Cardinal and Uterosacral Ligaments

Excellent knowledge of both intraperitoneal and extraperitoneal anatomy is critical to perform a hysterectomy. Uterine support is provided by the cardinal and uterosacral ligaments (Fig. 51-1). The cardinal ligaments extend laterally from the level of the cervical-uterine junction and divide the pelvic cavity in potential spaces: the paravesical spaces divide the cavity anteriorly and the pararectal spaces divide it posteriorly. The uterosacral ligaments extend from the cardinal ligaments posteriorly toward the ischial spines and sacrum. Between the uterosacral ligaments lies the uppermost portion of the rectovaginal septum covered by peritoneum. This area can serve as the entry point into the retrouterine space.

Round and Broad Ligaments

The round ligaments arise from the fundus of the uterus and extend laterally along the ventral aspect of the abdominal wall toward the inguinal canal. The round ligaments comprise smooth muscle and small vessels and terminate in the fat pad of the labium majora.

The broad ligament consists of an anteroposterior layer of peritoneum draped over the uterus and extends from the round ligament to the infundibulopelvic ligaments posteriorly (Fig. 51-2). The retroperitoneal space and structures can be accessed through the broad ligament, which contains areolar fat.

Vascular Landmarks and Ureteral Injury

Uterine blood supply is derived from the uterine artery, which originates in the anterior branch of the hypogastric (internal iliac) artery (Fig. 51-3, A). Additional branches and collateral vessels include the vaginal and cervical branches of the uterine artery. The uterine artery crosses the lower third of the ureter before the uterine entry point at the cervicouterine junction. The majority of pelvic surgery–related ureteral injuries occur at this location, and detailed knowledge of ureteral anatomy and the relationship to the uterus and uterine blood supply is necessary to avoid iatrogenic injury to the ureter (Fig. 51-3, B).

Additional uterine blood supply is obtained from the ovarian blood vessels (direct branch from aorta). Venous drainage enters into the hypogastric veins, inferior vena cava (right ovarian vein), and left renal vein (left ovarian vein).

Surgical Approach

The abdominal incision may be chosen on the basis of operator experience, patient body habitus, and uterine size or pathology. With a diagnosis of malignancy or large uterine size, the author recommends a traditional vertical midline incision. Once this incision is made and the peritoneal cavity entered, careful abdominal and pelvic exploration is undertaken. Pelvic washings are taken if necessary as part of a surgical staging procedure. The patient’s intestines are packed into the upper abdomen, and a self-retaining retractor (e.g., Balfour, Bookwalter) is used.

Kelley clamps are placed on the uterine cornua bilaterally, and gentle upward traction is used. The round ligaments are identified bilaterally and suture-ligated with 0 Vicryl (Fig. 51-4, A). These sutures are left long and tagged. The round ligaments are transected, and the retroperitoneal space is entered.

Abdominal Dissection

The vesicouterine peritoneum is grasped and cut just below the reflection onto the lower uterus. In this way the bladder is moved inferiorly away from the patient’s cervix. Gentle blunt dissection, dissection with a sponge forceps, or sharp dissection may be used. If the patient has a history of previous pelvic surgery, including cesarean section, the author would recommend sharp dissection. This maneuver may be facilitated by grasping the lower uterine segment and cervix between the thumb and forefinger and pushing the uterine cervix anteriorly.

The posterior broad ligament is dissected parallel to the course of the infundibulopelvic ligaments bilaterally (Fig. 51-4, B). If significant dissection into the retroperitoneum is planned, this dissection may be continued along the white line of Toldt, with mobilization of the cecum and the sigmoid colon. Once this dissection is performed, the retroperitoneal space is now clearly visible through the layer of areolar fat. This tissue may be dissected with gentle blunt dissection, monopolar cautery, or gentle dissection with a suction tip.

The ureter will be identified coursing along the medial leaf of the broad ligament, below the infundibulopelvic ligaments. The pararectal space may be developed by gentle dissection between the hypogastric artery and ureter (Fig. 51-5). The author recommends awaiting ureteral peristalsis so as not to confuse the ureter with anterior division of the hypogastric artery.

Once these structures are clearly identified and the ureters identified and out of harm’s way, bilateral salpingo-oophorectomy may be performed (see Chapter 52).

Ovarian Preservation

In the hysterectomy with ovarian preservation, a window is created beneath the infundibulopelvic ligament and parallel to it. This window may be extended to the level of the uterine artery. The utero-ovarian pedicles may be double-clamped with either slightly curved Heaney or Zeppelin clamps and the pedicle cut between the two clamps. The ovarian pedicle is double-ligated with 0 Vicryl suture. The clamps may remain on the uterine side to be used for gentle upward traction, and the previously placed Kelley clamps may be removed. The remaining tubes and ovaries may be gently packed into the upper abdomen.

Clamping and Mobilization

The uterine vessels are skeletonized bilaterally. The vessels are subsequently clamped with a slightly curved heavy clamp (e.g., Heaney, Zeppelin). A secondary clamp is placed above this clamp to prevent back-bleeding from the uterus. The vessels are cut with scissors and suture-ligated with a single 0 Vicryl suture. Care should be taken to pass the needle directly though the tip of the clamp to avoid passing it through the vascular portion of this pedicle. The heavy clamp is then removed.

The remaining cardinal ligaments and uterosacral ligaments are subsequently clamped with straight heavy clamps, cut with a scalpel, and suture-ligated with 0 Vicryl sutures. Care must be taken to remain close to the cervicouterine junction to avoid lateral migration and injury to the ureter.

Specimen Removal and Closure

The pubocervical fascia is incised and careful blunt traction used to ensure that the bladder is well below the cervix. Heavy right-angle clamps are then placed bilaterally below the patient’s cervix, thus clamping the top portion of the vagina.

Heavy scissors (Jorgensen) are used to amputate the specimen from the vagina. The specimen is inspected to make certain the cervix is intact and no portion remains. The vaginal angles are suture-ligated below the heavy clamps, which are removed. The angle sutures are left long and tagged. The remaining vaginal cuff is closed with interrupted figure-of-eight sutures with 0 Vicryl.

By placing gentle traction on the vaginal-angle sutures, the surgeon should inspect the cuff for hemostasis. The pelvis should be copiously irrigated and hemostasis achieved. The sutures remaining on the vaginal angles and round ligaments may then be cut. The fascia may be closed in standard fashion.

Baggish, MS, Karram, MM. Atlas of pelvic anatomy and gynecologic surgery, 3rd ed. Philadelphia: Saunders; 2010.

Rock, JA, Jones, HW. TeLinde’s operative gynecology, 9th ed. Philadelphia: Lippincott, Williams & Wilkins; 2003.

Wheeless, CR, Parker, J. Atlas of pelvic surgery, 3rd ed. Philadelphia: Lippincott, Williams & Wilkins; 1997.