Explanation of Step-by-Step Procedures
It is generally said that the procedure of radical hysterectomy is complicated and
relatively difficult to master. However, it will not be the case after reading this
article carefully. Since I have fully explained how to perform the radical hysterectomy
uneventfully, readers can master the actual procedure.
Opening Abdomen
Patient is laid in the supine position and urethral catheter is inserted for continuous
bladder drainage. The operator incises the abdominal wall longitudinally from the
pubis toward the umbilicus, and then extends the skin incision upward to approximately
3 cm above the umbilicus.
Before initiating the surgery, the operator should examine the pelvic organs, especially
palpating the parametrium. Reassessment of parametrial invasion is very important
to assess the feasibility of radical hysterectomy. Ascitic fluid is presented to pathology
laboratory for cytological examination, which is prognostic indicator especially for
cervical adenocarcinoma. If positive, partial omentectomy is usually performed to
examine the microscopic peritoneal dissemination.
Throughout the surgical procedures, the uterus is always maintained in the appropriate
traction by the assistant. Usually, a pair of long and straight Kocher clamps are
placed between the uterus and the adnexa. Various retractors are also used to show
the lymphadenectomy field and to open the three retroperitoneal spaces for the treatment
of ligaments.
Broad Ligament
The first step is the same as simple hysterectomy, i.e., ligation and cutting of the
round and infundibulopelvic ligaments, followed by incision of broad ligaments. If
the patient is young and the cancer is squamous cell carcinoma at stage IB or less,
the ovaries are usually preserved. In such case, the ovarian ligament is clamped,
cut, and ligated, instead of infundibulopelvic ligament. Recently, salpingectomy is
frequently performed considering the possible tubal origin of ovarian cancer. To do
so, mesosalpinx is clamped, cut, and ligated several times. All of the above-mentioned
procedures are done for both sides, and now, all of the peritoneal surfaces are incised,
except the posterior leaf of broad ligament and the cul-de-sac peritoneum. From now,
the surgical procedures in the retroperitoneal space start.
Paravesical Space
In the modern radical hysterectomy, pelvic lymphadenectomy precedes the treatment
of the three ligaments. The important first step to prepare lymphadenectomy is the
opening of paravesical space. To do so, the operator explores the space, using both
index fingers, vertically from beneath the cut end of round ligament, medial to the
external iliac artery, and can find easily the space that reaches to the pelvic floor
([Fig. 4A]). Connective tissue in this space is very loose, and the procedure can be done with
no resistance. Importantly, this space should be lateral to the internal iliac artery
(lateral umbilical ligament) ([Fig. 4B]), because there are several arterial branches running medially from the internal
iliac artery.
Fig. 4 Exploration of paravesical space. From beneath the cut end of round ligament, both
index fingers are inserted vertically, downward into the space, medial to the external
iliac vessels (A). This is paravesical space, which should be lateral to the internal iliac artery
(lateral umbilical ligament) (B).
After opening, the operator will extend the paravesical space cranially and caudally,
sliding the fingers along the external iliac vessels. Now, one can clearly recognize
the running of the external iliac vein under the iliac artery ([Fig. 4B]). The index fingers also reach downward to the levator ani muscle of pelvic floor.
Then, the retractor is inserted into the paravesical space, and its mild traction
toward the pubic bone is maintained by the assistant. Exploration results in the formation
of triangle-shaped space ([Fig. 5]), which is composed by the lateral (external iliac vessels), the medial (internal
iliac artery), and the base (pubic bone). This triangle is the surgical field for
pelvic lymphadenectomy.
Fig. 5 Triangle of paravesical space. The paravesical space is extended caudally and cranially,
and also reaches downward to the pelvic floor. Insertion of the retractor and its
mild traction toward the pubis forms the triangle-shaped space. This is the surgical
field of pelvic lymphadenectomy.
The surgical procedure exploring the paravesical space is very important not only
in radical hysterectomy but also in other gynecologic and urologic surgeries, especially
when the anatomy of pelvic organs is complicated. The landmarks for opening the paravesical
space are the cut end of round ligament and the external iliac artery. After exploring
this space, the operator can find easily the ureter, the obturator nerve, and the
uterine vessels. Thus, it becomes possible for the operator to continue the following
surgical procedures without injuring the urinary tract or causing massive bleedings.
Pelvic Lymphadenectomy
Surgery for lymphadenectomy is not the extirpation of only lymph nodes but the systematic
dissection of all lymphatic tissues. To do so, skeletonization of the blood vessels
is an ideal approach to lymphadenectomy, because the lymphatic channels and nodes
are present within the soft tissues on the surface of main blood vessels. After skeletonization,
only the adventitia of the blood vessels remains. It is also advantageous to prevent
unnecessary bleeding from the blood vessels. Risk of bleeding is much higher at skeletonization
of big vein than that of big artery, and therefore, the surgical procedure should
start from artery and then proceed to vein. For the procedure of dissection, we usually
use the aspirator, which can remove the adipose and loose connective tissues, but
not damage the lymphatic and blood vessels. By the aspirator action, the objective
tissues including the lymph nodes become apparent. After clarifying the anatomy, we
use the unipolar electric cautery, rather than the scissors, for the dissection. Bipolar
electric cautery is also useful to manage the bleeding from small vessels.
Pelvic lymph vessels and nodes are classified as two distinct lines, i.e., lateral
and medial chains. Lateral chain consists of lateral suprainguinal, external iliac,
and superficial common iliac nodes. Medial chain consists of medial suprainguinal,
obturator, internal iliac, and deep common iliac nodes. Dissection of lateral chain
should precede that of medial chain.
Lateral Chain
The lymph nodes that should be dissected first are the external iliac nodes, because
the risk of unnecessary trauma and unexpected bleeding is the least. To do so, the
operator should skeletonize first the external iliac artery, find small nodes, and
remove them ([Fig. 6]).
Fig. 6 Lymphadenectomy of lateral chain: external iliac nodes. During skeletonization of
external iliac artery, external iliac nodes appear on the artery and are dissected.
This is the first step of lymphadenectomy.
The second are suprainguinal nodes. The assistant lifts up the operation side of self-retaining
retractor and also attaches another retractor to the inguinal region of abdominal
wall to maximize the operative field. The operator removes the adipose and loose connective
tissues on the fascia of iliopsoas muscle using the aspirator and monopolar cautery,
and gradually approaches the suprainguinal region ([Fig. 7A]). Genitofemoral nerve should be preserved. Be careful about a small vein running
vertically on the surface of artery (circumflex iliac vein), which is usually preserved
but is ligated if injured. During the dissection, large suprainguinal lymph nodes
become evident ([Fig. 7A]). The lymph channels going from the nodes into the inguinal canal are clamped, cut,
and ligated ([Fig. 7B]). Ligation of lymph vessels is important to prevent the formation of lymphocyst
or lymphorrhea after the surgery.
Fig. 7 Lymphadenectomy of lateral chain: lateral suprainguinal nodes. Removal of connective
and adipose tissues on the fascia of iliopsoas muscle and on the external iliac vessels
using aspirator and monopolar cautery discloses the presence suprainguinal nodes (A). Then, lymph channels going into the inguinal canal are clamped, cut, and ligated
(B).
The third are superficial common iliac nodes. The assistant should place the retractor
on the common iliac artery and slide it upward carefully, and the ureter should be
placed medial to the retractor ([Fig. 8]). First, the operator removes the loose connective tissues on the common iliac vein
that is present lateral and beneath the common iliac artery. Vasa vasorum on the artery
is successfully managed with bipolar cautery. Then, the common iliac nodes on the
artery and vein become apparent, and are removed. The lymph channels going upward
from the nodes are clamped, cut, and ligated. Now, lymphadenectomy of the lateral
chain is completed.
Fig. 8 Lymphadenectomy of lateral chain: superficial common iliac nodes. Application of
retractor and its mild traction upward disclose the surface of common iliac artery,
and push the ureter medially. First, the aspiration of connective tissues lateral
to the artery is needed to identify the common iliac vein running through under the
artery. After such clarification of anatomy, the common iliac nodes are dissected
from those vessels.
Since the common iliac vein goes through under the artery and is hiding just lateral
to the artery, the operator should identify the vein first to prevent its injury and
massive bleeding. To do so, using the aspirator, the operator removes the connective
tissue, which exists lateral to the common iliac artery, and finds the running of
the vein. After clarification of the anatomy, the common iliac nodes on the artery
and vein become apparent, and can be removed safely.
Medial Chain
Before lymphadenectomy of medial chain, it is important to identify the obturator
nerve for clarifying the anatomy of obturator fossa. The assistant should lift up
the external iliac artery and vein using the scissors or other small retractor, and
the operator uses the aspirator to remove the loose connective tissues under the external
iliac vessels ([Fig. 9A]). Now, one can find the fascia of iliopsoas muscle near the lateral wall of pelvis.
Then, the white-colored, thick string appears. This is the obturator nerve, which
is now partially isolated ([Fig. 9B]). It is important to recognize the height level of the running nerve, since the
medial chain exists in the obturator fossa between the external iliac vein and the
obturator nerve. The operator should not touch the obturator nerve directly by the
monopolar cautery, because it will cause nerve stimulation and muscle contraction,
which will shake the operative field. And, it is better not to touch the connective
tissues under the obturator nerve, because the vascular-rich cardinal ligament is
present here and will be explored later.
Fig. 9 Lymphadenectomy of medial chain: identification of obturator nerve. Before identifying
the nerve, the external iliac vein is tentatively skeletonized, and the fascia of
iliopsoas muscle becomes visible (A). During the removal of connective tissue under the iliac vein by aspirator, the
white-colored string appears. This is the obturator nerve (B).
First, internal iliac nodes on the internal iliac artery and on the uterine artery
should be dissected. These nodes are classically known as “interiliac nodes.” It is
important to dissect these nodes completely, since they harbor metastases frequently.
The connective tissues containing the lymph nodes cover superficially the obturator
fossa, and so, isolation of the internal iliac artery discloses the lymphatic tissues
continuous with them ([Fig. 10A]), which will be dissected using the monopolar cautery ([Fig. 10B]).
Fig. 10 Lymphadenectomy of medial chain: internal iliac nodes. First, internal iliac nodes
on internal iliac artery and on the uterine artery are dissected. Isolation of the
arteries discloses the lymphatic tissues continuous with them (A), which are dissected using monopolar cautery (B).
Now, it is time to dissect thoroughly the medial chain continuing from the suprainguinal
nodes to the obturator nodes, which is located in the space between the external iliac
vein and obturator nerve. Complete isolation of the obturator nerve is essential.
Here, the operator can also find the obturator artery and vein, running parallel to
the obturator nerve, which are usually preserved during the dissection. However, if
these vessels will disturb the surgical procedure, they can be clamped, cut, and ligated.
Caudal skeletonization of the external iliac vein reveals gradually the presence of
large medial suprainguinal nodes ([Fig. 11A]), which will be detached from the vessels and from the nerve by the aspirator and
cautery. Finally, the lymphatic channels going into the femoral canal are identified,
and are clamped, cut, and ligated ([Fig. 11B]).
Fig. 11 Lymphadenectomy of medial chain: medial suprainguinal nodes. All of tissues containing
lymph nodes between the external iliac vein and obturator nerve should be removed.
Caudal skeletonization of the external iliac vein discloses the presence of suprainguinal
nodes (A), and then lymph channels going into the femoral canal are clamped, cut, and ligated
(B).
Next target is the obturator nodes. Since they are continuous with the medial suprainguinal
nodes, both tissues can be dissected en bloc. Complete removal of the obturator nodes
is very important because they harbor metastases most frequently. The lymphatic tissues
are detached from the obturator nerve and small vessels coming from the pelvic wall
([Fig. 12A]). The lymphatic channels of medial chain going upward under the external iliac vein
are identified, and so, they will be clamped, cut, and ligated here tentatively ([Fig. 12B]). Be careful not to injure the bifurcation point of the external and internal iliac
veins from the common iliac vein. Also, be careful not to cut the obturator nerve
here. The cut end of medial chain should be marked, because the continuous lymphatic
tissues will be treated soon later in the different surgical field.
Fig. 12 Lymphadenectomy of medial chain: obturator nodes. Obturator nodes are continuous
with the medial suprainguinal nodes. These lymphatic tissues are detached from the
obturator nerve and small vessels of the pelvic wall (A). Lymph vessels going up under the external iliac vein are clamped, cut, and tentatively
ligated (B). Cut end is marked.
Now, most procedures of pelvic lymphadenectomy have been completed, and the triangle
space clearly shows the anatomical relationship among the external and internal iliac
vessels, the ureter, the obturator nerve, and pelvic side wall ([Fig. 13]).
Fig. 13 Landscape of the triangle space after lymphadenectomy. Most procedures of pelvic
lymphadenectomy have been completed, and now the operator can recognize again the
running of external iliac artery, vein, fascia of iliopsoas muscle, pelvic wall, obturator
nerve, internal iliac artery, and ureter. The main trunk of internal iliac vein is
partially seen. The lymphatic tissues under the obturator nerve will be dissected
later.
Before initiating the dissection of medial chain, the external iliac artery and vein
are lifted up for identification of the obturator nerve. Here, it is important for
the operator to watch the fascia of iliopsoas muscle lateral to the external iliac
vein, and recognize the anatomical relationship among vessels, nerve, and pelvic wall.
The metastatic or recurrent tumor is frequently present here and adheres to the fascia.
In such case, the operator can perform curable operation via complete removal of recurrent
tumor with co-resection of the fascia. After resection of the fascia, red-colored
striated muscle can be seen. Thus, the gynecologic surgeon should be familiar with
the iliopsoas muscle of pelvic side wall.
Deep Common Iliac Area
Finally, the deep common iliac nodes should be dissected. To do so, the operator explores
the upper space between the common iliac artery and the iliopsoas muscle, using fingers,
scissors, and aspirator ([Fig. 14A]). Then, one can find the obturator nerve, the common iliac vein, and the marked
cut end of medial chain of lymphatics ([Fig. 14B]). The superior gluteal vein is also seen here. The lymphatic tissues continuous
from the obturator are dissected.
Fig. 14 Lymphadenectomy of deep common iliac nodes. The operator explores a different surgical
field, inserting the scissors and the index finger between the common iliac artery
and iliopsoas muscle (A). The obturator nerve and the marked cut end of lymph channels can be found. The
deep common iliac nodes continuous with the obturator are dissected (B).
Pararectal Space
First, the ureter should be detached from the posterior leaf of broad ligament. The
ureter is covered by the ligamentlike connective tissue continuous to the sacrouterine
ligament, which is called “mesoureter.” For the detachment of ureter, broad ligament
is lifted up by two Kelly clamps, and then the ureter with the “mesoureter” is separated
from the broad ligament using the scissors ([Fig. 15A]). Then, the operator should extend, using the index finger and scissors, this space
between the ureter/“mesoureter” and the posterior leaf of broad ligament, anteriorly
and posteriorly, and also extend caudally toward the uterine origin of sacrouterine
ligament ([Fig. 15B]). Here, the operator can touch the sacrouterine ligament by finger. This is an artificial
space, but usually, there is little resistance from tissues during the procedure.
This space extending downward along the posterior leaf of broad ligament is the pararectal
space (Latzko's space). Then, the operator incises the “mesoureter,” resulting in
the complete isolation of ureter, which will be marked with a yellow-colored tape.
Fig. 15 Exploration of pararectal space (Latzko's space). First, the ureter with “mesoureter”
should be detached from the posterior leaf of broad ligament using the scissors (A). Insertion of the finger or scissors toward the sacrouterine ligament results in
the formation of pararectal space (Latzko's space) (B). Then, the ureter is isolated by the incision of “mesoureter,” and is marked by
a yellow tape.
Uterine Artery
It is time to cut the uterine artery. The operator has already identified the internal
iliac artery (lateral umbilical ligament), and can identify the uterine artery from
its relatively cranial portion, by recognizing its characteristic feature of running
with meandering fashion ([Fig. 16A]). The uterine artery is clamped, cut, and ligated at the point of origin in the
internal iliac artery ([Fig. 16B]). Here, the internal iliac artery is marked by red-colored tape. The superior vesical
artery is recognized caudally from the uterine artery, and is preserved. Tracing the
cut end of uterine artery downward, the operator finds the ureter running into the
entrance of “ureter tunnel” under the uterine artery. Loose connective tissues surrounding
the ureter and the uterine artery around the entrance of “ureter tunnel” are removed
tentatively here, for easier access in the later surgery for vesicouterine ligament.
Fig. 16 Identification of uterine artery. Identification and isolation of the internal iliac
artery disclose the presence of uterine artery, which runs with meandering fashion
(A). This is clamped, cut, and ligated at the point of origin in the internal iliac
artery (B). The superior vesical artery is usually preserved. Internal iliac artery is marked
by a red tape.
Hypogastric Nerve
For nerve-sparing radical hysterectomy, preservation of the hypogastric nerve is mandatory
to maintain the urinary function of the patient. The posterior leaf of broad ligament
is lifted again firmly by two Kelly clamps, and the white-colored strings in the deep
area are found. They are separated from the broad ligament by the scissors ([Fig. 17A]). This is the hypogastric nerve, which will be marked with a white-colored tape
([Fig. 17B]). If cancer invasion into the cardinal ligament or rectovaginal ligament is suspected,
the hypogastric nerve cannot be preserved and will be sacrificed.
Fig. 17 Identification of hypogastric nerve. For nerve-sparing radical hysterectomy, preservation
of the hypogastric nerve is mandatory. In the deep area of posterior leaf of broad
ligament (A), white-colored strings are identified, detached, and marked using a white tape (B).
Cardinal Ligament
Now, the operator has reached the important point for the treatment of cardinal ligament,
which exists between the paravesical space and the pararectal space (Latzko's space).
Historically, this was the most dramatic scene of radical hysterectomy. First, the
two long retractors are inserted into the two spaces, and pushed medially, keeping
the retractors in parallel. Internal iliac artery is retracted laterally, and the
ureter is pushed medially. Traction of the uterus upward is also necessary. Here,
the operator recognizes the characteristic feature of cardinal ligament ([Fig. 18]), which is based broadly on the pelvic wall and reaches the cervix, resembling that
of Mount Fuji. However, clamping and cutting of ligament should not be done at this
point, because dissection of lymphatic tissues of the cardinal ligament should precede.
Fig. 18 Exploration of cardinal ligament. Two long retractors are inserted into the two spaces,
i.e., one at paravesical space and another at pararectal space (Latzko's space). Internal
iliac artery is retracted laterally (red tape), and the ureter is pushed medially
(yellow tape). Between the two retractors, you can see clearly the cardinal ligament,
which originates from the pelvic side wall and reaches the cervix. Clamping and cutting
of ligament should not be done here, because dissection of lymphatic tissues of the
cardinal ligament should precede.
Since the connective tissues having many small lymph nodes are still present within
the cardinal ligament, the operator should remove carefully these tissues existing
in the area under the obturator nerve ([Fig. 19A]). This is an important procedure to prevent the side wall recurrence. Using the
aspirator and monopolar or unipolar cautery, the operator carefully removes the lymphatic
tissues from anterior and posterior sides of the cardinal ligament, and then the blood
vessels appear gradually ([Fig. 19B]). The main trunk of the internal iliac vein also appears in the deep area of pelvic
wall. Thus, such dissection expose the pelvic side wall as well as the arteries and
veins in the cardinal ligament ([Fig. 20]), including the deep uterine vein, which connects directly to the main trunk of
the internal iliac vein. Cutline of the cardinal ligament has become truly clear after
the dissection.
Fig. 19 Dissection of lymphatic tissues of the cardinal ligament. Removal of connective and
lymphatic tissues in the area under the obturator nerve is carefully performed using
aspirator and cautery (A). Dissection of lymph nodes in the cardinal ligament is very important to prevent
the side wall recurrence (B).
Fig. 20 Appearance of the blood vessels of cardinal ligament. Dissection of lymphatic tissues
discloses the arteries and veins in the cardinal ligament, pelvic side wall, and the
main trunk of the internal iliac vein. Thus, the cutline of ligament has become clear.
Now, the blood vessels of cardinal ligament are clearly visible, and therefore, their
treatment can be done without the risk of massive bleeding. Thus, in modern radical
hysterectomy, we do not encounter unexpected bleeding from the cardinal ligament.
Usually, Kelly clamps are inserted into the avascular space ([Fig. 21A]), and first, the superficial vessels are clamped, cut, and ligated, either one by
one or en bloc ([Fig. 21B]). Then, the operator approaches the deep uterine vein, which is the hallmark of
cardinal ligament ([Fig. 22A]). In the deepest part of ligament, the deep uterine vein originating from the main
trunk of internal iliac vein is recognized. And, it is clamped, cut, and ligated at
the point close to the internal iliac vein ([Fig. 22B]). The treatment of cardinal ligament has been completed. Here, when the operator
looks at the uterus and the entire image of anatomy, one can understand that the cut
end of cardinal ligament (deep uterine vein) is running into the cervix, crossing
just over the preserved hypogastric nerve.
Fig. 21 Treatment of the superficial vessels of cardinal ligament. Since the blood vessels
of cardinal ligament are clearly visible now, their treatment can be done without
the risk of massive bleeding. Usually, Kelly clamps are inserted into the avascular
space (A), and first, the superficial vessels are clamped, cut, and ligated, either one by
one or en bloc (B).
Fig. 22 Treatment of the deep uterine vein of cardinal ligament. In the deep area of the
cardinal ligament, the deep uterine vein originating from the internal iliac vein
is recognized (A). This is the hallmark among the blood vessels of cardinal ligament, and is clamped
(B), cut, ligated, and marked as the symbolic cut end of cardinal ligament.
The aforementioned surgical procedures, such as the exploration of paravesical space,
pelvic lymphadenectomy, exploration of pararectal space, treatment of uterine artery,
identification of hypogastric nerve, and the treatment of cardinal ligament, are also
done in the same way for the left side.
In each surgery for radical hysterectomy, the operator should always clarify the running
of the external and internal iliac veins, the obturator nerve, and the iliopsoas muscle.
Then, the operator becomes familiar with the anatomy of pelvic side wall, and soon
recognizes that the running of internal iliac vein varies greatly, sometimes very
close to pelvic wall and other times near the uterus. This is very important to decide
the cutline of ligament for radical hysterectomy and also essential to assess how
to perform “super-radical” hysterectomy, i.e., co-resection of the internal iliac
vein if necessary.
Rectovaginal Ligament
Then, the operator starts the posterior part of the surgical procedure, i.e., the
treatment of rectovaginal ligament. The first step is to incise the peritoneum. The
operator stretches the cul-de-sac peritoneum, and incise it using the scissors or
monopolar cautery ([Fig. 23A]). Yellow-colored adipose tissues appear ([Fig. 23B]). Then, for separation of the rectum from the vagina, the operator inserts the midfinger
into the incised space ([Fig. 24A]), sliding the finger just beneath the vaginal wall, not toward the rectal wall.
Alternatively, the careful separation can be performed visually using the monopolar
cautery. Then, the posterior leaf of broad ligament is incised downward, and the sacrouterine
ligament is clamped, cut, and ligated.
Fig. 23 Incision of cul-de-sac peritoneum. Now the operator starts the procedure of posterior
part. The cul-de-sac peritoneum is stretched (A), and is incised using the scissors or monopolar cautery (B). Yellow-colored adipose tissues appear.
Fig. 24 Exploration of pararectal space (Okabayashi). The operator inserts the midfinger
into the space between the vagina and the rectum, sliding the finger just beneath
the vaginal wall (A). The posterior leaf of broad ligament is incised, and the sacrouterine ligament
is clamped, cut, and ligated. Now, the rectovaginal ligament is recognized. The rectum
is detached from the rectovaginal ligament using the scissors (B), and then the pararectal space (Okabayashi) has developed.
The rectovaginal ligament is continuous from the sacrouterine ligament, very thick
and firm, and directed downward to the sacrum. The operator should detach the rectum
from the rectovaginal ligament medially, using the scissors ([Fig. 24B]). Then, using the index fingers, this space is extended downward, cranially, and
caudally. Here, the pararectal space (Okabayashi) has been opened, and the rectum
is completely free from the rectovaginal ligament and the vagina.
Then, the operator inserts one finger into the pararectal space (Okabayashi) and another
into the pararectal space (Latzko's space), pushing the rectum medially and the hypogastric
nerve laterally ([Fig. 25]). This procedure is very important for prevention of rectal injury and for preservation
of the hypogastric nerve. Thus, the rectovaginal ligament is now isolated from the
surrounding tissues, and is clamped, cut, and ligated, several times until reaching
the point where the cut end of cardinal ligament (deep uterine vein) is present. The
height level of cutting depends on the degree of cancer invasion into the rectovaginal
ligament.
Fig. 25 Treatment of the rectovaginal ligament. The operator inserts one finger into the
pararectal space (Okabayashi) and another into the pararectal space (Latzko's space),
pushing the rectum medially and the hypogastric nerve laterally. The rectovaginal
ligament between the two fingers is clamped, cut, and ligated. The procedure is repeated
several times, until the cutline reaches to the cut end of cardinal ligament.
This procedure is also performed for the left side. The cancer is now free from the
posterior (rectum) and from the lateral (pelvic side wall) planes.
Exploring the two different pararectal spaces, i.e., Latzko and Okabayashi, is also
important in the surgeries for advanced ovarian cancer, in which the cancer cells
metastasized to the cul-de-sac peritoneum. Not infrequently, the cul-de-sac peritoneum
having the disseminated nodules can be separated from the rectum, and radical surgery
is possible without resecting the rectum. In such case, exploration of the pararectal
spaces makes it possible to dissect the peritoneum and to preserve the rectum safely.
Vesicouterine Ligament
Now, the operator starts the anterior part of the surgical procedure, i.e., the treatment
of vesicouterine ligament. Of the two leaves of vesicouterine ligament, the anterior
serves as the roof, while the posterior provides with the floor of ureter running.
Anterior Leaf
The first step is bladder mobilization at the midline of the cervix. The operator
cut the loose connective tissue in the vesicouterine fossa with the scissors and monopolar
cautery ([Fig. 26A]). The surface of the cervical and vaginal walls gradually appears. If the invasion
of cancer near the surface of cervix or vagina is suspected, the operator should not
touch the cancer but treat only the connective tissues. Then, using the monopolar
cautery, the operator removes carefully the superficial loose connective tissues in
the lateral area, covering the vesicouterine ligament. The bladder is detached caudally
to the level of about 3 cm below the fornix ([Fig. 26B]). However, the depth level of dissection is dependent on the degree of vaginal invasion.
Fig. 26 Mobilization of bladder. The operator moves to anterior part. After incision of the
connective tissues of vesicouterine fossa (A), the bladder is detached from the cervix and mobilized downward using monopolar
cautery (B). Loose connective tissues covering the anterior leaf of vesicouterine ligament are
removed carefully. The dissection reaches to the level of ∼3 cm below the fornix.
Since the anterior leaf of vesicouterine ligament has appeared at both sides, the
operator understands the anatomical relationships among the ureter, vesicouterine
ligament, and bladder ([Fig. 26B]). The end point of the procedure is the complete removal of the anterior leaf that
covers the ureter running into the bladder. This portion is named “ureter tunnel.”
The anterior leaf contains the cervicovesical vessels, and so, its injury will result
in the massive bleeding. The following procedures should be performed step by step
carefully.
First, the entrance of “ureter tunnel” should be identified. The assistants retract
the uterus cranially, the ureter upward laterally, and the bladder caudally using
retractors, and fix them. The cut end of uterine artery is lifted up to show clearly
the entrance. Using the scissors, the operator can find the entrance of “ureter tunnel”
at medial upper portion of the ureter. Then, the operator inserts the scissors into
the tunnel ([Fig. 27A]), pushing the ureter laterally. Gradually, during the procedure, the inner wall
of “tunnel” becomes clearly visible ([Fig. 27B]).
Fig. 27 Approach to “ureter tunnel.” The cut end of uterine artery is lifted and the ureter
is mildly retracted cranially. The entrance of “ureter tunnel” appears just beneath
the anterior leaf of vesicouterine ligament. Then, the operator inserts the scissors
into the space between the ligament and the cervix (at 10 o'clock position for the
right, and at 2 o'clock position for the left) (A), and pushes the scissors laterally (B).
The operator now understands the direction of “tunnel” by the gradual exploration
of the “tunnel,” and then some part of the anterior leaf of vesicouterine ligament
is clamped ([Fig. 28A]), cut ([Fig. 28B]), and ligated, being apart from the ureter. The operator can recognize the exit
of “ureter tunnel,” and so, for the remaining part of anterior leaf, Kelly clamps
are inserted ([Fig. 29A]). The remaining ligament is clamped, cut, and ligated. Thus, clamping and cutting
of the anterior leaf are repeated usually two or three times, and result in the complete
appearance of the ureter and its running into the bladder ([Fig. 29B]).
Fig. 28 Treatment of anterior leaf of vesicouterine ligament. When the ureter is pushed laterally
using the scissors, some part of the anterior leaf of vesicouterine ligament is clamped
(A), cut (B), and ligated.
Fig. 29 Completion of anterior leaf of vesicouterine ligament. For the remaining part of
anterior leaf of vesicouterine ligament, the ureter is pushed downward using the scissors,
Kelly clamps are inserted (A), and the ligament is clamped, cut, and ligated. After completion of the anterior
leaf, the ureter and its running into the bladder become clearly visible (B).
For removal of the anterior leaf of vesicouterine ligament, it is important to identify
the “ureter tunnel.” For the right side, the entrance of “ureter tunnel” is present
at the 10 o'clock position of the ureter (2 o'clock position for the left), i.e.,
upper and medial space between the ureter and ligament. When the operator insets the
scissors into this point and push the ureter toward lateral and downward, the entrance
of “ureter tunnel” will open. For safety, it is very important to watch the surface
of ureter with the eyes of operator during the procedure.
Posterior Leaf
Then, the operator should detach the ureter from the floor and push the ureter laterally.
Such lateral mobilization of the ureter is essential for the next step ([Fig. 30A]). During this procedure, the narrow space of yellow-colored adipose tissues appears
between the paracolpium and the posterior leaf ([Fig. 30B]). This yellow space is an important landmark for the next step. Thus, anatomical
relationships among the ureter, the bladder, the posterior leaf of the vesicouterine
ligament, and the paracolpium become clearly visible.
Fig. 30 Lateral mobilization of ureter. The ureter is mobilized completely by detachment
from the posterior leaf of vesicouterine ligament using the monopolar cautery and
scissors (A). During this procedure, the narrow space of yellow-colored adipose tissues appears
between the paracolpium and the posterior leaf (B).
Now, the operator recognizes the posterior leaf of vesicouterine ligament running
from the bladder to the cervix ([Fig. 31A]), where it meets with the cut end of the cardinal ligament. This is because the
vesical vein in the posterior leaf anastomoses with the deep uterine vein. There is
a space between the posterior leaf and the vagina, and its landmark is the yellow
space. Thus, for actual identification and cutting of the posterior leaf, the operator
should palpate the ligament, using the index finger and the thumb, and confirm the
absence of vessels or bladder in the yellow space ([Fig. 31B]). The ligament contains two to three vesical veins anastomosing with the deep uterine
vein, and their injury results in massive bleeding. Therefore, palpation is very important
to prevent the trauma to bladder or injury to vessels in the ligament.
Fig. 31 Identification of posterior leaf of vesicouterine ligament. Now, the operator recognizes
the posterior leaf of vesicouterine ligament running from the bladder to the cervix
(A), where it meets with the cut end of cardinal ligament. This is because the vesical
vein in the posterior leaf anastomoses with deep uterine vein. The operator should
palpate the ligament, using the index finger and the thumb, and confirm the absence
of vessels or bladder in the space between the paracolpium and the posterior leaf
(B). You can see my index finger bulging at the yellow space.
Where is the posterior leaf of vesicouterine ligament? Anatomically, the vesical vessels
in the ligament flow from the bladder and continuous to deep uterine vein, and the
ligament reaches to the cut end of cardinal ligament (deep uterine vein). To identify
the medial border of the ligament, it is said that the yellow space can be seen between
the posterior leaf and the paracolpium. Complete mobilization of the ureter laterally
is needed to find it. Sometimes, it is not possible to find the yellow color visually.
Therefore, it is important to confirm the space by palpation using the thumb and the
index finger.
After palpation, the operator inserts vertically two Kelly clamps into the yellow
space ([Fig. 32A]). Then, the posterior leaf of the vesicouterine ligament is clamped, cut, and ligated
([Fig. 32B]).
Fig. 32 Treatment of posterior leaf of vesicouterine ligament. The Kelly clamps are inserted
into the yellow space, which has been confirmed to be safe by palpation (A). The isolated posterior leaf of vesicouterine ligament is clamped, cut, and ligated
(B).
The above-mentioned treatment for anterior and posterior leaves of the vesicouterine
ligament is also performed for the left side.
Paracolpium
Now, the ligaments covering the ureter have completely been removed, and the paravaginal
tissues (paracolpium) become evident ([Fig. 33A]). The operator will clamp, cut, and ligate it at the appropriate level ([Fig. 33B]).
Fig. 33 Treatment of paracolpium. After cutting the posterior leaf of vesicouterine ligament,
the paracolpium appears (A). At the appropriate level, the paracolpium is clamped, cut, and ligated (B).
This procedure is completed also for the left side.
Amputation of Vagina
Now the cancer is completely free from all of the ligaments supporting the uterus.
Anterior vaginal wall is opened by the scalpel or monopolar cautery ([Fig. 34]). The vagina is prepared by povidone-iodine, and a gauze is inserted into the vaginal
cavity. The vaginal vault is closed with Z-figure sutures.
Fig. 34 Amputation of vagina. Anterior vaginal wall is opened by the scalpel or monopolar
cautery. Vaginal vault is closed by suturing. Radical hysterectomy has been completed
now.
If the dissected pelvic lymph nodes are proven to be positive for metastasis, para-aortic
lymphadenectomy till the level of inferior mesenteric artery will be added from here.
Closing Abdomen
The retroperitoneal space is washed by warm saline, and is confirmed for no bleedings
and no foreign bodies. Two drains are placed in the field of lymphadenectomy. Pelvic
peritoneum is not sutured in order to prevent formation of lymphocyst. The intestines
are restored to normal position, and the abdomen is closed with each suture for the
peritoneum, fascia, and skin.
