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458 Nerve-Sparing Surgery in Cervical Carcinoma
Figure 6. (A). Isolation and division of the deep uterine vein reveals the pelvic splanchnic nerve (B). Along the rectal side wall of the
pararectal space, the hypogastric nerve is appreciated, isolated, and a vessel tape is applied for a marker.
3: Isolation and Separation of The Hypogastric (1) Anatomy of The Vesicouterine Ligament (Figure 7A,B
Nerve (Figure 6B) and Figure 8A,B)
In the rectal side-wall of the pararectal space, 2 to 3 cm
dorsal portion from the ureter, a white bundle of the Since the ureter is running in the vesicouterine ligament,
hypogastric nerve running parallel with the rectum is it is essential to separate the connective tissue of the
appreciated. This bundle should be searched on the same vesicouterine ligament during radical hysterectomy.
connective tissue plane of the ureter. The hypogastric At first, the ventral part of the ureter should be
nerve is scraped and separated from the rectal side-wall unroofed. However, the detailed vascular anatomy of
(Figure 6B). A vessel tape is applied for a marker of the the vesicouterine ligament was unclear for more than
isolated hypogastric nerve. Hypogastric nerve should be 100 years. Always there existed unexpected bleeding
separated as close as possible to the uterine-side of the that is usually difficult to control because the ureter is
pelvic splanchnic nerve (Figure 6B). running very close to these bleeding points. Without
confirmation of the figure of the ureter, tissue clamping
4: Separation of The Connective Tissue Between is also dangerous and a surgeon usually tries to avoid
the Rectum and The Vagina making damage to the ureter. Therefore, hemostasis
often becomes insufficient. This results in a considerable
5: Division of The Uterosacral Ligament amount of blood loss. Therefore, the detailed anatomy
of blood vessel in the vesicouterine ligament is essential
6: Separation of the cut end of the deep uterine for the doctors who would like to perform radical
vein from the pelvic splanchnic nerve hysterectomy. The Figure 7A is a transparent view of the
ureter and blood vessels in the vesicouterine ligament
7: Separation of the urinary bladder and the drawn by Shingo Fujii (Figure 7A).
vesicouterine ligament
(2) Anatomy of The Anterior Leaf of The Vesicouterine
Ligament
Figure 7B is illustrating the blood vessels residing in
the anterior leaf of the vesicouterine ligament that are
Figure 7. (A). A transparent view of the ureter and blood vessels in the vesicouterine ligament (B). Blood vessels in the anterior leaf of
the vesicouterine ligament.
