreciate a yellow-white solid string running in the obtura- shown in Figure 6.24b, the connective tissue with lymph
tor fossa. This is the obturator nerve. The obturator nerve nodes is separated toward the obturator nerve.
a b
paravesical space accessory obturator vein

uterine artery
external iliac vein
elevation of
external
iliac vessels
obturator nodes
internal iliac vessels

obturator nerve
obturator
obturator artery vessels
Figure 6.24 Confirmation of the obturator nerve in the obturator the obturator nerve. The obturator nerve becomes a landmark of the
fossa. (a) In the dorsal level of the external iliac vein, we usually appre- obturator fossa. (b) As illustrated using a dotted arrow line, the connec-
ciate a yellow-white solid string running in the obturator fossa. This is tive tissue with lymph nodes is separated toward the obturator nerve
6.2.13 Lymphadenectomy of the Obturator Fossa [1] (Figure 6.25)
Using a small retractor to lift up both the external iliac artery tor nerve from the foot/caudal side (obturator canal) to the
and vein at the pelvic wall side opens the space of the cranial side (between the common iliac vein and iliopsoas
obturator fossa as widely as possible. Picking up the adipose muscle). In the dorsal side of the obturator nerve, the obtura-
tissues of the dorsal side of external iliac vein, the connec- tor artery and vein are usually running parallel to the obtura-
tive/adipose tissues surrounding the obturator nerve are sep- tor nerve (Figure 6.25b). In order to avoid unnecessary
arated. The obturator nerve is easily stripped from the hemorrhage, attention should be paid to these vessels.
adipose tissues (Figure 6.25a). It is better to trace the obtura-
a paravesical space accessory obturator vein b

uterine artery
external iliac vein
obturator nodes
obturator nerve
internal iliac artery internal iliac vessels
obturator
vessels
obturator nerve
Figure 6.25 Lymphadenectomy of the obturator fossa. (a) Stripping relationship between the obturator nerve and obturator vessels are also
of the adipose tissues surrounding the obturator nerve. (b) A dotted illustrated
arrow is showing the separation line from the iliopsoas muscle side. The
In the inguinal side of the external iliac vein, the internal the accessory obturator vein can be divided and ligated. At
supra-inguinal node is residing between the accessory obtu- this stage, the adipose tissues with lymph nodes on the side
rator vein and iliopsoas muscle/pubic bone. From the foot of the iliopsoas muscle can be separated from both the exter-
side, the lymph node is separated and passed to the dorsal nal iliac artery and vein.
side of the accessory obturator vein. If this step is difficult,
Figure 6.26 The internal internal suprainguinal node

supra-inguinal node is accessory obturator vein
separated and passed to the deep circumflex iliac vein
dorsal side of the accessory
obturator vein
elevation of
paravesical
space
obturator nerve
Latzko’s
pararectal
obturator nodes
space

After the separation of the internal supra-inguinal node, the arated from the obturator nerve. The denuded obturator nerve
lymph nodes of the external iliac artery/vein are passed into can be traced cranially along the external iliac vessels to the
the obturator fossa. Lifting up the passed internal supra- dorsal space between the iliopsoas muscle and the common
inguinal node, the adipose tissues with lymph nodes are sep- iliac vessels.

accessory obturator vein
the obturator lymph node
from the obturator fossa
obturator vessels
obturator nerve
obturator nodes external iliac vessels
uterine artery
internal iliac
artery
6.2.16 En Bloc Removal of the Lymph Nodes in the Obturator Fossa (Figure 6.28)
By separating the adipose tissue with lymph nodes sur- obturator nerve and from the base of the pelvis. Usually the
rounding the obturator nerve, lymph node dissection on the adipose tissue in the retroperitoneal space is easily aspirated
ventral side of the obturator nerve is completed. Using the and the network of the small blood/lymph vessels becomes
metal tube suction, try to aspirate the adipose tissues sur- visible. Confirming the anatomy of the network, en bloc
rounding the obturator nerve, which makes it easier to sepa- removal of the lymph nodes in the obturator fossa is
rate the connective tissues with lymph nodes from the possible.
Figure 6.28 En bloc accessory obturator vein

removal of the lymph nodes
obturator vessels
in the obturator fossa
paravesical
space
obturator nodes
obturator nerve
Latzko’s
pararectal
space
internal iliac
artery
ureter
6.2.17 Lymphadenectomy for the Dorsal Side of the Obturator Nerve (Figure 6.29)
In the dorsal portion of the obturator nerve, the obturator division of these vessels is necessary if lymph nodes are
artery and vein are usually running parallel to the obtura- adherent to these blood vessels. Ligation and division of
tor nerve. Therefore, in order to preserve these vessels, these vessels usually has no adverse side effects to the
careful separation is necessary (Figure 6.29a). However, patient.
a paravesical b
space obturator vessels
Latzko’s obturator nerve

pararectal
space
internal iliac
artery & vein
internal iliac
artery
obturator vessels
deep obturator nodes
Figure 6.29 Lymphadenectomy for the dorsal side of the obturator nerve. (a) Removal of the lymph nodes in the dorsal side of the obturator nerve
can skeletonize the obturator artery and vein. (b) Two dotted arrow lines are indicating the separation point of the dorsal side of the obturator nerve
Cranially, separate the connective tissues with lymph

nodes from the bifurcation of the external and internal iliac nosis (more than 90% 5-year survival rate without
vessels. The obturator artery and vein are often branching any adjuvant therapy) following the complete
from the bifurcation area, where careful separation is neces- removal of lymph nodes within the base of the car-
sary. The adipose tissues and lymph nodes in the base of the dinal ligament as a mass of internal iliac blood ves-
cardinal ligament are also removed. The base of the cardinal sel system (laterally extended parametrectomy) in
ligament takes drainage from the deep uterine vein into the case of lymph node positive patients. This report
internal iliac vein. This step enables greater appreciation of demonstrates the importance of the extent of
the anatomical structure of the cardinal ligament. Through lymphadenectomy for the survival of invasive cer-
these procedures, the lymphadenectomy for the dorsal side vical cancer patients. The removal of the adipose
of the obturator nerve is completed. It is convenient to use tissues by liposuction using a suction device reveals
monopolar or bipolar coagulation tools for lymphadenec- the network of small lymphatic channels, small
tomy. If the anesthesia is not deep enough, using monopolar blood vessels, and small lymph nodes with adipose
energy close to the obturator nerve can lead to contraction tissues in the dorsal side of the obturator nerve.
movements in the patient’s leg which can sometimes jolt the Using a bipolar coagulation tool, these vessels and
surgeon’s movements. In order to avoid unexpected injury to the small lymph nodes with adipose tissues in the
the pelvic organs, the bipolar system appears to be safer than dorsal side of the obturator nerve are well treated.
the monopolar system. However, given the possibility of many variations
of the branches from the internal iliac vein, such as
the obturator vein and the deep uterine vein, careful
Notes separation of these structures is required.
1. It is often said that the lymphadenectomy for the 2. Liposuction procedure was introduced by Fujiwara
dorsal side of the obturator nerve is not necessary. T. in 1983 [1] in Japan. The report of Heckels M.
However, if we may observe this region, there are a et al. [2, 3] is not the first on the use of liposuction
considerable number of small lymph nodes. for lymphadenectomy and radical hysterectomy.
Recently Ungar L. et al. reported very good prog-
6.2.18 Confirmation of the Base of the Cardinal Ligament (Figure 6.30)
By the removal of the adipose tissues with lymph nodes on side is better appreciated. The base of the cardinal ligament
the dorsal side of the obturator nerve, the internal iliac vein is the draining portion of the deep uterine vein into the inter-
becomes well delineated in the obturator fossa. Moreover, nal iliac vein.
venous drainage into the internal iliac vein from the uterine
Figure 6.30 Confirmation of paravesical space

the base of the cardinal
ligament (a purple dotted line)
deep circumflex
iliac vein
uterine artery
obturator vessels

Latzko’s
pararectal
space
obturator nerve
internal iliac
artery & vein
base of cardinal lig.

6.2.19 The Lymphadenectomy of the Common Iliac Nodes (Figures 6.31 and 6.32)
The connective tissues with lymph nodes at the bifurcation tissues on the external iliac artery, the loose connective tissue
of the external and internal iliac vessels are already sepa- between the iliopsoas muscle and the external iliac artery is
rated. The cranial side of the bifurcation is the common iliac also separated.
artery and vein. Separating the ventral side of the connective
paravesical space
deep circumflex
iliac vein
Latzko’s obturator vessels

pararectal space
internal iliac
artery & vein
common iliac artery
deep common iliac node
sacral node
superficial common iliac node
Figure 6.31 Lymphadenectomy of the common iliac nodes [1]

a b
Latzko's
pararectal
space
sacral nod
common obturator nerve

iliac
artery
deep common iliac node
superior
superficial common iliac node gluteal
vein
Figure 6.32 Lymphadenectomy of the common iliac nodes [2]. (a) The anatomical location of the deep common iliac node. (b) The anatomical
relationship between the obturator nerve of the cranial side and the superior gluteal vein
Separation is extended deep enough to visualize the obtura- by the level of the obturator nerve that disappears into the major
tor nerve and the superior gluteal vein. The adipose tissues and psoas muscle cranially. The adipose tissues are separated from
lymph nodes surrounding the obturator nerve are dissected both the common iliac artery and vein as much as possible, and
between the common iliac artery/vein and the iliopsoas muscle the deep common iliac nodes are removed (Figure 6.32a, b).
6.2.20 Lymphadenectomy of the Sacral Nodes (Figure 6.33a–c)
Separation of the connective tissue on the common iliac node is included in the separated connective tissues
artery is extended medially along the internal iliac artery. (Figure 6.33a, b).
The pararectal space has already been (Latzko’s pararectal The cranial side of the separated adipo-connective tissues
space) developed between the internal iliac artery and the is divided. The divided adipo-connective tissues are sepa-
lateral side of the rectum. The connective tissue in the para- rated from the sacral bone along with the internal iliac vein
rectal space is separated as wide and deep as possible. Then toward the foot/distal side (Figure 6.33c). Usually, small
the internal iliac vein running parallel to the internal iliac blood vessels are included in this area; therefore, careful
artery is appreciated. Connective tissues of the presacral separation using electrocoagulation device such as bipolar
space are separated toward the sacral bone. Then, the sacral forceps or scissors is necessary.
a c
obturator vessels
internal iliac
artery & vein
internal iliac
node
internal iliac node
sacral node
superior
obturator nerve
gluteal
vein
presacral space
Figure 6.33 Lymphadenectomy of the sacral node. (a) The connective the separated connective tissues. (c) The cranial side of the separated
tissue in the pararectal space is separated toward the presacral space (a adipo-connective tissues is divided. The divided adipo-connective tis-
dotted arrow line). (b) Connective tissues of the presacral space are sues are separated from the sacral bone along with the internal iliac vein
separated toward the sacral bone. Then, the sacral node is included in toward the foot/distal side
6.2.21 Removal of the Common Iliac Nodes (Figure 6.34)
The cranial side of the common iliac lymphadenectomy is iliac artery medially to develop the space between the com-
undertaken by separating the loose connective tissue layer mon iliac artery/vein and the psoas muscle. The adipo-con-
from the bifurcation of the common iliac artery to the aorta. nective tissue in this area is removed from the common iliac
Ligating the cranial side of the adipo-connective tissues, the artery/vein and obturator nerve, avoiding injury to the supe-
ventral side of the common iliac lymphadenectomy is car- rior gluteal vein.
ried out. Retract the psoas muscle laterally and the common
Figure 6.34 Removal of the

common iliac nodes
obturator
vessels
superior vesical
artery external
iliac
vessels
uterine artery
internal iliac vein
obturator nerve
common iliac
artery
superficial common
iliac node
6.2.22 A View of the Pelvic Cavity After the Pelvic Lymphadenectomy (Figure 6.35)
After the pelvic lymphadenectomy, the majority of the artery Thoroughness or completeness of lymphadenectomy is
and vein along the internal and external iliac artery/vein are one of the most important prognostic factors and hence,
exposed clearly. Lymphadenectomy should be undertaken should be undertaken carefully and as meticulously as
thoroughly in the pelvic cavity. If pelvic lymph nodes are possible.
positive, lymphadenectomy is usually extended cranially to
the level of the inferior mesenteric artery.
paravesical space
obliterated umbilical artery obturator

vessels
superior vesical external

artery iliac
vessels
uterine artery
Latzko's
pararectal
space
obturator nerve
ureter
internal iliac
artery & vein
superficial gluteal vein

common iliac artery
obturator
obturator nerve vessels
Figure 6.35 A view of the pelvic cavity after the pelvic lymphadenectomy
6.3 Treatment of the Cardinal Ligament 91
6.3 Treatment of the Cardinal Ligament
6.3.1 A View of the Pelvis After the Lymphadenectomy (Figure 6.36)
After pelvic lymphadenectomy, both external and internal obturator nerve and artery/vein in the obturator fossa. The
iliac blood vessels are almost skeletonized with a view of the paravesical space and pararectal space are well recognized.
Figure 6.36 A view of the

pelvis after the
lymphadenectomy
paravesical spac
external
iliac
vessels
obturator
vessel
Latzko's
pararectal space
obturator nerve
common iliac artery

6.3.2 S
eparation of the Loose Connective Tissue Between the Uterine Artery and the Superior
Vesical Artery (Figure 6.37)
In order to give tension to the uterine artery, the obliterated separated. The loose connective tissue layer between the
umbilical artery (bladder side of the internal iliac artery) is uterine artery and the superior vesical artery is now appreci-
picked up with the forceps, and the loose connective tissue ated. The connective tissue layer is separated to penetrate the
between the bladder and the obliterated umbilical artery is paravesical space.

the loose connective tissue
between the uterine artery and obliterated umbilical artery
the superior vesical artery (a
purple arrow)
superior vesical paravesical space

artery
separation of
connective tissue
uterine artery
internal illiac
Latzko’s artery
pararectal
space common iliac artery
6.3.3 Development of the Paravesical Space and Confirmation of the Uterine Artery (Figure 6.38)
A long L-shaped retractor is inserted into the paravesical the internal iliac artery is stretched between its origin at the
space through the divided connective tissue, to retract the internal iliac artery and the sidewall of the uterus. This is a
structures to the upper-inguinal area, including the isolated safer way to identify the uterine artery along its entire
obliterated umbilical artery. Then, the uterine artery from length.

the paravesical space and obliterated umbilical artery paravesical space
confirmation of the uterine
artery
superior vesical artery
uterine artery

Latzko’s
pararectal space common iliac artery
6.3.4 Definition of the Cardinal Ligament (Figure 6.39)
Another long L-shaped retractor is inserted into the pararectal ment (a two-directional arrow in Figure 6.39). The cardinal
space pushing the rectum to the craniolateral side, in turn ligament is a thick connective tissue bundle formed between
gradually expanding the pararectal space. The thick connec- the internal iliac blood vessels and the sidewall of the uterus/
tive tissue bundle is created between the paravesical space and upper vagina. The uterine artery and the superficial uterine
pararectal space. This is a gross feature of the cardinal liga- vein run along the most ventral side of the cardinal ligament.
Figure 6.39 Definition of

the cardinal ligament (a paravesical space
dotted two-directional arrow)
cardinal lig.
uterine artery
common iliac artery

Latzko’s
pararectal space
Notes:
Do not insert the long L-shaped retractor too deep into
the pelvic floor. There is a risk of the connective tissue
of the pelvic floor being torn by the retractor, which
can lead to considerable bleeding. The bleeding is usu-
ally difficult to manage and therefore, it is prudent to
pay attention to the location of the retractor tip in the
pararectal space.
6.3.5 Isolation and Division of the Uterine Artery (Figure 6.40)
The uterine artery originating from the internal iliac artery is and divided between the two ligatures. The suture on the
appreciated on the most ventral side of the cardinal ligament. uterine side of the uterine artery is usually left longer to act
The uterine artery is easily isolated, doubly clamped, ligated, as an anatomical landmark.
Figure 6.40 Isolation and

division of the uterine artery
paravesical space
(a dotted two-directional
arrow is the location of the
cardinal ligament)
cut end of
uterine artery
cardinal lig.
Latzko’s
pararectal space
6.3.6 Separation of the Superficial Uterine Vein (Figure 6.41)
Careful separation of the cut-end of uterine side of the uter- does tear, an electric vessel sealing system such as m
onopolar
ine artery from the connective tissue of the cardinal ligament or bipolar coagulation is effective. The superficial uterine
usually reveals a vein running parallel to the uterine artery. vein is not always running parallel to the uterine artery.
This is the superficial uterine vein, which is fragile. Therefore, Rarely, it may run parallel to the ureter.
a careful approach is required in order to isolate it. If the vein

the superficial uterine vein paravesical space
cut end of
uterine artery
superficial
uterine vein
Latzko’s
pararectal space
6.3.7 Clamp, Divide, and Ligate the Superficial Uterine Vein (Figure 6.42)
The superficial uterine vein is isolated and doubly clamped each small blood vessel should be sealed either by electro-
by Pean forceps. Then the superficial uterine vein is cautery or ligature. However, the deep uterine vein always
divided between the two clamps and each clamp is replaced resides in the dorsal part of the cardinal ligament.
by ligature. The connective tissue of the cardinal ligament Therefore, careful separation of the connective tissue and
is separated toward the pelvic floor. A small vein or artery lymph nodes in the cardinal ligament is required to iden-
may be identified in the cardinal ligament. In such case, tify the deep uterine vein.
Figure 6.42 Clamp, divide,

and ligate the superficial
uterine vein paravesical space
cut end of
uterine artery
cut end of
superficial
uterine vein
Latzko’s
pararectal space
6.3.8 Separation of the Deep Uterine Vein (Figure 6.43)
Careful separation of the connective tissue and lymph nodes in vein. The connective tissue and adipose tissue surrounding the
the cardinal ligament can reveal a vein running from the uter- deep uterine vein should be divided as much as possible. This
ine sidewall to the internal iliac vein. This is the deep uterine is very important for the isolation of the deep uterine vein.

the deep uterine vein
cut end of
uterine artery
cut end of
uterine artery
cut end of
superficial
uterine vein
cut end of
superficial
uterine vein
deep uterine vein

6.3.9 Clamp, Divide, and Ligate the Deep Uterine Vein (Figure 6.44)
In the dorsal part of the deep uterine vein, a white-yellow divided between the two clamps. Each clamp is replaced by
bundle is usually appreciated parallel to the deep uterine ligature. Cleaning up the connective tissue and the adipose
vein. This is one of the branches of the pelvic splanchnic tissue in the base of the cardinal ligament (draining portion
nerve. After isolation, the deep uterine vein is doubly of the deep uterine vein into the internal iliac vein) is a very
clamped by Pean forceps. The deep uterine vein is then important step to perform a safe radical hysterectomy.
Figure 6.44 Clamp, divide, pelvic splanchnic nerve

and ligate the deep uterine
vein
cut end of
uterine artery
cut end of
uterine artery
cut end of
superficial
uterine vein
cut end of
superficial
uterine vein
cut end of
deep uterine vein
Notes:
If damage to the deep uterine vein occurs, a consider-
able amount of bleeding can be expected. However, if
the deep uterine vein is already isolated, it is possible
to clamp the damaged portion of the deep uterine vein
and manage the bleeding safely.
6.3.10 Confirmation and Division of the Pelvic Splanchnic Nerve (Figure 6.45)
The pelvic splanchnic nerve merges with the hypogastric clamp the pelvic splanchnic nerve using Pean forceps and
nerve to form the inferior hypogastric plexus bilaterally at divide between the two clamps. Each clamp is replaced by
the level of the sidewall of the cervix/upper vagina. During ligature. A loose connective tissue layer in the dorsal part is
Okabayashi’s radical hysterectomy, one of the branches of easily separated and the two spaces (the paravesical space
the pelvic splanchnic nerve is often divided. Since the nerve and the pararectal space) are connected with the base of the
is usually accompanied by a small blood vessel, it is better to pelvic floor.
Figure 6.45 Confirmation
and division of the pelvic division of
splanchnic nerve pelvic splanchnic nerve
cut end of
uterine artery
cut end of
uterine artery
cut end of
superficial
uterine vein
cut end of
superficial
uterine vein
cut end of
deep uterine vein
Notes:
By the division of the cardinal ligament, the middle
part of the three uterine supportive tissues is divided at
a level close to the internal iliac vein.
6.4 Development of the Rectovaginal Space and Division of the Uterosacral Ligament 101
6.4 Development of the Rectovaginal Space and Division of the Uterosacral Ligament
6.4.1 Separation and Division of the Peritoneum of the Douglas’ Pouch (Figure 6.46)
The uterus is drawn toward the pubic arch and the rectum space of the broad ligament. The rectum is then gently
with its peritoneal surface is stretched by hand toward the freed from the cervical/vaginal wall with scissors or with a
cranial side. The peritoneum between the uterus and the finger. With the uterus held over to the pubic arch and the
rectum is lifted from the bottom of the Pouch of Douglas. rectum stretched toward the cranial side by hand, a loose
An incision is made on the elevated peritoneum and car- connective tissue layer between the rectum and the cervix/
ried with scissors across the dorsal side (back) of the cer- vagina is appreciated. This is the landmark of the recto-
vix. This step connects both sides of the retroperitoneal vaginal space.
Figure 6.46 Separation and cut end of

division of the peritoneum pelvic splanchnic nerve
of the Douglas’ pouch
Douglas’ pouch
peritoneum
hypogastric nerve ureter
Internal iliac artery

6.4.2 Development of the Rectovaginal Space (Figure 6.47)
If there is no infectious adhesion or cancer invasion, the correct plane. There is risk of injury to the rectum, if the
loose connective tissue layer between the rectum and the plane is developed too close to the surface of the rectum. At
vagina is easily separated and can develop the rectovaginal this stage, the bilateral thick connective tissue bundles
space. Pressing the tips of scissors against the cervical fas- (uterosacral ligament) become defined between the recto-
cia, the rectum is bluntly detached from the cervix/upper vaginal space and the retroperitoneal space of the broad
part of the vagina. The separation should be carried in the ligament.

cut end of
the rectovaginal space
rectovaginal space
uterosacral lig.

6.4.3 Division of the Uterosacral Ligament (Figure 6.48)
The uterosacral ligament on either side is stretched forward

and dissected at its base at the rectal sidewall. Hypogastric
nerve is often divided by this procedure.
Figure 6.48 Division of the cut end of

uterosacral ligament pelvic splanchnic nerve
rectovaginal space
ureter
rectum
cut end of
hypogastric nerve
6.4.4 F
urther Division of the Uterosacral Ligament and Development of the Okabayashi’s
Pararectal Space (Figure 6.49)
Further division of connective tissue of the uterosacral liga- and the connective tissue layer in which the hypogastric
ment toward the base of the pelvis reveals a space filled with nerve is included. This space is the Okabayashi’s pararectal
cobweb-like connective tissues between the rectal sidewall space.
Figure 6.49 Entrance to

cut end of
Okabayashi’s pararectal space
(circle filled with blue color)
ureter
rectovaginal space
uterosacral lig.
Okabayashi’s
pararectal space rectum
Internal iliac
artery
Latzko’s
pararectal space
cut end of hypogastric nerve
Notes:
Ureter is already reflected laterally from this connec-
tive tissue layer toward the pelvic sidewall.
6.4.5 Development of the Pararectal Space (Figure 6.50)
Okabayashi’s pararectal space is very close to the rectum, (pelvic sidewall), the sacral bone (cranial side), and blood
and so it is necessary to expand the space toward the pelvic vessels and connective tissue of the cardinal ligament (ingui-
sidewall. During the process of expanding the pararectal nal side). The pararectal space is filled with the loose con-
space, the hypogastric nerve is usually divided. With this nective tissues to the base of the pelvis. The development of
step, Okabayashi’s pararectal space connects with Latzko’s the pararectal space can be done using fingers inserted
pararectal space. The pararectal space is surrounded by the between the rectum and the internal iliac artery/vein. The
rectal sidewall (uterine side), the internal iliac blood vessels direction of insertion is toward the pelvic axis.
Cross section view of the surgical spaces
vesico-
vesicouterine
cervical/vaginal
bladder ligament (anterior
space
(ventral) and
posterior (dorsal))
Ureter
paraveiscal
space
Middle supportive tissue
cardinal ligament
pelvic splanchnic
nerve
cervix
rectovaginal
space
Latzko’s
Latzko’s
pararectal
pararectal
space
space
rectum
Okabayashi’s
uterosacral ligament pararectal
hypogastric nerve space
Figure 6.50 The relationship between the surgically developable oped very close to the rectal sidewall is named Okabayashi’s pararectal
spaces and the supportive tissues of the female pelvic organ. The surgi- space. The next space from the Okabayashi’s pararectal space to the
cally developable spaces are the paravesical space, vesicovaginal space, internal iliac vessels is named Latzko’s pararectal space
rectovaginal space, and pararectal space. The pararectal space devel-
6.5 Separation of the Urinary Bladder and the Vesicouterine Ligament
6.5.1 Separation of the Urinary Bladder from the Cervical Fascia (Figure 6.51)
Picking up the bladder itself with the peritoneum, the bladder dles become defined on both sides of the cervix. The connec-
is separated from the center of the cervical fascia to the level tive tissue bundle contains the ureter, the uterine artery, and
of the trigone of the urinary bladder. Connective tissue bun- several blood vessels. This is the vesicouterine ligament.

the urinary bladder from the fascia of uterine cervix
cervical fascia
anterior (ventral) leaf of
bladder
ureter
ureter
cut-end of cut-end of
cardinal lig. uterine artery
6.5 Separation of the Urinary Bladder and the Vesicouterine Ligament 107
6.5.2 Anatomy of the Vesicouterine Ligament (Figure 6.52)
Since the ureter is running in the vesicouterine ligament, sep- detailed anatomy of the vesicouterine ligament was unclear
aration of the connective tissue of the vesicouterine ligament for more than 100 years, until it was clarified in 2007. The
is essential during radical hysterectomy. At first, it is neces- illustration below is a transparent view of the ureter and the
sary to separate the ventral part of the ureter. However, the blood vessels in the vesicouterine ligament by Shingo Fujii.
Figure 6.52 Anatomy of the vesicouterine ligament.

The surrounded area with a purple dotted line is showing the BLACK BOX
anatomical location of the vesicouterine ligament and its
vagina
detailed anatomy was a black box for more than 100 years.
The inserting line of the ureter to the urinary bladder and the cervix
existing blood vessels in the vesicouterine ligament are uterus
illustrated faintly in the figure
bladder
ureter
vesicouterine lig.
6.5.3 Anatomy of the Anterior (Ventral) Leaf of the Vesicouterine Ligament (Figure 6.53)
Figure 6.53 illustrates the cut-ends of the blood vessels After the separation of the anterior (ventral) leaf of the vesi-
which reside in the anterior (ventral) leaf of the vesicouterine couterine ligament, it is possible to roll the ureter laterally
ligament and the blood vessels in the posterior (dorsal) leaf from the surface of the posterior (dorsal) leaf of the vesico-
of the vesicouterine ligament (shown as a transparent view). uterine ligament.
Figure 6.53 The divided blood vessels in the anterior (ventral) cut-end of uterine artery
leaf of the vesicouterine ligament is illustrated with a
transparent view of the blood vessels in the posterior (dorsal) cut-end superficial uterine vein
leaf of the vesicouterine ligament (a surrounded area with a cut end of
purple dotted line) cervico-vesical vessels
bladder
ureter

6.5.4 Anatomy of the Posterior(Dorsal) Leaf of the Vesicouterine Ligament (Figure 6.54)
By mobilizing the ureter toward the inguinal side, the surface of cervix/vagina and the ureter/the cranioventral side of the urinary
the posterior (dorsal) leaf of the vesicouterine ligament is bladder. Figure 6.54 shows a transparent view of the blood ves-
exposed as the connective tissue triangle formed by the upper sels in the posterior (dorsal) leaf of the vesicouterine ligament.
Figure 6.54 Exposed figure cut-end of uterine artery

of the posterior (dorsal) leaf
of the vesicouterine ligament cut end of superficial uterine vein
(a surrounded area with a
dotted purple line) is showing
a transparent view of the each
blood vessel in the ligament
bladder
posterior (dorsal) leaf of ureter

vesicouterine lig.
cut end of
cervico-vesical vessels
6.5.5 C
ross-Sectional Pelvic View of the Blood Vessels in the Vesicouterine Ligament with Each
Surgical Step
6.5.5.1 Division of the Uterine Artery and the Superficial Uterine Vein (Figure 6.55)
anterior (ventral) leaf of vesicouterine ligament anterior (ventral) leaf of vesicouterine ligament
cervicovesical vessels

bladder
uterine artery vagina

ureter
superficial uterine vein

cervix cardinal ligament
internal iliac vein
deep uterine vein
rectum
Figure 6.55 Cross-sectional view of the blood vessels in the vesicouterine ligament and the cardinal ligament in the left side of the pelvic cavity.
The uterine artery and the superficial uterine vein are divided
6.5.5.2 Division of the Deep Uterine Vein (Figure 6.56)
anterior (ventral) leaf of vesicouterine ligament anterior (ventral) leaf of vesicouterine ligament

bladder
uterine artery vagina

ureter

internal iliac vein
deep uterine vein

rectum
Figure 6.56 The deep uterine vein is divided

6.5.5.3 D
ivision of the Superior Vesical Vein That Drains into the Superficial Vein in the Anterior
(Ventral) Leaf of the Vesicouterine Ligament (Figure 6.57)
anterior (ventral) leaf of vesicouterine ligament
uterine artery
bladder

vagina
ureter

internal iliac vein
deep uterine vein uterosacral ligament
rectum
Figure 6.57 The superior vesical vein is divided

6.5.5.4 D
ivision of the Cervicovesical Vessels in the Anterior (Ventral) Leaf of the Vesicouterine
uterine artery
posterior (ventral) leaf of vesicouterine ligament


bladder ureter
vagina inferior vesical vein

superficial uterine vein middle vesical vein

internal iliac vein
deep uterine vein
rectum
Figure 6.58 The cervicovesical vessels in the anterior (ventral) leaf of the vesicouterine ligament are divided. In the right side of this figure, the
veins in the posterior (dorsal) leaf of the vesicouterine ligament are illustrated between the urinary bladder and the deep uterine vein
6.5.5.5 D
ivision of Vesical Veins in the Posterior(Dorsal) Leaf of the Vesicouterine Ligament (Arrow
in the Right Side) (Figure 6.59)
anterior (ventral) leaf of vesicouterine ligament posterior (ventral) leaf of vesicouterine ligament
uterine artery
superior vesical vein bladder ureter
vagina
inferior vesical vein
middle vesical vein

cardinal ligament
cervix
internal iliac vein
deep uterine vein uterosacral ligament
rectum
Figure 6.59 The vesical veins that drain into the deep uterine vein in the posterior (dorsal) leaf of the vesicouterine ligament are divided (right
side)
6.5.6 L
ateral(Right) Side View of the Treatment of the Anterior (Ventral) Leaf of the Vesicouterine
Ligament with Each Surgical Step
6.5.6.1 S
eparation of the Uterine Artery and Superficial Uterine Vein from the Ventral Surface
of the Ureter
6.5.6.2 Isolation of the Ureteral Branch of the Uterine Artery (Figure 6.60)

The cut-end of the uterine artery at the uterine side is lifted device is enough to seal the ureteral branch. Nevertheless,
with forceps. The connective tissue between the ureter and excessive electrocoagulation near the ureter can lead a heat-
the uterine artery is carefully divided. The ureteral branch of induced necrosis to the ureter (delayed onset: postoperative
the uterine artery is often appreciated. It is usually better to 7–14 days) and lead to fistula formation. Therefore, every
clamp, cut, and ligate the ureteral branch. However, if the possible care should be taken when using electrical energy
ureteral branch of the uterine artery is not well developed, during the separation of the ureter in the vesicouterine
the vessel sealing system such as monopolar or bipolar ligament.
Figure 6.60 Isolation of the

ureteral branch of the uterine
artery
cut-end of
uterine artery
ureteral
branch of cut end of
uterine artery superficial uterine vein
ureter
cut end of deep uterine vein
cut end of
6.5.6.3 Division of the Ureteral Branch of the Uterine Artery (Figure 6.61)

The identified ureteral branch of the uterine artery is usually ureter. In addition, the superficial uterine vein is often found
clamped, cut, and ligated. Following this step, the uterine on the ventral surface of the ureter, which should also be
artery is completely separated from the ventral surface of the separated from the ventral surface of the ureter.

artery
cut-end of
uterine artery
cut end of
cut end of superficial
ureteral
uterine vein
branch of
uterine artery
ureter
cut end of
6.5.6.4 S eparation of the Superficial Uterine Vein from the Surface of the Ureter and Confirmation

of the Superior Vesical Vein That Drains into the Superficial Uterine Vein (Figure 6.62)
The cut-end of the superficial uterine vein is lifted and sepa- and the urinary bladder. This vein drains blood from the uri-
rated gently from the ventral surface of the ureter. This nary bladder to the superficial uterine vein and is located in
allows a connecting vein from the urinary bladder to the the most superior (ventral) portion of the urinary bladder. It
superficial uterine vein to be identified between the ureter is therefore named as the superior vesical vein.

the superficial uterine vein
from the surface of the ureter
and confirmation of the cut end of superficial
cut-end of
superior vesical vein that uterine vein
uterine artery
drains into the superficial
uterine vein
cut end of
ureteral
branch of
uterine artery
ureter
cut end of
6.5.6.5 I solation and Division of the Superior Vesical Vein That Drains into the Superficial Uterine Vein
(Figure 6.63)
The superior vesical vein is carefully isolated, clamped, of uterine artery with the superficial uterine vein is com-
divided, and ligated. At the end of this step, the uterine side pletely separated from the ventral surface of the ureter.

division of the superior
vesical vein that drains into
the superficial uterine vein cut end of superficial
cut-end of uterine vein
uterine artery
cut end of superior

vesical vein
ureter

(cut end of deep uterine vein
and pelvic splanchnic nerve)
Notes:
This is the most difficult step during the separation of
the anterior (ventral) leaf of the vesicouterine liga-
ment. The superficial uterine vein as well as the supe-
rior vesical vein is very fragile and bleeds easily.
6.5.6.6 S eparation of the Cut-Ends of the Uterine Artery and the Superficial Uterine Vein

from the Ventral Surface of the Ureter (Figure 6.64)
The separation of both the uterine artery and the superficial dissection of the anterior (ventral) leaf of the vesicouterine
uterine vein from the ventral surface of the ureter can reduce ligament.
hemorrhage and is the most important step prior to further
Figure 6.64 Separation of anterior (ventral) leaf of vesicouterine lig.

the cut-ends of the uterine cut end of superficial uterine vein
artery and the superficial
uterine vein from the ventral
surface of the ureter (a cut end of superior
cut-end of
surrounded area with a dotted uterine artery vesical vein
line is the location of the
vesicouterine ligament)
ureter

6.5.6.7 C onfirmation of the Anterior (Ventral) Leaf of the Vesicouterine Ligament and the Ureter

Tunnel (Figure 6.65)
With the completion of the separation of the uterine artery the ureter, the anterior (ventral) leaf of the vesicouterine liga-
and the superficial uterine vein from the ventral surface of ment and the so-called ureteral tunnel are appreciated.
Figure 6.65 By the traction cut end of anterior (ventral) leaf of vesicouterine lig.
of both cut-ends of the uterine superficial uterine vein
artery and the superficial
uterine vein to the uterine
side, the whole surface of the
anterior (ventral) leaf of the cut-end of
vesicouterine ligament (an uterine artery
area surrounded by a dotted
line) is revealed. The entrance
of the ureter tunnel is the
cranial side of the ligament.
Two-directional arrow line is
showing the location of the
cut-end of the cardinal
ligament
ureter
tunnel
ureter

6.5.7 Step-by-Step Separation of the Anterior (Ventral) Leaf of the Vesicouterine Ligament
6.5.7.1 S eparation of the Connective Tissues in the Anterior (Ventral) Leaf of the Vesicouterine

Instead of the development of the ureter tunnel described in 1–1.5 cm apart, a pair of small blood vessels that cross the
Chaps. 4 and 5, the connective tissue of the ventral side of ureter from the bladder to the cervix are appreciated in the
the ureter is carefully separated and divided from the entrance anterior (ventral) leaf of the vesicouterine ligament. As the
of the tunnel toward the urinary bladder at the point of ure- blood vessels run between the bladder and the cervix, these
teric insertion. From the entrance of the ureteric tunnel are named as the cervicovesical vessels.
Figure 6.66 Separation of cut end of anterior (ventral) leaf of

the connective tissue in the superficial uterine vein vesicouterine lig.
vesicouterine ligament (an
area surrounded by a dotted cervicovesical vessels
cut-end of
line) reveals the blood vessels
uterine artery
that run between the bladder
and the cervix (cervicovesical
vessels)
ureter
tunnel
ureter

6.5.7.2 Division of the Cervicovesical Vessels (Figure 6.67)

The connective tissue is separated from the ventral surface of ligament because other blood vessels are usually not identi-
the ureter, in order to isolate the cervicovesical vessels. The fied in the anterior (ventral) leaf of the vesicouterine liga-
isolated cervicovesical vessels are doubly clamped, divided, ment. By separating the connective tissues from the anterior
and ligated. After the division of the cervicovesical vessels, (ventral) leaf of the vesicouterine ligament, the ureter is
the connective tissues surrounding the ureter are easily sepa- completely freed from its attachment to the posterior (dorsal)
rated from the anterior (ventral) leaf of the vesicouterine leaf of the vesicouterine ligament.

cervicovesical vessels cervicovesical vessels
uterine cervix
bladder
cut end of
cut-end of
uterine artery

6.5.7.3 M obilization of the Ureter to the Symphysis Side and Confirmation of the Posterior (Dorsal)

Leaf of the Vesicouterine Ligament (Figure 6.68)
The connective tissue can be easily separated from the dorsal bladder to the symphysis side in order to reveal the ventral
side of the ureter, in order to detach the ureter from the ven- side of the posterior (dorsal) leaf of the vesicouterine liga-
tral side of the posterior (dorsal) leaf of the vesicouterine ment as wide as possible. By these steps, the anterior (ven-
ligament. The ureter is separated at its junction to the urinary tral) leaf of the vesicouterine ligament is completely
bladder to allow the ureter to be mobilized with the urinary separated with minimal blood loss.
Figure 6.68 Mobilization of cut end of

the ureter to the symphysis cervicovesical vessels
side and confirmation of the uterine cervix
posterior (dorsal) leaf of the
vesicouterine ligament (an bladder
area surrounded by a dotted cut end of
line) superficial uterine vein
cut-end of
uterine artery
posterior (dorsal)
leaf of vesicouterine lig.

6.6 Treatment of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament
6.6.1 Step-by-Step Separation of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament
6.6.1.1 Treatment of a Vein Between the Ureter and the Cervix (Figure 6.69)

By mobilizing the ureter with the urinary bladder to the The vein is isolated from the connective tissue and doubly
symphysis side, the posterior (dorsal) leaf of the vesico- clamped, divided, and ligated. Following this step, there is
uterine ligament is appreciated. In the cranial side of the increased mobility of the ureter with the urinary bladder,
posterior (dorsal) leaf of the vesicouterine ligament, a facilitating the shift of the ureter toward the symphysis
vein running from the ureter to the cervix is appreciated. side.
Figure 6.69 Mobilization of

the ureter and the urinary cut end of cervicovesical vessels
bladder toward the symphysis uterine cervix
side reveals the posterior
(dorsal) leaf of the bladder
vesicouterine ligament. In the
cut end of superficial
cranial side of the posterior
uterine vein
(dorsal) leaf of the
vesicouterine ligament, a vein
running from the ureter to the
cervix is usually observed.
The vein is divided (not
shown in this figure)
cut-end of
uterine artery
a vein connectin
ureter and cervix

6.6 Treatment of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament 125
6.6.1.2 C onfirmation of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament by the Mobilization

of the Ureter with the Urinary Bladder Toward the Symphysis Side and the Separation
of the Cut-End of the Cardinal Ligament from the Pelvic Sidewall and the Sidewall
of the Rectum (Figure 6.70)
The cut-end of cardinal ligament (with the deep uterine tive tissue of the posterior (dorsal) leaf of the vesicouterine
vein and one of the branches of the pelvic splanchnic ligament to be stretched and well defined between the cra-
nerve) is then clamped with Pean forceps. The connective nial side of the bladder and the uterine side of the cardinal
tissue on the dorsal side of the cardinal ligament should ligament. Providing tension to the connective tissue between
be separated from the pelvic wall and the sidewall of the the cardinal ligament and the urinary bladder is very impor-
rectum. tant for the separation of the posterior (dorsal) leaf of the
After the division of the vein connecting the ureter and vesicouterine ligament. In the connective tissue of posterior
the cervix, the ureter and the urinary bladder are pulled (dorsal) leaf of the vesicouterine ligament, veins pass from
toward the symphysis side, using two L-shaped forceps. the urinary bladder into the deep uterine vein in the cardinal
This also lifts up the cut-end of cardinal ligament (with the ligament. The tension given to the connective tissue is help-
deep uterine vein and one of the branches of the pelvic ful to identify the veins in the posterior (dorsal) leaf of the
splanchnic nerve) cranially. This traction allows the connec- vesicouterine ligament.
Figure 6.70 Pulling down

cut end of cervicovesical
the ureter and the urinary
vessels
bladder toward the symphysis
side and lifting up the cut-end
of the cardinal ligament
toward the cranial side, give
cut end of superficial posterior (dorsal)
tension to the posterior
uterine vein leaf of
vesicouterine lig.
vesicouterine ligament for the
recognition of the vesical
veins connecting with the
deep uterine vein in the
ligament (an area surrounded cut-end of
uterine artery
by a dotted line)
cut end of a vein

connecting ureter
and cervix

(cut end of deep uterine vein ureter
6.6.1.3 Isolation of the Middle Vesical Vein (Figure 6.71)

The connective tissue in the posterior (dorsal) leaf of the ligament, the middle vesical vein that runs from the urinary
vesicouterine ligament is carefully separated. In the cranial bladder into the deep uterine vein in the cardinal ligament is
portion of the posterior (dorsal) leaf of the vesicouterine appreciated. The middle vesical vein is isolated.
Figure 6.71 Isolation of the

middle vesical vein cut end of cut end of cervicovesical vessels
cut-end of middle vesical vein

uterine artery
cut end of a vein

connecting ureter
and cervix

6.6.1.4 Division of the Middle Vesical Vein and Isolation of the Inferior Vesical Vein (Figure 6.72)
The middle vesical vein is doubly clamped, divided, and In addition, a vein (the inferior vesical vein) that runs
ligated. parallel to the cervix from the posterior aspect of the urinary
bladder and drains into the deep uterine vein is isolated.

middle vesical vein and cut end of cut end of cervicovesical vessels
isolation of the inferior superficial uterine vein
vesical vein
cut-end of
uterine artery
cut end of a vein

connecting ureter
and cervix

cut end of middle vesical vein

6.6.1.5 Division of the Inferior Vesical Vein (Figure 6.73)

The inferior vesical vein is doubly clamped, ligated, and from the lateral cervix and the upper vagina. In the sidewall
divided. Usually, by the division of the inferior vesical vein, of the cervix and upper vagina, the blood vessels from the
the urinary bladder with the ureter is completely separated vagina (paracolpium) can be identified.

inferior vesical vein cut end of inferior vesical vein
cut-end of
uterine artery

(cut end of deep uterine
vein and pelvic
splanchnic nerve)
ureter
6.6.1.6 A View After the Division of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament

(Figure 6.74)
The division of the posterior (dorsal) leaf of the vesicouter- der with ureter and the lateral side of the cervix/upper vagina
ine ligament enables the separation of the ureter with the uri- resembles that of an open book. The complete separation of
nary bladder from the cervix and the upper vagina. The the posterior (dorsal) leaf of the vesicouterine ligament frees
picture formed between the cranial side of the urinary blad- the urinary bladder with ureter from the vaginal wall.
Figure 6.74 Complete
division of the posterior
open the book
vesicouterine ligament creates
the situation of the urinary
bladder with ureter free from
the vaginal wall with the
paracolpium (vaginal blood
vessels). The anatomical
structure formed by the
cranial side of the urinary
bladder with ureter and by the
lateral side of the cervix/
upper vagina resembles that
of an open book
6.6.1.7 A n Advantage of the Division

of the Posterior (Dorsal) Leaf Notes
of the Vesicouterine Ligament 1. The connective and adipose tissues are not always
The division of the posterior (dorsal) leaf of the vesicouter- the same during the step-by-step separation of the
ine ligament means the division of the vesical veins that posterior (dorsal) leaf of the vesicouterine liga-
drain into the deep uterine vein. As a result, the urinary blad- ment. Sometimes, isolation and separation of each
der with the ureter becomes detached from the blood vessels vessel can be complicated by adhesions. In such
of the uterus and the vagina. Moreover, if the urinary bladder cases, the classic approach of Okabayashi’ radical
can be separated from the ventral vaginal wall (the c onnective hysterectomy that describes penetrating/piercing
tissue between the trigone of the urinary bladder and the ven- Okabayashi’s paravaginal space using scissors or
tral vaginal wall), the urinary bladder with the ureter becomes Pean forceps permits the separation of the posterior
free from the uterus and the vagina. In this situation, the (dorsal) leaf of the vesicouterine ligament from the
uterus is connected with the vagina by the remaining vaginal vaginal blood vessels (paracolpium), giving you an
blood vessels (paracolpium) bilaterally. The appropriate alternative route (described in Chaps. 4 and 5).
division level of the paracolpium is dependent on the extent 2. The removal of the adipose tissue in the paravesical
of the disease. The independent division of the posterior space, especially in the dorsal portion of the poste-
(dorsal) leaf of the vesicouterine ligament has an advantage rior (dorsal) leaf of the vesicouterine ligament and
of being able to tailor the division of the paracolpium accord- that of the urinary bladder, helps the identification
ing to the extent of the disease. of the blood vessels in the posterior (dorsal) leaf of
The concept of the independent division of the posterior the vesicouterine ligament.
(dorsal) leaf of the vesicouterine ligament and the paracol-
pium did not exist in the radical hysterectomy undertaken in
Western countries. The surgical procedure of the indepen-
dent division of the posterior (Dorsal) leaf of the vesicouter-
ine ligament was introduced by Hidekazu Okabayashi. This
is one of the most novel points of Okabayashi’s radical
hysterectomy.
6.6.1.8 S eparation of the Cut-End of the Cardinal Ligament (the Deep Uterine Vein and the Pelvic
Splanchnic Nerve) from the Lateral Surface of the Rectum (Figure 6.75)
The cut-end of the cardinal ligament (the deep uterine vein the level where the pelvic splanchnic nerve merges with the
with the pelvic splanchnic nerve) is lifted and separated from hypogastric nerve. This merging point is the inferior hypo-
the connective tissues of the lateral surface of the rectum at gastric plexus.
Figure 6.75 Separation cut end of

of the cut-end of the cut end of cervicovesical
cardinal ligament (the deep vessels blood vessels of
superficial uterine
uterine vein and the pelvic paracolpium
cut end of vein
splanchnic nerve) from the uterine artery
lateral surface of the
rectum. A purple bladder branch
two-directional arrow is
indicating the blood
vessels of the paracolpium cut end of
cut end of a vein

connecting ureter
and cervix cut end of
middle vesical
vein

6.6.2 Division of the Rectovaginal Ligament
6.6.2.1 Cranial Side View (Figure 6.76)

Draw the uterus to the ventral/pubic bone side and stretch polar or bipolar electrocautery. Division of the rectovaginal
the rectum toward cranial portion by the hand. This helps ligament frees the dorsal side of the vaginal wall. Therefore,
delineate the connective tissue bundle between the rectum the length of the vaginal cuff can be tailored to the desired
and the vagina bilaterally. This bundle is the rectovaginal length, depending on extent of disease.
ligament. The rectovaginal ligament is divided using mono-
Figure 6.76 A cranial side cut end of cardinal lig.

view of the division of the (cut end of deep uterine vein
rectovaginal ligament. The cut end of and pelvic splanchnic nerve)
hypogastric nerve is usually uterine artery
cut end of
divided at the time of the hypogastric
development of Okabayashi’s nerve
pararectal space, the
connective tissue bundle
between the rectum and the
upper vagina is the
rectovaginal ligament. This
cut end of
ligament is divided
hypogastric
nerve
ureter
rectum
cut end of
uterosacral
cut end of
ligament
uterosacral
ligament rectovaginal lig.
6.6.2.2 Pelvic Side View (Figure 6.77)

Figure 6.77 demonstrates the division of the rectovaginal
ligament visualized laterally from the pelvic side.
Figure 6.77 The location of

the rectovaginal ligament is
illustrated as the pelvic side
view
cut end of
uterine artery
cut end of pelvic splanchnic nerve

rectum
rectovaginal lig.
cut end of
hypogastric nerve cut end of cardinal lig.

ureter
6.6.3 Further Division of the Rectovaginal Ligament (Figure 6.78)
Traction of the uterus toward the cranial side stretches the bladder branch from the inferior hypogastric plexus is likely
bladder branch of the inferior hypogastric plexus in the uter- to be sacrificed.
ine side. During the division of the rectovaginal ligament the
Figure 6.78 The further

direction of the division of the
rectovaginal ligament is
illustrated. The bladder
branch from the hypogastric
plexus is usually damaged or cut end of
divided during the process of uterine artery
the division of the
rectovaginal ligament cut end of deep uterine vein
rectum

hypogastric nerve
division of
rectovaginal lig.
cut end of
bladder branch
ureter
6.6.4 Division of the Paracolpium (Vaginal Blood Vessels) (Figure 6.79)
The division of the rectovaginal ligament can separate the dally to obtain vaginal length deemed appropriate by the
vaginal blood vessels (the paracolpium) from the connective extent of cervical disease. At the designated level, the blood
tissue of the rectal sidewall. The division is extended cau- vessels of the paracolpium are clamped, cut, and ligated.
Figure 6.79 Clamp the

paracolpium (vaginal blood
vessels) and divide between
the two forceps
cut end of
uterine artery
rectum
cut end of
hypogastric nerve paracolpium
division of
rectovaginal lig.
cut end of
bladder branch cut end of cardinal lig.
(cut end Of deep uterine vein
ureter
6.6.5 Incision to the Vaginal Wall (Figure 6.80)
The division of the paracolpium leads to the detachment of cuff is confirmed. The incision is then made in the ventral
the uterus from all structures except the vagina. Once the wall of the vagina.
paracolpium is divided bilaterally, the length of the vaginal
Figure 6.80 Incision to the

vaginal wall
cut end of
uterine artery
rectum
cut end of
hypogastric nerve
cut end of
paracolpium
division of
rectovaginal lig.
cut end of
bladder branch
ureter
6.6.6 Amputation of the Vaginal Wall and Closure of the Vaginal Cuff (Figure 6.81)
Figure 6.81 is a ventral side view of the extirpation of the and cancer cells are pushed down the vagina by placing a
uterus. Long L-shaped forceps is applied to the uterine side of gauze in the vagina. At the division of the vaginal wall, long
the vagina at the level of vaginal length that is deemed appro- Kocher forceps is applied to the foot side of the divided vagi-
priate for the disease state. Long L-shaped forceps can be nal wall. After extirpation of the uterus, each long Kocher
used to secure the length of the vaginal cuff and for the con- forceps is replaced by ligature. Two to three interrupted
finement of cancer cells and fluid from the upper vagina. At stitches are taken from the ventral vaginal edge to the dorsal
the time of opening of the vaginal wall, the accumulated fluid vaginal edge and the vaginal cuff is closed by ligature.
Figure 6.81 Amputation of division of vagina

the vaginal wall
cut end of
paracolpium
cut end of
cut end of bladder branch
uterine artery

cut end of
hypogastric nerve
6.6.7 P
artial Suture to the Pelvic Peritoneum and Insertion of Drains into the Retroperitoneal
Space (Figure 6.82)
Careful observation of the pelvic cavity is undertaken to pararectal space is not closed in order to facilitate absorption
identify bleeding and ensure hemostasis. The pelvic cavity is of lymph fluid by the surface of the peritoneum secondary to
then washed with saline water. Partial closure of the visceral lymphadenectomy. Pelvic drains are inserted transabdomi-
peritoneum is undertaken between the peritoneum of the cra- nally into the retroperitoneal space bilaterally. The drainage
nial side of the urinary bladder and the peritoneum of the tubes are usually removed if bleeding is not observed for
Pouch of Douglas. The peritoneum of the ventral side of the 2 days.
Figure 6.82 Partial suture to

the pelvic peritoneum and
insertion of drains into the
retroperitoneal space
drain
rectum
6.6.8 Closure of the Abdominal Cavity (Figure 6.83)
Following closure of the ventral abdominal peritoneum lum, the packed gauze is removed from the vagina and the
and the fascia, interrupted skin suture is undertaken. vaginal stump suture is checked. The surgery is now
Cosmetic sutures are popular now. Using a vaginal specu- finished.
Figure 6.83 Closure of the

abdominal cavity
drain in retroperitoneal space
abdominal wall suture

References surgical anatomy, and feasibility study. Am J Obstet Gynecol.

1998;178:971–6.
3. Horn LC, Fischer U, Höckel M. Occult tumor cells in surgical spec-
imens from cases of early cervical cancer treated by liposuction-
Igakushoin; 1983.
assisted nerve-sparing radical hysterectomy. Int J Gynecol Cancer.
2. Höckel M, Konerding MA, Heussel CP. Liposuction-assisted
2001;11:159–63.
nerve-sparing extended radical hysterectomy: oncologic rationale,
What Is Nerve-Sparing Radical
Hysterectomy? 7
7.1 evere Bladder Dysfunction/Colorectal Motility Disorders Are Common Complications

S
of Radical Hysterectomy (Figure 7.1)
Since Wertheim introduced radical hysterectomy in 1911 [1], a “better” surgery and Okabayashi established an anatomy
his method became the standard procedure for the surgical oriented method to accomplish more radical surgery than
treatment of cervical cancer in Western Countries. However, that of Wertheim’s method in 1921 [2]. However, postopera-
in Japan, Takayama and Okabayashi at Kyoto Imperial tively both methods have often been associated with severe
University thought that Wertheim’s method is not radical bladder dysfunction and colorectal motility disorders that
enough for invasive cervical cancers. They pursued to create adversely impacted the patient’s quality of life.
Figure 7.1 Common complications of radical hysterectomy

Severe bladder dysfunction
and
colorectal motility disorders
are
common complications of radical hysterectomy
such as
Wertheim's method and Okabayashi's method
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142 7 What Is Nerve-Sparing Radical Hysterectomy?
7.1.1 Nerve Supply to the Uterus, Rectum, and Urinary Bladder (Figure 7.2)
The uterus, vagina, urinary bladder, and rectum are inner- The parasympathetic fibers come from S2, 3 and 4 at the
vated by a motor and sensory autonomic nerve supply (sym- pelvic wall to form the pelvic splanchnic nerve. These fibers
pathetic and parasympathetic origin). The sympathetic fibers merge and construct the inferior hypogastric plexus that has
come from T10-L2 to form the inferior hypogastric nerve. branches to the uterus and to the urinary bladder [3–6].
Figure 7.2 Nerve supply to

the uterus, rectum, and
urinary bladder uterus
uterine branch
rectum
inferior
hypogastric bladder
plexus
hypogastric nerve
(sympathetic) bladder
T10-L2 branch

(parasympathetic)
S2,3 and 4
7.1 Severe Bladder Dysfunction/Colorectal Motility Disorders Are Common Complications of Radical Hysterectomy 143
7.1.2 Locations of Nerve Damages During Radical Hysterectomy (Figure 7.3)
During radical hysterectomy, such as Wertheim’s method Wertheim’s method usually does not divide the deep uter-
and Okabayashi’s method, surgical procedures to the ine vein (cardinal ligament). Therefore, it appears unlikely
uterosacral ligament and the rectovaginal ligament can to injure the pelvic splanchnic nerve. However, instead of
lead to injury of the hypogastric nerve [7, 8]. The surgical dividing the cardinal ligament, Wertheim’s method divides
procedures to the paracolpium (vaginal blood vessels) can the paracervical tissues including the parametrial tissues
give rise to damage to the bladder branch of the inferior and the paracolpium. During the division of the paracervi-
hypogastric plexus [7, 8]. During Okabayashi’s method, cal tissues, Wertheim’s method increases the possibility of
the treatment to the deep uterine vein in the cardinal liga- injury to the bladder branch from the inferior hypogastric
ment can injure the pelvic splanchnic nerve. In contrast, plexus.
Figure 7.3 Locations of

Wertheim and Okabayashi Wertheim and Okabayashi
nerve damages during radical
hysterectomy
(3) division of the
(1) division of rectovaginal ligament
(4) ligation and division of
hypogastric nerve paracolpium
bladder branch
Okabayashi
(2) division of
deep uterine vein
inferior hypogastric plexus (IHGP)
7.1.3 Efforts on Nerve-Sparing Radical Hysterectomy (Figure 7.4)
Japanese doctor Takashi Kobayashi at Tokyo University is a usually no clear description on the pelvic splanchnic nerve or
pioneer of the nerve-sparing radical hysterectomy. Modifying the bladder branch from the inferior hypogastric plexus [14–
Okabayashi’s radical hysterectomy Kobayashi tried to pre- 20]. The reason is clear because Wertheim and Piver Type III
serve nerve functions during radical hysterectomy. In 1961, surgeries neither reveal nor isolate the deep uterine vein
Kobayashi [9] described the concept for the improvement of beneath which the pelvic splanchnic nerve resides. Moreover,
postoperative bladder function by preserving the pelvic although these surgeries divide the anterior (ventral) leaf of
splanchnic nerve by the separation of the vascular part (the the vesicouterine ligament, the concept of separation and
deep uterine vein) from the dorsal hard bundle (the pelvic division of the posterior (dorsal) leaf of the vesicouterine
splanchnic nerve) during the division of the cardinal liga- ligament, beneath which the bladder branch resides, is lack-
ment. Sakamoto [10, 11] and Kuwabara [12] succeeded in ing. In contrast, Japanese doctors usually perform
these concepts. Then, in 1983, Fujiwara [13] at Kitano Okabayashi’s radical hysterectomy [26]. Okabayashi’s radi-
Hospital described the importance of the preservation of the cal hysterectomy separates and divides the posterior (dorsal
hypogastric nerve with the pelvic splanchnic nerve and the leaf of the vesicouterine ligament. Therefore, the publica-
bladder branch by the division of only the uterine branch tions from Japan have described both inferior hypogastric
from the inferior hypogastric plexus. Since then, many nerve and pelvic splanchnic nerve, and provided more infor-
Japanese as well as Western countries’ doctors started to mation on the inferior hypogastric plexus [21–25]. In 2007,
undertake a nerve-sparing radical hysterectomy and pub- Fujii et al. [3] published a clear description of the surgical
lished many papers on nerve-sparing radical hysterectomy anatomy of the cross-shaped inferior hypogastric plexus
[14–25]. Nevertheless, almost all published papers on nerve- (Figures 7.4, 7.5, and 7.6) and reported how to divide the
sparing radical hysterectomy could not clearly show the sur- uterine branch alone from the plexus. If the uterine branch is
gical anatomy of the inferior hypogastric plexus with the solely divided, the urinary bladder function is preserved fol-
bladder branch and the uterine branch. Publications using lowing surgery. This publication stimulated and generated
Wertheim or Piver Type III surgery show mainly the process great interest in many doctors as a result of which nerve-
of isolation of the inferior hypogastric nerve, and there is sparing radical hysterectomy became very popular [27–29].
Figure 7.4 Inferior
hypogastric plexus: a photo
of the cross-shaped inferior
hypogastric nerve composed
by the hypogastric nerve,
pelvic splanchnic nerve,
bladder branch and uterine
branch during nerve-sparing
radical hysterectomy
7.1.4 Principle of Nerve-Sparing Radical Hysterectomy (Figure 7.5)
The principle of nerve-sparing radical hysterectomy is very plexus and the branches to the uterus (uterine branch)/the
simple. Firstly, identification of the inferior hypogastric urinary bladder (bladder branch) is required before the uter-
nerve, confirmation of the cross-shaped inferior hypogastric ine branch can be isolated and divided.
Figure 7.5 The principle

of nerve sparing radical
hysterectomy: the division of
solely the uterine branch from uterus
the inferior hypogastric nerve
is illustrated as a red line with cut line of
two-directional arrow uterine branch
uterine branch
rectum
urinary
bladder
cross shaped IHP
paracolpium
hypogastric nerve
pararectal space bladder branch
pelvic splanchnic nerve paravesical space

7.1.5 The Description of Anatomy for Nerve-Sparing Radical Hysterectomy (Figure 7.6)
By solely dividing the uterine branch, the cross-shaped infe- hypogastric plexus is the goal of nerve-sparing radical hys-
rior hypogastric plexus changes into a T-shaped one com- terectomy. This provides the outcome of satisfactory urinary
posed of hypogastric nerve, the pelvic splanchnic nerve, and function for patients.
the bladder branch. The preservation of the T-shaped inferior
Figure 7.6 By the division

of solely the uterine branch
(shown as a red line with
two-directional arrow), the uterus
cross-shaped inferior
hypogastric plexus changes
into a T-shaped one (shown as
a yellow T-shaped line with
three-directional arrow) uterus branch
rectum
urinary bladder
T-shaped nerve plane

paracolpium
hypogastric nerve
bladder branch
pararectal space
paravesical space
7.1.6 Indication of Nerve-Sparing Radical Hysterectomy (Figure 7.7)
The nerve-sparing radical hysterectomy separates and pre- preservation of unilateral T-shaped inferior hypogastric
serves medially one tissue’s layer (containing the pelvic plexus can also result in satisfactory bladder function.
nerve plane) more than that of the classical radical hysterec- However, it is very important to confirm the extension of the
tomy. Therefore, the indication of nerve-sparing radical hys- cancer lesion very carefully. In case of younger patients with
terectomy should be reserved for patients with FIGO IB an invasive lesion in the cardinal ligament on either side,
stage disease. In case of stage IB2 disease, if invasion is total extirpation of the cardinal ligament with internal iliac
strongly suspected, the preservation of the nerve is not rec- blood vessel system (TEIIBS) or lateral extended paramet-
ommended. For patients with FIGO IIB stage disease, nerve- rectomy (LEP) is the choice of surgery. However if the oppo-
sparing procedures should not be selected because the site side does not contain invasive disease, unilateral
location of the inferior hypogastric plexus is usually very nerve-sparing radical hysterectomy can be a surgical option
close to the invasive foci of IIB lesion. In such cases, if the for that side. If we can preserve T-shaped nerve plane in
invasion is confined to only one side of the parametrium, either side of the rectum, urinary function is preserved in the
nerve-sparing surgery on the opposite side is feasible. The patient.
Cutting line of Cutting line of

Okabayashi's radical hysterectomy cut end of deep nerve-sparing radical hysterectomy
uterine vein
vagina urinary bladder

cut end of
middle vesical vein
ureter
cervix
cut end of
inferior deep uterine vein
vesical vein
rectum
rectovaginal ligament pelvic splanchnic nerve

uterine branch hypogastric nerve
from hypogastric plexus
Figure 7.7 On a cross section of the pelvis at the level of the cervix in two different lengths in the right side of the pelvis is showing the cut-
the vagina, the cutting line of Okabayashi’s radical hysterectomy is ting line of nerve-sparing radical hysterectomy
illustrated as a dotted line (left side of the pelvis). A dotted line using
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JM. A nerve-sparing radical hysterectomy: guidelines and feasibil-
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17.
Possover M. Technical modification of the nerve-sparing
colli Uteri (auf Grund von 500 Fallen). Berlin: Urban &
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F, Kusamura S. Nerve-sparing radical hysterectomy: a surgical
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M, Baba T, Yoshioka S. Anatomic identification and functional
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4. Maas CP, Trimbos JB, DeRuiter MC, van de Velde CJ, Kenter
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20. Raspagliesi F, Ditto A, Fontanelli R, Zanaboni F, Solima E, Spatti
historical perspective. Crit Rev Oncol Hematol. 2003;48:271–9.
G, Hanozet F, Vecchione F, Rossi G, Kusamura S. Type II versus
5. Dursun P, Ayhan A, Kuscu E. Nerve-sparing radical hyster-
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22. Kato T, Murakami G, Yabuki Y. A new perspective on nerve-sparing
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radical hysterectomy: nerve topography and over-preservation of
Okabayashi himself in 1932, and two films of the precise anatomy
the cardinal ligament. Jpn J Clin Oncol. 2003;33:589–91.
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Step-by-Step Nerve-Sparing Radical
Hysterectomy with Pelvic 8
Lymphadenectomy
8.1 he Surgical Process of the

T 8.3 Contents in Chap. 8
Step-by-Step Nerve-Sparing
Radical Hysterectomy Is Listed 1. Treatment of the cardinal ligament
in the Following Pages 2. Treatment of the hypogastric nerve
3. Development of the rectovaginal space and division of
However, each surgical procedure until the division of the the uterosacral ligament
deep uterine vein in the cardinal ligament is the same as that 4. Separation of the urinary bladder and anatomy of the
of the step-by-step radical hysterectomy without nerve- vesicouterine ligament
sparing radical hysterectomy as described in Chap. 5. 5. Treatment of the anterior(ventral) leaf of the vesicouter-
Therefore, the detailed surgical procedure necessary for ine ligament
nerve-sparing radical hysterectomy shall start from the divi- 6. Treatment of the posterior (dorsal) leaf of the vesico-
sion of the cardinal ligament. uterine ligament
7. Confirmation of the inferior hypogastric plexus
8. The concept of the pelvic nerve plane
8.2 The Following Are Described 9. Separation of the rectovaginal ligament
in Chap. 6 10. Separation of the bladder branch from the paracolpium
11. Separation of the uterine branch from the inferior hypo-
1. Open the abdominal cavity gastric plexus
2. Exposure of the pelvic cavity 12. Division of the uterine branch
3. Visual and manual examination of the spread of the dis- 13. Separation of the rectovaginal ligament preserving
ease and operability T-shaped nerve plane
4. Traction of the uterus 14. Clamp of the paracolpium
5. Ligation and division of the round ligament (open the 15. Ligation and division of the paracolpium
connective tissue of the broad ligament) 16. Incise the vaginal wall for amputation of the vagina
6. Ligation and division of suspensory ligament of ovary 17. Removal of the uterus preserving T-shaped nerve plan
(ovarian vessels) and confirmation of the ureter 18. Closure of the vaginal cuff
7. Tentative development of the pararectal space 19. Partial suture to the pelvic peritoneum and insertion of
8. Division of the peritoneum of the Douglas’ pouch drains into the retroperitoneal space
9. Separation of the peritoneum of the vesicouterine pouch 20. Closure of the abdominal wall
10. Pelvic lymphadenectomy 21. Treatment after the operation
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(https://doi.org/10.1007/978-981-13-8098-3_8) contains supplemen-
tary material, which is available to authorized users.

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150 8 Step-by-Step Nerve-Sparing Radical Hysterectomy with Pelvic Lymphadenectomy
8.4 Treatment of the Cardinal Ligament
8.4.1 A View of Pelvis After the Lymphadenectomy (Figure 8.1)
After pelvic lymphadenectomy, both the external and inter- The paravesical space and Latzko’s pararectal space are well
nal iliac blood vessels are almost skeletonized with a view of recognized.
the obturator nerve and artery/vein in the obturator fossa.
Figure 8.1 A view of pelvis

after the lymphadenectomy
paravesical space external iliac vessels
obturator vessels
Latzko’s
pararectal space
obturator nerve
common iliac artery

8.4.2 S
eparation of the Loose Connective Tissue Between the Uterine Artery and Superior Vesical
Artery (Figure 8.2)
In order to give tension to the uterine artery, the obliterated artery is separated. The loose connective tissue layer between
umbilical artery (bladder side of the internal iliac artery) is the uterine artery and the superior vesical artery is separated.
picked up with the forceps, and the loose connective tissue The connective tissue layer is separated and penetrated, to
between the urinary bladder and the obliterated umbilical enter the paravesical space.

loose connective tissue
between the uterine artery and
superior vesical artery obliterated umbilical artery
paravesical space
separation of
connective tissue
uterine artery

Latzko’s
pararectal space
common iliac artery
8.4.3 Development of the Paravesical Space and Confirmation of the Uterine Artery (Figure 8.3)
A long L-shaped retractor is inserted through the penetrated iliac artery is stretched between its origin of the internal iliac
connective tissue and into the paravesical space to retract the artery and the side wall of the uterus. This is a safer way to
tissue (including the isolated obliterated umbilical artery) expose the uterine artery along its whole length.
toward the inguinal side. The uterine artery from the internal

uterine artery obliterated umbilical artery paravesical space
uterine artery

Latzko’s
pararectal space common iliac artery
8.4.4 Confirmation of the Cardinal Ligament (Figure 8.4)
Another long L-shaped retractor is inserted into the pararec- bundle created between the paravesical space and pararectal
tal space to push the rectum craniolateral side. The pararectal space is a gross feature of the cardinal ligament (a two-
space is gradually expanded. Insertion of the L-retractor too directional arrow in Figure 8.4). The cardinal ligament is a
deep into the pelvic floor risks the pelvic floor connective thick connective tissue bundle formed between the internal
tissue being torn, resulting in bleeding which can be difficult iliac blood vessels and the sidewall of the uterus/upper
to manage. Therefore, diligent placement of retractor tip in vagina. The uterine artery and the superficial uterine vein run
the pararectal space is important. The thick connective tissue along the most ventral side of the cardinal ligament.
Figure 8.4 Confirmation of

the cardinal ligament. A two paravesical space
directional arrow is indicating
the connective tissue bundle
of the cardinal ligament
surgically created between the
cardinal lig.
pararectal space and
paravesical space
uterine artery
Latzko’s common iliac artery

pararectal space
8.4.5 Isolation and Division of the Uterine Artery (Figure 8.5)
The uterine artery originates from the internal iliac artery and ligated. The uterine artery between the two ligatures is
and passes into the sidewall of the uterus. The uterine artery divided. The suture of the uterine side of the uterine artery is
is appreciated on the most ventral side of the cardinal liga- usually left as a longer piece to act as an anatomical
ment. The uterine artery is easily isolated, doubly clamped, landmark.
Figure 8.5 Development
of the paravesical space and paravesical space
confirmation of the uterine
artery
cut end of
uterine artery
cardinal lig.
Latzko’s
pararectal space
8.4.6 Separation of the Superficial Uterine Vein (Figure 8.6)
Careful separation of the cut-end of uterine side of the uter- careful approach is required. If the vessel is inadvertently
ine artery from the connective tissue of the cardinal ligament damaged, monopolar or bipolar coagulation can be effective
usually reveals the superficial uterine vein running parallel to in achieving hemostasis. The superficial uterine vein does
the uterine artery. The superficial uterine vein is often fragile. not always run parallel to the uterine artery. Rarely, it may
Therefore, in order to isolate the superficial uterine vein, a run parallel to the ureter.

superficial uterine vein paravesical space
cut end of
uterine artery
superficial
uterine vein
Latzko’s
pararectal space
8.4.7 Clamping and Division of the Superficial Uterine Vein (Figure 8.7)
The superficial uterine vein is isolated and doubly clamped small blood vessel should be sealed either by electrocautery
by Pean forceps. Then the superficial uterine vein is divided or ligature. However, the deep uterine vein always resides in
between the two clamps. Each clamp is replaced by ligature. the dorsal part of the cardinal ligament. Careful separation of
The connective tissue of the cardinal ligament is then sepa- the connective tissue and lymph nodes in the cardinal liga-
rated toward the pelvic floor. In the cardinal ligament, a ment is required to identify the deep uterine vein.
small vein or artery may be identified. In such cases, each

paravesical space
cut end of
uterine artery
cut end of
superficial
uterine vein
Latzko’s
pararectal space
8.4.8 Separation of the Deep Uterine Vein (Figure 8.8)
Careful separation of the connective tissue and lymph nodes pose tissue surrounding the deep uterine vein should be
in the cardinal ligament can reveal a vein running from the cleaned as much as possible. Skeletonizing the dorsal side of
uterine sidewall to the internal iliac vein (Figure 8.8a, b). the deep uterine vein is very important for the isolation of the
This is the deep uterine vein. The connective tissue and adi- deep uterine vein.
Figure 8.8 Separation of the a

deep uterine vein. (a) is
illustrating the deep uterine paravesical space
vein running between the
uterine cervix and the internal
uterine artery internal iliac vein
iliac vein. (b) is a surgical
photo of the deep uterine vein
isolated between the uterine internal iliac artery
cervix and the internal iliac
vein
pararectal space
b
deep uterine vein
paravesical space
pararectal space
8.4.9 Division of the Deep Uterine Vein Reveals the Pelvic Splanchnic Nerve (Figure 8.9)
In the dorsal part of the deep uterine vein, a white yellow effectively if the deep uterine vein has been clearly identi-
bundle is usually running parallel to it. This is the pelvic fied, and the damaged portion of the vessel can be detected.
splanchnic nerve. After isolation, the deep uterine vein is The skeletonization of the connective tissue and the adipose
doubly clamped by Pean forceps. The deep uterine vein is tissue in the base of the cardinal ligament (draining portion
then divided between the two clamps. Each clamp is replaced of the deep uterine vein into the internal iliac vein) is a very
by ligature. There is a risk of heavy bleeding if the deep uter- important step in performing safer nerve-sparing radical
ine vein is injured. However, hemostasis can be achieved hysterectomy.
Figure 8.9 Division of the a

deep uterine vein reveals the internal iliac vein
beneath the vein. (a)
Relationship between the cut end of
uterine artery
divided deep uterine vein and deep uterine vein
the pelvic splanchnic nerve.
(b) A surgical photo of the
divided deep uterine vein and
the pelvic splanchnic nerve

b
cut end of
deep uterine vein
cut end of
deep uterine vein

8.5 Treatment of the Hypogastric Nerve 159
8.5 Treatment of the Hypogastric Nerve
8.5.1 Isolation of the Hypogastric Nerve (Figure 8.10)
In the rectal sidewall of the pararectal space, 2–3 cm dorsal connective tissue of the ureter. The hypogastric nerve is dis-
to the ureter, a white yellow bundle of the hypogastric nerve sected and separated from the rectal sidewall.
is appreciated. The hypogastric nerve is residing in the same
Figure 8.10 Isolation of the pelvic splanchnic nerve

hypogastric nerve. (a) An a b
illustration of the separated
hypogastric nerve from the
lateral side wall of the rectum.
hypogastric nerve isolated
from the lateral side wall of
the rectum ureter

rectal
side wall

8.5.2 Apply a Vessel Tape to the Isolated Hypogastric Nerve (Figure 8.11)
A vessel tape is applied for a marker of the isolated hypo- close as possible to the uterine side of the pelvic splanchnic
gastric nerve. The hypogastric nerve is better separated as nerve.
Figure 8.11 Application of a

vessel tape to the isolated pelvic splanchnic nerve
hypogastric nerve
vessel tape
ureter hypogastric nerve

8.5 Treatment of the Hypogastric Nerve 161
8.5.3 S
eparation of the Ureter from the Connective Tissue Plane and Application of a Vessel Tape
to the Isolated Ureter (Figure 8.12)
The ureter can be identified on the ventral side of the hypo- possible to the cut-end of the uterine side of the uterine
gastric nerve. The ureter is isolated and a vessel tape is artery.
applied as a marker. The ureter is better separated as close as
Figure 8.12 Separation of Latzko’s pararectal space rectal side wall Okabayashi’s pararectal space
the ureter from the connective
tissue plane and application of a b
a vessel tape to the isolated
ureter. (a) A illustration of the
isolated ureter and the Latzko’s
hypogastric nerve with pararectal
respective vessel tape. space
isolated ureter and the
hypogastric nerve with
respective vessel tape
internal iliac
artery
rectal
side wall
ureter
ureter
hypogastric nerve :connective tissue plane

8.6 Development of the Rectovaginal Space and Division of the Uterosacral Ligament
8.6.1 Separation and Division of the Peritoneum of the Douglas’ Pouch (Figure 8.13)
The uterus is drawn toward the pubic arch and the rectum the broad ligament are connected. The rectum is gently freed
with its peritoneal surface is stretched by hand toward the from the cervical/vaginal wall with scissors or with a finger.
cranial side. The peritoneum between the uterus and the rec- With the uterus held over to the pubic arch and the rectum
tum is lifted from the base of the Pouch of Douglas. The stretched toward the cranial portion by hand, a loose connec-
incision is made on the elevated peritoneum and extended tive tissue layer between the rectum and the cervix/vagina is
with scissors across the dorsal side (back) of the cervix. At appreciated. This is the landmark of the rectovaginal space.
the end of this step, both sides of the retroperitoneal space of
Figure 8.13 Separation and ureter

division of the peritoneum
of the Douglas’ pouch
Douglas’ pouch peritoneum
rectum
rectal side wall hypogastric nerve

8.6.2 Development of the Rectovaginal Space (Figure 8.14)
If there are no dense adhesions or cancer invasion, the loose part of the vagina. The separation should be carried out in the
connective tissue layer between the rectum and the cervix/ correct plane. The bilateral thick connective tissue bundles
vagina is easily separated and the rectovaginal space can be (the uterosacral ligament) can be identified between the rec-
developed. Pressing the tips of scissors against the cervical tovaginal space and the pararectal space.
fascia, the rectum is bluntly detached from the cervix/upper
Figure 8.14 Development of ureter pelvic splanchnic nerve

the rectovaginal space
rectovaginal space
rectum
hypogastric nerve
rectal side wall
8.6.3 Division of the Uterosacral Ligament (Figure 8.15)
The uterosacral ligament on either side is stretched forward the hypogastric nerve. If the uterosacral ligament is divided
and dissected at its base at the level of the rectal side wall. without confirmation of the hypogastric nerve, division of
After confirmation/identification of the hypogastric nerve, the hypogastric nerve can occur inadvertently during the
the uterosacral ligament is isolated, and divided preserving division of the uterosacral ligament.
Figure 8.15 Division of the ureter pelvic splanchnic nerve

rectovaginal space
rectum
rectal side wall hypogastric nerve

8.7 Separation of the Urinary Bladder and Anatomy of the Vesicouterine Ligament 165
8.7 Separation of the Urinary Bladder and Anatomy of the Vesicouterine Ligament
8.7.1 Separation of the Urinary Bladder from the Cervical Fascia (Figure 8.16)
The peritoneum is divided across the ventral side of the cer- bladder. Connective tissue bundles are formed on the both
vix, just 1–2 cm below the vesicouterine fold where scissors sides of the cervix. The connective tissue bundle contains the
can separate the peritoneum easily without any damage to ureter, the uterine artery, and several blood vessels. This is
the urinary bladder. The bladder is separated from the center the vesicouterine ligament.
of the cervical fascia at the level of the trigone of the urinary
Figure 8.16 Separation of fascia of uterine cervix

the urinary bladder from
the cervical fascia
anterior (ventral) leaf of
bladder
ureter
ureter
cut-end of cut-end of
cardinal lig. uterine artery
8.7.2 Anatomy of the Vesicouterine Ligament (Figure 8.17)
Since the ureter is running in the vesicouterine ligament, for more than 100 years, until recently when it was clarified
separation of the connective tissue of the vesicouterine liga- in 2007. Figure 8.17 (illustrated by Shingo Fujii) is showing
ment is essential for radical hysterectomy. At first, the ven- a transparent view of the ureter and blood vessels in the vesi-
tral part of the ureter should be unroofed. However, the couterine ligament.
detailed anatomy of the vesicouterine ligament was unclear
Figure 8.17 Anatomy of the

vesicouterine ligament. An
area surrounded by a purple black box
dotted line is a transparent
view of the ureter and blood vagina
vessels in the vesicouterine
ligament cervix
uterus
bladder
ureter
vesicouterine lig.
8.7.3 Anatomy of the Anterior (Ventral) Leaf of the Vesicouterine Ligament (Figure 8.18)
Figure 8.18 illustrates the cut-ends of the blood vessels After the separation of the anterior (ventral) leaf of the vesi-
which reside in the anterior (ventral) leaf of the vesicouterine couterine ligament, it is possible to roll the ureter laterally
ligament and the blood vessels in the posterior (dorsal) leaf from the surface of the posterior (dorsal) leaf of the vesico-
of the vesicouterine ligament (shown as a transparent view). uterine ligament.
Figure 8.18 The anatomy of

the divided blood vessels in cut-end of uterine artery
the anterior (ventral) leaf of
the vesicouterine ligament cut end of superficial uterine vein
with a transparent view of the
blood vessels in the posterior
(dorsal) leaf of the cut end of
vesicouterine ligament (an cervico-vesical vessels
area surrounded by a purple
dotted line)
bladder
ureter
posterior (dorsal)
leaf of
vesicouterine lig.
8.7.4 Anatomy of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament (Figure 8.19)
By mobilizing the ureter toward the inguinal side, the surface u rinary bladder. Figure 8.19 shows a transparent view of the
of the posterior (dorsal) leaf of the vesicouterine ligament is blood vessels in the posterior (dorsal) leaf of the vesicouter-
exposed as the connective tissue triangle formed by the upper ine ligament.
cervix/vagina and the ureter/the cranioventral side of the
Figure 8.19 Transparent
cut-end of uterine artery
view of the blood vessels in
cut end of superficial uterine vein
the vesicouterine ligament (an
dotted line)
bladder
ureter
cut end of
cervico-vesical vessels
posterior (dorsal) leaf of vesicouterine lig.

8.7.5 S
keletonized View of the Blood Vessels and the Ureter in the Vesicouterine Ligament
(Figure 8.20)
Figure 8.20 is a skeletonized view of the blood vessels and uterine ligament and the uterus/cervix/vagina is also shown
the ureter in the vesicouterine ligament. The inferior hypo- in Figure 8.20.
gastric plexus (IHP) between the blood vessels in the vesico-
Figure 8.20 Skeletonized
view of the blood vessels and
the ureter in the vesicouterine
ligament from the symphysis cervicovesical vessels
side to the cranial side uterus
ureter
ureteral branch of UA
urinary bladder
uterine artery (UA) vagina
inferior hypogastric plexus superior vesical vein

8.8 Treatment of the Anterior(Ventral) Leaf of the Vesicouterine Ligament
8.8.1 Isolation of the Ureteral Branch of the Uterine Artery (Figure 8.21)
The cut-end of the uterine artery at the uterine side is lifted cut, and ligated. However, if the ureteral branch of the uter-
with forceps. The connective tissue between the ureter and ine artery is not well developed, the vessel sealing system
the uterine artery is carefully divided. The ureteral branch of such as monopolar or bipolar device is enough to seal the
the uterine artery is often appreciated. It is usually clamped, ureteral branch.
Figure 8.21 Isolation of the a

artery. (To provide more cut end of uterine artery (UA)
anatomical information of the cervicovesical vessels
paracervical area, two types
of illustration are prepared for
each surgical step). (a)
Magnified skeletonized view
of the paracervical area from
the symphysis side to the ureteral branch of UA
cranial side. (b) Skeletonized
view of the paracervical area
and the pelvic cavity from the
lateral side of the uterus

cut end of
deep uterine vein
b
cut end of
uterine artery (UA)
cut end of
ureteral branch of
uterine artery
paravesical space
ureter
pararectal space cut end of deep uterine vein

8.8 Treatment of the Anterior(Ventral) Leaf of the Vesicouterine Ligament 171
8.8.2 Division of the Ureteral Branch of the Uterine Artery (Figure 8.22)
The ureteral branch of the uterine artery is usually clamped,

cut, and ligated. Following this step, the uterine artery is
completely separated from the ventral side of the ureter.

artery. (a) A view from the cut end of uterine artery (UA)
symphysis side to the cranial cervicovesical vessels
side. (b) A view from the
cut end of
ureteral branch of UA
cut end of
deep uterine vein superior vesical vein
b
cut end of
uterine artery (UA)
cut end of ureteral superficial uterine vein

branch of uterine artery
paravesical space
ureter

pararectal space
8.8.3 S
eparation of the Superficial Uterine Vein from the Ureter and Isolation of the Superior
Vesical Vein (Figure 8.23)
The superficial uterine vein usually runs parallel to the uter- draining from the urinary bladder into the superficial uterine
ine artery. The cut-end of the superficial uterine vein is lifted vein. The vein is located in the most superior (ventral) por-
gently with forceps and is carefully separated from the tion of the urinary bladder and named the superior vesical
surface of the ureter. The separation of the connective tissue vein. The superior vesical vein is carefully isolated.
between the ureter and the urinary bladder exposes the vein
Figure 8.23 Separation of a cut end of uterine artery (UA)

the superficial uterine vein
from the ureter and isolation cut end of superficial uterine vein
of the superior vesical vein.
(a) A view from the cervicovesical vessels
symphysis side to the cranial
ureter

cut end of
deep uterine vein
b cut end of
superficial uterine vein superior vesical vein
cut end of
uterine artery (UA)
cut end of ureteral

branch of uterine artery
paravesical space
ureter
pararectal space cut end of deep uterine vein

8.8.4 Division of the Superior Vesical Vein (Figure 8.24)
The superior vesical vein is clamped, divided, and ligated.
Figure 8.24 Division of the a cut end of uterine artery (UA)

superior vesical vein. (a) A
view from the symphysis side
to the cranial side. (b) A view cut end of superficial uterine vein
from the lateral side of the
uterus
ureter
cut end of
deep uterine vein cut end of superior vesical vein
b cut end of
superficial uterine vein cut end of
cut end of
uterine artery (UA)
entrance of
ureter tunnel
paravesical space
ureter

pararectal space
8.8.5 C
omplete Separation of the Uterine Side of the Uterine Artery and the Superficial Uterine
Vein from the Ventral Side of the Ureter (Figure 8.25)
The uterine side of the uterine artery with the superficial ventral side of the ureter. The connective tissue of the ante-
uterine vein is picked up and completely separated from the rior (ventral) leaf of the vesicouterine ligament is exposed.
Figure 8.25 Complete a
separation of the uterine side
of the uterine artery and the cut end of
superficial uterine vein from superior vesical vein
the ventral side of the ureter. cut end of
(a) A figure just picking up uterine artery (UA)
the cut-ends of both the
uterine artery and the
superficial uterine vein. (b)
After the division of the
superior vesical vein, both
cut-ends of the uterine artery
and the superficial uterine
vein are separated completely
entrance of
from the ureter and reveals
ureter tunnel
the surface of the anterior
(ventral) leaf of the
dotted line)
paravesical space
ureter

pararectal space
b cut end of
superior vesical vein anterior (ventral) leaf of
cut end of the vesicouterine ligament
uterine artery (UA)
entrance of
ureter tunnel
paravesical space
ureter

pararectal space
8.8.6 Separation of the Anterior (Ventral) Leaf of the Vesicouterine Ligament (Figure 8.26)
Instead of developing the ureter tunnel, the connective tissue 1–1.5 cm apart from the entrance of the ureter tunnel, a pair
of the vesicouterine ligament is carefully separated by trac- of small blood vessels cross over the ureter from the bladder
ing the ureter from the entrance of the ureter tunnel. Usually, to the cervix, and are named as the cervicovesical vessels.
in the anterior (ventral) leaf of the vesicouterine ligament
Figure 8.26 Separation of cut end of uterine artery (UA)

the anterior (ventral) leaf of a
the vesicouterine ligament (an
dotted line) reveals the
cervicovesical vessels. (a) A cervicovesical vessels
view from the symphysis side
to the cranial side. (b) A view
from the lateral side of the anterior (ventral) leaf of
uterus the vesicouterine ligament
ureter
cut end of
cut end of superior vesical vein
deep uterine vein
b cervicovesical anterior (ventral) leaf of

vessels the vesicouterine ligament
cut end of cut end of

superficial uterine vein superior vesical vein
cut end of
uterine artery (UA)
entrance of
ureter tunnel
ureter
paravesical space
cut-end of deep uterine vein

pararectal space
8.8.7 Isolation and Division of the Cervicovesical Vessels (Figure 8.27)
The cervicovesical vessels are isolated, doubly clamped, identified in the anterior (ventral) leaf of the vesicouterine
divided, and ligated. After the division of the cervicovesical ligament. By dividing the connective tissues from the ante-
vessels, the connective tissues surrounding the ureter are eas- rior (ventral) leaf of the vesicouterine ligament, the ureter is
ily separated from the anterior (ventral) leaf of the vesico- completely freed from its attachment to the posterior (dorsal)
uterine ligament because other blood vessels are usually not leaf of the vesicouterine ligament.

division of the cervicovesical a cut end of uterine artery (UA)
vessels. (a) A view from the
symphysis side to the cranial cut end of superficial uterine vein
lateral side of the uterus cut end of cervicovesical vessels
ureter
cut end of cut end of superior vesical vein

deep uterine vein
cut end of cut end of cervicovesical vessels

b superior vesical vein
cut end of
cut end of
uterine artery (UA)
paravesical space
ureter

pararectal space
8.9 Treatment of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament
8.9.1 M
obilize the Ureter to the Symphysis Side and Confirm the Posterior (Dorsal)
Leaf of the Vesicouterine Ligament (Figure 8.28)
Separate the connective tissue of the dorsal side of the ureter While mobilizing the ureter to the symphysis side, the con-
to detach the ureter from the ventral connective tissue of the nective tissue bundle between the ureter and the uterine cer-
posterior (dorsal) leaf of the vesicouterine ligament. Mobilize vix may give resistance, which is usually caused by a vein
the ureter to the symphysis side to expose the posterior (dor- connecting the ureter with the cervix in the connective tissue
sal) leaf of the vesicouterine ligament as wide as possible. bundle.
Figure 8.28 Mobilizing the cut end of uterine artery (UA)

ureter to the symphysis side a cut end of superficial uterine vein
and confirm the posterior cut end of superior vesical vein
cut end of cervicovesical vessels
dotted line). (a) A view from
the symphysis side to the
cranial side. (b) A view from
the lateral side of the uterus
ureter
a vein connecting ureter and cervix

cut end of
deep uterine vein
cut end of cut end of cervicovesical vessels
b superior vesical vein
cut end of
superficial uterine vein posterior (dorsal) leaf of
cut end of
uterine artery (UA)
pararectal space
ureter

pararectal space
8.9.2 Isolation of a Vein Connecting the Ureter with the Cervix (Figure 8.29)
A vein connecting the ureter with the cervix is isolated.
cut end of uterine artery (UA)

a

ureter
cut end of
a vein connecting ureter and cervix
deep uterine vein
b cut end of cut end of cervicovesical vessels

cut end of
superficial uterine vein posterior (dorsal) leaf of
cut end of
uterine artery (UA)
a vein connecting
ureter and cervix
pararectal space
ureter

pararectal space
Figure 8.29 Isolation of a vein connecting the ureter with the cervix vessels in the cardinal ligament and the posterior (dorsal) vesicouterine
from the cranial side of the posterior (dorsal) leaf of the vesicouterine ligament (an area surrounded by a purple dotted line) with a transparent
ligament (an area surrounded by a purple dotted line). (a) A view from view of the hidden blood vessels and the nerve structure of the inferior
the symphysis side to the cranial side. (b) A view from the lateral side hypogastric plexus
of the uterus. (c) A lateral side view of the isolated or divided blood
c
cut end of
cut end of
cut end of
uterine artery (UA)
cut end of
hypogastric nerve

cut end of deep uterine vein a vein connecting ureter and cervix
Figure 8.29 (continued)
8.9.3 Division of a Vein Connecting the Ureter with the Cervix (Figure 8.30)
A vein connecting the ureter with the cervix is isolated, dou-

bly clamped, divided, and ligated. Mobility of the ureter
increases significantly following this step.
Figure 8.30 Division of a a

vein connecting the ureter cut end of uterine artery (UA) cut end of superficial uterine vein
with the cervix. (a) A view
from the symphysis side to
the cranial side. (b) A view
from the lateral side of the
uterus. (c) A lateral side view cut end of cervicovesical vessels
of the isolated or divided
blood vessels in the cardinal
ligament and the posterior
(dorsal) vesicouterine
ligament (an area surrounded
by a purple dotted line) with a
transparent view of the hidden
blood vessels and the nerve
structure of the inferior
hypogastric plexus
ureter
cut end of cut end of inferior vesical vein

deep uterine vein a vein connecting
ureter and cervix middle vesical vein
b cut end of cut end of cervicovesical vessels

cut end of
cut end of
uterine artery (UA)
cut end of a vein connecting

ureter and cervix
pararectal space
ureter

pararectal space
Figure 8.30 (continued) c
cut end of
cut end of
cut end of
uterine artery (UA) cut end of
hypogastric nerve

8.9.4 S
eparation of the Cut-End of the Deep Uterine Vein from the Pelvic Splanchnic Nerve
(Figure 8.31)
Using two L-shaped forceps, the ureter and the urinary blad-
der are pulled toward the symphysis side as shown in Notes:
Figure 8.31b. Then, the cut-end of the deep uterine vein is Giving tension between the cardinal ligament (the
picked up and separated from the pelvic splanchnic nerve deep uterine vein) and the urinary bladder during the
close to the sidewall of the rectum. Cranial traction of the separation of the posterior (dorsal) leaf of the vesico-
cut-end of the deep uterine vein and the symphysis side uterine ligament will apply tension to the veins from
traction of the ureter/the urinary bladder using L-shaped the urinary bladder draining into the deep uterine vein.
retractors gives tension to the posterior (dorsal) leaf of the Separation of the connective tissue in the posterior
vesicouterine ligament. This retraction exposes the structure (dorsal) leaf of the vesicouterine ligament will help
of the connective tissues of the posterior (dorsal) leaf of the expose and identify each vein from the bladder to the
vesicouterine ligament between the bladder and the cut-end deep uterine vein.
of the deep uterine vein.
Figure 8.31 Separation of the cut-end of the a cut end of uterine artery (UA)
deep uterine vein from the pelvic splanchnic
nerve. (a) A view from the symphysis side to cut end of superior vesical vein
the cranial side. (b) A view from the lateral
side of the uterus. (c) A lateral side view of
the isolated or divided blood vessels in the
cardinal ligament and the posterior (dorsal)
vesicouterine ligament with a transparent
view of the hidden blood vessels and the
nerve structure of the inferior hypogastric cut end of
plexus deep uterine vein
ureter

cut end of
a vein connecting
ureter and cervix middle vesical vein
b cut end of
cut end of
cut end of
uterine artery (UA)
cut end of
deep uterine vein
paravesical space
ureter

pararectal space
c
cut end of
cut end of
uterine artery (UA)
cut end of
cut end of a vein cut end of

connecting cervicovesical vessels
ureter and cervix
cut end of
deep uterine vein
hypogastric nerve
middle vesical vein
cut end of deep uterine vein cut end of a vein connecting

ureter and cervix
8.9.5 I mportance of the Removal of the Adipose Tissues in the Posterior (Dorsal) Leaf

of the Vesicouterine Ligament (Figure 8.32)
During the processes of the step-by-step nerve-sparing radi- in the sidewall of the rectum and the dorsal side of the uri-
cal hysterectomy, the most important part is the separation of nary bladder should be removed as much as possible as
the posterior (dorsal) leaf of the vesicouterine ligament. shown in the right side of Figure 8.32. The removal of adi-
Usually, adipose tissues are covering the rectal side of the pose tissues is essential for an ideal nerve-sparing radical
vesicouterine ligament to the dorsal side of the urinary blad- hysterectomy and enables the step-by-step separation of the
der as shown in the left side of Figure 8.32. Adipose tissues posterior (dorsal) leaf of the vesicouterine ligament.
Figure 8.32 Importance of adipose tissues

the removal of the adipose after removal of adipose tissues
tissues in the posterior
vesicouterine ligament.
Adipose tissues in the side
wall of the rectum/upper
vagina and the dorsal side of
the urinary bladder are
illustrated in the left side of
figure. Removal of the
adipose tissues is illustrated in
the right side
8.9.6 Clamp and Divide the Middle Vesical Vein (Figure 8.33)
The connective tissue in the posterior (dorsal) leaf of the ligament, a vein (the middle vesical vein) which runs from
vesicouterine ligament is carefully separated. In the cranial the urinary bladder to the deep uterine vein is visualized. The
part of the posterior (dorsal) leaf of the vesicouterine middle vesical vein is doubly clamped, divided and ligated.
a cut end of uterine artery (UA) cut end of superficial uterine vein
cut end of inferior vesical vein

deep uterine vein
ureter
cut end of
a vein connecting
ureter and cervix
cut end of cut end of

b superficial uterine vein cervicovesical vessels
cut end of
cut end of
uterine artery (UA)
middle vesical vein
cut end of
deep uterine vein
ureter

pararectal space
Figure 8.33 Clamp and divide the middle vesical vein. (a) A view vessels in the cardinal ligament and the posterior (dorsal) vesicouterine
from the symphysis side to the cranial side. (b) A view from the lateral ligament with a transparent view of the hidden blood vessels and the
side of the uterus. (c) A lateral side view of the isolated or divided blood nerve structure of the inferior hypogastric plexus
cut end of
cut end of
uterine artery (UA)
cut end of
cut end of a vein cut end of

connecting cervicovesical vessels
ureter and cervix
cut end of
deep uterine vein
hypogastric nerve
cut end of
middle vesical vein

ureter and cervix
8.9.7 Clamp and Divide the Inferior Vesical Vein (Figure 8.34)
In addition, a vein (the inferior vesical vein) that runs parallel the urinary bladder with the ureter is completely separated
to the cervix from the posterior part of the urinary bladder, from the lateral cervix and the upper vagina. Along the side-
which also drains into the deep uterine vein, is also identi- wall of the cervix and upper vagina, the blood vessels from
fied. The inferior vesical vein is doubly clamped, ligated, and the vagina can be identified. This is the paracolpium.
divided. Usually, by the division of the inferior vesical vein,
Figure 8.34 Clamp and cut end of uterine artery (UA) cut end of superficial uterine vein
divide the inferior vesical
a
vein. (a) A view from the
symphysis side to the cranial cut end of superior vesical vein
lateral side of the uterus. (c) cut end of cervicovesical vessels
A lateral side view of the
isolated or divided blood
vessels in the cardinal
ligament and the posterior
(dorsal) vesicouterine cut end of
ligament with a transparent deep uterine vein
view of the hidden blood
vessels and the nerve
hypogastric plexus
ureter
cut end of inferior vesical vein
cut end of
a vein connecting
ureter and cervix cut end of middle vesical vein
cut end of
b superficial uterine vein cut end of cervicovesical vessels
cut end of
uterine artery (UA) cut end of Inferior vesical vein
cut end of
middle vesical vein
cut end of
deep uterine vein
ureter

pararectal space
cut end of
uterine artery (UA)

cut end of a vein
connecting cut end of
ureter and cervix cervicovesical vessels
cut end of
deep uterine vein
hypogastric nerve cut end of inferior vesical vein
cut end of
middle vesical vein

ureter and cervix
8.10 Confirmation of the Inferior Hypogastric Plexus (IHP) 189
8.10 Confirmation of the Inferior Hypogastric Plexus (IHP) (Figure 8.35)
Following the removal of the adipose tissues residing nerve to the pelvic splanchnic nerve (the IHP). From the IHP
between the dorsal part of the urinary bladder and the rectal nerve bundles, the uterine branch and the bladder branch can
sidewall, the pelvic splanchnic nerve is traced from the pel- be seen passing toward the uterus and the urinary bladder.
vic floor to the sidewall of the rectum. The hypogastric nerve The IHP formed by the hypogastric nerve, pelvic splanchnic
can be followed from the cranial side of the rectum to the nerve, uterine branch, and bladder branch can be seen as a
urinary bladder, up to the merging point of the hypogastric shape of a cross at the plexus (Figure 8.35a–c).
a
cut end of cut end of superficial uterine vein
uterine artery (UA)
cut end of
cut end of a vein
connecting
ureter and cervix
cut end of
deep uterine vein
inferior hypogastric plexus cut end of inferior vesical vein
hypogastric nerve
cut end of
middle vesical vein cut end of a vein connecting
ureter and cervix
uterine branch
hypogastric nerve
cross shaped IHP
bladder branch
Figure 8.35 Confirmation of the inferior hypogastric plexus (IHP). (a) A lateral side view of the nerve structure of the inferior hypogastric plexus
(IHP). (b) A view from the symphysis side to the cranial side. (c) A surgical photo of the inferior hypogastric plexus (IHP)
c
8.11 The Concept of the Pelvic Nerve Plane 191
8.11 The Concept of the Pelvic Nerve Plane (Figure 8.36)
During the surgical processes of radical hysterectomy two ligament and the rectal side of the two surgical spaces (para-
spaces (such as the paravesical space and pararectal space) vesical and pararectal). Surgically, this connective tissue
are developed, isolating the cardinal ligament between the layer is separable from the rectum and the uterus/vagina
two spaces. In the most dorsal part of the cardinal ligament, without blood loss. In the ventral side of the same connective
the pelvic splanchnic nerve runs from the pelvic wall to the tissue layer, the ureter runs parallel to the hypogastric nerve.
sidewall of the rectum and merges with the hypogastric The connective tissue surrounding the ureter is called as the
nerve. The merging point is the IHP with branches to the mesoureter. However, the dorsal side of the connective tissue
uterus and the urinary bladder. The IHP is formed by the layer from the hypogastric nerve including all the compo-
hypogastric nerve, the pelvic splanchnic nerve, the bladder nents of the IHP can be called as the pelvic nerve plane. An
branch, and the uterine branch. Anatomically, all these nerves appropriate separation of the pelvic nerve plane is necessary
compose the IHP and can be identified in the same connec- for nerve-sparing radical hysterectomy.
tive tissue plane between the lateral side of the uterosacral
Figure 8.36 Pelvic nerve

plane that includes the whole
hypogastric plexus is
illustrated using a square
sheet surrounded by a blue pelvic nerve plane
line
uterine branch
hypogastric nerve
cross shaped IHP

bladder branch
8.12 Separation of the Rectovaginal Ligament (Figure 8.37)
Pushing the rectum up separates the lateral side of the con- rectovaginal ligament is appreciated between the rectum and
nective tissue layer between the rectum and the cervix/ the vagina.
vagina. After the division of the uterosacral ligament, the

the rectovaginal ligament
uterosacral lig. and cut end of cervicovesical vessels

rectovaginal lig.
cut end of
hypogastric nerve

cut end of a vein connecting
ureter and cervix
cut end of
middle vesical vein

8.13 Separation of the Bladder Branch from the Paracolpium 193
8.13 Separation of the Bladder Branch from the Paracolpium (Figure 8.38)
In order to perform nerve-sparing radical hysterectomy, iso- required. During the separation of the bladder branch from
lation of the uterine branch from the IHP is necessary. Before the paracolpium, at the ventral side of the bladder branch
the isolation of the uterine branch, separation of the bladder close to the IHP, a loose connective tissue depression
branch from the vaginal blood vessels (paracolpium) is (v-shaped depression) is appreciated.
Figure 8.38 Separation of a uterine branch

the bladder branch from the
paracolpium. At the cranial
side of the bladder branch, a a hollow
hollow is created between the
bladder branch and the
paracolpium. (a) A view from
the symphysis side to the
cranial side. (b) A lateral side
view of the nerve structure of hypogastric nerve
the inferior hypogastric
plexus. (c) A surgical photo
of the inferior hypogastric
plexus
cross shaped IHP

bladder branch
division of uterosacral and

rectovaginal ligament uterine branch
paracolpium
cross shaped IHP
a hollow
hypogastric nerve
bladder branch
c
8.14 Separation of the Uterine Branch from the IHP 195
8.14 Separation of the Uterine Branch from the IHP (Figure 8.39)
From the ventral level of the v-shaped depression created nerve. Pean forceps can isolate the uterine branch of the IHP
between the bladder branch and the paracolpium, Pean for- from the cervix/vagina.
ceps is insinuated towards the ventral level of the hypogastric
uterine branch
hypogastric nerve
cross shaped IHP
bladder branch
uterine branch
hypogastric nerve
cross shaped IHP bladder branch
Figure 8.39 Separation of the uterine branch from the inferior hypogastric plexus. (a) A view from the symphysis side to the cranial side. (b) A
lateral side view of the nerve structure of the inferior hypogastric plexus. (c) A surgical photo of the inferior hypogastric plexus
c
8.15 Division of the Uterine Branch 197
8.15 Division of the Uterine Branch (Figure 8.40)
Two Pean forceps are applied to the separated uterine branch. is divided with scissors. When the uterine branch is divided,
One is applied parallel to the hypogastric nerve/the bladder the surgeon will experience a sensation similar to that of a
branch, and another is applied to the cervical side. The r eason stretched string breaking with a snap. Each forceps is
why two Pean forceps are applied to the uterine branch is to replaced by ligature. Electrocautery is not recommended for
avoid bleeding from the small vessel running parallel to the the division of the uterine branch, in case of inadvertent dam-
uterine branch. The uterine branch between the two forceps age to the remaining nerves.

uterine branch. (a) A view
from the symphysis side to
the cranial side (T-shaped cut end of uterine branch
IHP). (b) A lateral side view
of T-shaped inferior
hypogastric plexus. (c) A hypogastric nerve
surgical photo of T-shaped
inferior hypogastric plexus
T-shaped IHP
pelvic splanchnic nerve bladder branch

division of uterine branch
paracolpium
T-shaped IHP
hypogastric nerve bladder branch

c
rectum rectovaginal ligament uterus
hypogastric nerve
cut-end of
uterine branch
Pararectal
space
T-shaped IHP
bladder branch

8.16 Separation of the Rectovaginal Ligament Preserving T-Shaped Nerve Plane 199
8.16 S
eparation of the Rectovaginal Ligament Preserving T-Shaped Nerve Plane
(Figure 8.41)
After the division of the uterine branch from the IHP, the using bipolar scissors toward the upper vagina excluding the
rectovaginal ligament is divided toward the vaginal wall. The T-shaped IHP. The separation can extend caudally to obtain
bladder branch is gradually separated from the blood vessels a vaginal length that is deemed appropriate by the extent of
of the paracolpium. By pushing the rectum up, the rectovagi- cervical disease.
nal ligament between the rectum and the vagina is divided
Figure 8.41 Separation of the a

rectovaginal ligament preserving
T-shaped nerve plane. (a) A view from
the symphysis side to the cranial side. cut end of uterine branch
(b) A lateral side view of the T-shaped
inferior hypogastric plexus. (c) A
surgical photo of the T-shaped inferior
hypogastric plexus and rectovaginal
hypogastric nerve
ligament
T-shaped IHP
bladder branch

cut end of uterine branch
paracolpium
T-shaped IHP
hypogastric nerve
bladder branch

c
rectovaginal ligament uterus
rectum
cut end of
uterine branch
hypogastric nerve
pararectal space
bladder branch
T-shaped IHP

8.17 Clamp of the Paracolpium 201
8.17 Clamp of the Paracolpium (Figure 8.42)
At the appropriate level, the blood vessels of the paracol-

pium are doubly clamped.
a cut end of uterine branch
paracolpium
T-shaped IHP
hypogastric nerve
bladder branch
b
division of
paracolpium
T-shaped IHP
hypogastric nerve bladder branch
Figure 8.42 Clamp the paracolpium. (a) A view from the symphysis side to the cranial side. (b) A lateral side view of the paracolpium. (c) A
surgical photo of the paracolpium
c uterus
paracolpium
rectum cut end of
uterine branch
hypogastric nerve
pararectal space
T-shaped IHP
bladder branch
paravesical space
8.18 Ligation and Division of the Paracolpium 203
8.18 Ligation and Division of the Paracolpium (Figure 8.43)
Between the two forceps, the paracolpium is divided. The preserved. The uterus is left connected only with the vagina.
forceps are replaced by the ligature. The T-shaped nerve After the same step is completed on the opposite side, the
plane formed by the hypogastric nerve, the pelvic splanchnic length of the vaginal cuff that needs to be excised is
nerve, and the bladder branch from the IHP is completely confirmed.
hypogastric nerve
T-shaped IHP
bladder branch
division of rectovaginal ligament ligation and division of paracolpium
T-shaped IHP
bladder branch
hypogastric nerve
Figure 8.43 Ligation and division of the paracolpium. (a) A view from the symphysis side to the cranial side. (b) A lateral side view of the para-
colpium. (c) A surgical photo of the paracolpium
c
rectum
vagina
vaginal wall
hypogastric nerve
cut end of
paracolpium
T-shaped IHP
cut end of
uterine branch bladder branch
8.19 Incise the Vaginal Wall for Amputation of the Vagina 205
8.19 Incise the Vaginal Wall for Amputation of the Vagina (Figure 8.44)
An incision is made on the vagina and the uterus along with

the vaginal cuff is amputated from the vagina.
Figure 8.44 Incision of the

vaginal wall for amputation of
the vagina
division of
rectovaginal ligament incision to vaginal wall
T-shaped IHP
hypogastric nerve ligation and division of

paracolpium
bladder branch
8.20 Removal of the Uterus Preserving T-Shaped Nerve Plane (Figure 8.45)
After the removal of the uterus, T-shaped IHP is preserved. good feeling of bladder fullness, and a satisfactory feeling of
The goal of nerve-sparing radical hysterectomy is achieved. micturition.
The urinary functions after surgery are complete voiding, a
Figure 8.45 Removal of the incision to vaginal wall

a extirpation of uterus with vagina
uterus preserving T-shaped
nerve plane. (a) A view from
the symphysis to the cranial
side. (b) A lateral side view of
vaginal stump and the division of paracolpium
preserved T-shaped nerve
plane
hypogastric nerve
T-shaped IHP
bladder branch
b cut end of uterine branch stump of rectovaginal ligament
vaginal stump
hypogastric nerve
T-shaped IHP
bladder branch

8.24 Management After Nerve-Sparing Radical Hysterectomy 207
8.21 Closure of the Vaginal Cuff gauze is removed from the vagina and the vaginal stump
suture is checked. The surgery is now finished.
At the division of the vaginal wall, long Kocher forceps is
applied to the foot side of the divided vaginal wall. After
extirpation of the uterus, each long Kocher forceps is 8.24 M
anagement After Nerve-Sparing
replaced by ligature. Two to three stitches are taken from the Radical Hysterectomy
ventral vaginal edge to the dorsal vaginal edge and the vagi-
nal cuff is closed by ligature. Postoperatively, bladder function is objectively measured
by assessing the time to obtain a postvoid residual volume
(PVR) of less than 50 mL. Subjective measures of self-
8.22 P
artial Suture to the Pelvic reported sensation of bladder fullness and satisfaction of
Peritoneum and Insertion of Drains micturition are evaluated after draining the bladder for
into the Retroperitoneal Space 4 days using a Foley catheter. The Foley catheter is
clamped and the urinary bladder is filled with urine. If the
Careful observation of the pelvic cavity is undertaken to iden- patient feels a good sensation of bladder fullness, the cath-
tify bleeding and ensure hemostasis. The pelvic cavity is then eter is removed. If the patient does not feel a good sensa-
washed with saline water. Partial closure of the visceral peri- tion of bladder fullness, the Foley catheter is not removed
toneum is undertaken between the peritoneum of the cranial by postoperative day (POD) 7. If surgery could preserve
side of the urinary bladder and the peritoneum of the Pouch of complete T-shaped nerve plane on either side of the rec-
Douglas. The peritoneum of the ventral side of the pararectal tum/upper vagina, the patient should retain good sensation
space is not closed in order to facilitate absorption of lymph of bladder fullness within 7 days after the surgery.
fluid by the surface of the peritoneum secondary to lymphad- Spontaneous voiding with a postvoid residual urine vol-
enectomy. Pelvic drains are inserted transabdominally into ume (PVR) less than 50 mL is usually achieved within a
the retroperitoneal space bilaterally. The drainage tubes are couple of days after the removal of the Foley catheter.
usually removed if bleeding is not observed for 2 days. Satisfaction of micturition is typically obtained within
7 days after removal of the Foley catheter. If the uterine
branch from the IHP is divided using electrocautery, recov-
8.23 Closure of the Abdominal Cavity ery of the urinary function can be delayed.
After the suture of the ventral abdominal peritoneum and the

fascia, interrupted skin suture is undertaken with cosmetic
suture being popular. Using a vaginal speculum, the packed

Precise Neurovascular Anatomy For Radical Hysterectomy: Shingo Fujii Kentaro Sekiyama

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Precise Neurovascular Anatomy For Radical Hysterectomy: Shingo Fujii Kentaro Sekiyama

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Shingo Fujii

ISBN 978-981-13-8097-6 ISBN 978-981-13-8098-3 (eBook)

© Springer Nature Singapore Pte Ltd. 2020

Kyoto, Japan Shingo Fujii

1 Brief History of Surgical Treatment for Cervical Cancer����������������������������������������� 1

4.2.7 Development of the Retrovaginal Space and Dissection

6.1.9 Application of a Vessel Tape for a Marker of the Ureter��������������������������� 60

6.4.4 Further Division of the Uterosacral Ligament and Development

8.4.4 Confirmation of the Cardinal Ligament ��������������������������������������������������� 153

8.14 Separation of the Uterine Branch from the IHP����������������������������������������������������� 195

1.1 Cervical Amputation and Simple Total Hysterectomy (Figure 1.1)

Figure 1.1 History of

Cervical amputation of normal positioned uterus

Electronic Supplementary Material The online version of this c­ hapter

© Springer Nature Singapore Pte Ltd. 2020 1

1.2  xtended Hysterectomy with Lymph Node Resection as a Radical Approach for Cervical

Figure 1.2 Introduction of

Extended hysterectomy Radical vaginal hysterectomy

Wertheim started a new chapter in surgical treatment for cervical cancer

Wertheim’s method became the standard “radical hysterectomy” in Western

1.3  odification of Wertheim’s Radical Hysterectomy with Pelvic Lymphadenectomy

Figure 1.3 Modification of

1.4 Situation of Radical Hysterectomy in Mid-Twentieth Century (Figures 1.4 and 1.5)

Radical hysterectomy (RH) with pelvic lymphadenectomy

Latzko (1919) Okabayashi (1921)

Surgery was not always safe in that time period,

Western Countries Japan

Figure 1.5 Revival of Radical hysterectomy (RH)

1.5 Recent Novel Findings and Methods on Radical Hysterectomy

1.6 Super-Radical Hysterectomy

Figure 1.6 Anatomy of the

external iliac vessels

internal iliac vein

deep uterine vein internal pudendal vein

Figure 1.7 Sites of ligation

Figure 1.8 Extirpated figure

cut end of obliterated

1.7.1 Surgical Novel Concepts and Anatomical Findings on Radical Hysterectomy

Figure 1.9 is a list of surgical novel concepts and anatomical

1895 Clark Abdominal extended (radical) hysterectomy

1.7.2 History of Radical Hysterectomy in Western Countries and in Japan

Western Countries Japan (Kyoto & Tokyo Univ.)

1911 Wertheim Radical Hysterectomy (RH)

1917 Takayama (1917) Tried to modify Wertheim’s RH

1941 Mibayashi Super-radical hysterectomy (#1)

1961 Kobayashi Pioneer of Nerve-sparing RH

2007 Fujii Open the black-box of vesicouterine

References 11. Sakamoto S. Radical hysterectomy with pelvic lymphadenectomy—

© Springer Nature Singapore Pte Ltd. 2020 11

2.2  uerler & Morrow’s Classification

2.3  lassification of Radical Hysterectomy and Corresponding Surgical

Figure 2.1 Relationship Classification of radical hysterectomy

Type II-III Type B Extended simple total hysterectomy or

Type C1 Radical hysterectomy with Nerve-sparing

Type III? Type C2 Radical hysterectomy (Latzko’s or Meigs’ surgery)

References anatomical template for parametrial resection. Gynecol Oncol.

3.1  rinciples of Okabayashi’s Radical

© Springer Nature Singapore Pte Ltd. 2020 15

Figure 3.1 Sagittal section Cutting line of simple total hysterectomy

Kyoto, Japan Shingo Fujii

1 Brief History of Surgical Treatment for Cervical Cancer�� 1

4.2.7 Development of the Retrovaginal Space and Dissection

6.1.9 Application of a Vessel Tape for a Marker of the Ureter�� 60

6.4.4 Further Division of the Uterosacral Ligament and Development

8.4.4 Confirmation of the Cardinal Ligament �� 153

8.14 Separation of the Uterine Branch from the IHP�� 195

1.1 Cervical Amputation and Simple Total Hysterectomy (Figure 1.1)

Electronic Supplementary Material The online version of this c hapter

1.2 xtended Hysterectomy with Lymph Node Resection as a Radical Approach for Cervical

1.3 odification of Wertheim’s Radical Hysterectomy with Pelvic Lymphadenectomy

1.4 Situation of Radical Hysterectomy in Mid-Twentieth Century (Figures 1.4 and 1.5)

1.5 Recent Novel Findings and Methods on Radical Hysterectomy

1.6 Super-Radical Hysterectomy

1.7.1 Surgical Novel Concepts and Anatomical Findings on Radical Hysterectomy

1.7.2 History of Radical Hysterectomy in Western Countries and in Japan

2.2 uerler & Morrow’s Classification

2.3 lassification of Radical Hysterectomy and Corresponding Surgical

3.1 rinciples of Okabayashi’s Radical

4.1 urgical Steps of Original

4.2 Illustrated Surgical Steps of Original Okabayashi’s Radical Hysterectomy

4.2.3 Isolation, Ligation, and Division of the Uterine Artery (Figure 4.3)

4.2.4 Separation of the Ureter from the Dorsal Peritoneal Layer of the Broad Ligament (Figure 4.4)

4.2.6 Separation of the Peritoneal Layer of the Pouch of Douglas (Figure 4.5)

4.2.9 Further Development of the Pararectal Space (Figure 4.11)

4.2.10 Development of the Paravesical Space and Separation of the Connective Tissue of the Base

4.2.11 Clamp the Cardinal Ligament (Figure 4.13)

4.2.12 Dissection of the Cardinal Ligament (Figure 4.15)

4.2.13 The Procedures on the Opposite Side

4.2.14 Separation of the Peritoneum Between the Urinary Bladder and the Uterus (Figure 4.16)

4.2.15 Separation of the Connective Tissue Between the Urinary Bladder and the Ventral-Side

4.2.16 Separation of the Anterior (Ventral) Leaf of the Vesicouterine Ligament (Left Side)

4.2.17 Clamp and Dissect the Anterior (Ventral) Leaf of the Vesicouterine Ligament (Figure 4.19)

4.2.18 Separation of the Posterior (Dorsal) Leaf of the Vesicouterine Ligament and the Paravaginal