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Nerve-Sparing Surgery in Cervical Carcinoma 457
cardinal ligament with internal iliac blood vessel system
(super-radical hysterectomy (11)), (lateral extended
parametrectomy (LEP) (12) ) is a radical approach for
the patient. However, if the other side is intact, unilateral between the internal iliac blood vessels of the pelvic
nerve-sparing radical hysterectomy is a surgical choice.
Preservation of T-shaped nerve plane in either side of
the rectum results in satisfactory urinary function for the
patient.
It is necessary to perform a randomized study
comparing the effectiveness, complications, and
oncologic outcomes of classical radical hysterectomy with
nerve-sparing radical hysterectomy. However, in order to
perform a randomized study, the uniform surgical steps
are required for reproducible results and to compare the
data between the studies (4)
Operative Procedure
The anatomy of the inferior hypogastric plexus
encompassing the hypogastric nerve, the pelvic
splanchnic nerve and the bladder branch/the uterine
branch from this plexus is complicated and is not easy to
appreciate during the surgery of radical hysterectomy. In
order to detect the structure of the inferior hypogastric
plexus, it is essential to have the knowledge of the
anatomy of the cardinal ligament (deep uterine vein) to
preserve the pelvic splanchnic nerve (5, 10). Moreover,
the anatomy of the vesicouterine ligament, particularly
the posterior leaf of the vesicouterine ligament (13) is
very important. As well as it is necessary to have surgical
skill to separate carefully these tissues in order to reveal
the structure of the inferior hypogastric plexus. The
surgical steps for nerve-sparing radical hysterectomy
after the pelvic lymphadenectomy are described in this
chapter.
1: Treatment of The Cardinal Ligament
After the pelvic lymphadenectomy, the paravesical
space and pararectal space are well developed. The thick
connective tissue bundle between the paravesical and
Figure 5. (A). Cardinal ligament between the paravesical space and paravesical space after division of the uterine artery (B). After isola-
tion and division of the uterine artery and superficial uterine vein, in the cardinal ligament the deep uterine vein running from the side-
wall of the uterus to the internal iliac vein is appreciated.
the pararectal spaces is the cardinal ligament (Figure
5A). The cardinal ligament usually contains vascular
structures and nerve structure that are running laterally
side wall and the uterine/upper-vaginal side wall. In
the cardinal ligament, from the ventral to the dorsal-
side, the uterine artery, the superficial uterine vein, the
deep uterine vein and the pelvic splanchnic nerve are
appreciated (Figure 5A shows the cardinal ligament
after the division of the uterine artery). The uterine
artery originated from the internal iliac artery and runs
into the side wall of the uterus is easily isolated, doubly
clamped and ligated. The uterine artery between the two
ligatures is divided (Figure 5A). Then, in the connective
tissue of the cardinal ligament the superficial uterine vein
running parallel to the uterine artery is appreciated. The
superficial uterine vein is isolated and doubly clamped
by Pean forceps. Then the superficial uterine vein is
divided between the two clamps. Each clamp is replaced
by ligature. In the remaining cardinal ligament, the deep
uterine vein is always appreciated.
2: Isolation and Separation of The Deep Uterine
Vein From The Pelvic Splanchnic Nerve
Careful separation of the connective tissue and lymph
nodes in the cardinal ligament between the side wall of
the uterus and the internal iliac blood vessels can reveal a
vein running from the uterine side wall to the internal iliac
vein. If we can confirm this anatomy, a vein is the deep
uterine vein. The connective tissue and adipose tissue
surrounding the deep uterine vein should be cleaned as
much as possible. Particularly, the dorsal side of the deep
uterine vein is very important for the isolation of the deep
uterine vein from the pelvic splanchnic nerve (Figure 5B).
After isolation, the deep uterine vein is doubly clamped by
Pean’s forceps. The deep uterine vein is divided between
the two clamps. Each clamp is replaced by ligature (Figure
6A). In the dorsal part of the deep uterine vein, a white
yellow bundle is running parallel to the deep uterine vein.
This is the pelvic splanchnic nerve (Figure 6B).