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Nerve-Sparing Surgery in Cervical Carcinoma 459

Figure 8. (A). A transparent view of the posterior leaf of the vesicouterine ligament after the separation and division of the blood vessels
in the anterior leaf of the vesicouterine ligament (B). A view of the blood vessels in the posterior leaf of the vesicouterine ligament after
the displacement of the ureter.

separated or divided; 1) uterine artery, 2) superficial (4) Division of Blood Vessels in The Posterior Leaf of The
uterine vein, 3) ureter branch of the uterine artery, 4) Vesicouterine Ligament
superior vesical vein that drains into the superficial Division of the middle vesical vein (Figure 9A).and
uterine vein, and 5) cervicovesical vessels (13). Separation the inferior vesical vein (Figure 9B) reveal the inferior
and division of the vessels in the anterior leaf of the hypogastric plexus. Wertheim’s method separates
vesicouterine ligament reveals the ventral-surface of the the anterior leaf of the vesicouterine ligament, but
ureter (Figure 8A, B). not intentionally separates the posterior leaf of the
vesicouterine ligament. In contrast, Okabayashi’s method
(3) Anatomy of The Posterior Leaf of The Vesicouterine identifies the deep uterine vein and pelvic splanchnic
Ligament nerve in the cardinal ligament (5, 10) and intentionally
The Figures 8A and B are illustrating the surface of the separates the posterior leaf of the vesicouterine
posterior leaf of the vesicouterine ligament on where ligament (10, 13) that results in the identification of the
the ureter is rolled laterally. The posterior leaf of the inferior hypogastric plexus beneath the posterior leaf
vesicouterine ligament is the tissue residing dorsal-side of the vesicouterine ligament. Therefore, if we would
of the ureter with connection between the posterior wall like to perform nerve-sparing radical hysterectomy,
of the bladder and the lateral cervix/cranial vagina. The Okabayashi’s method is easier to identify the inferior
detailed anatomy of each blood vessel in the vesicouterine hypogastric plexus during the surgery.
ligament is described as the transparent view (Figure
8A). In the posterior leaf of the vesicouterine ligament, 8: Identification of the Inferior Hypogastric
we usually appreciate two major vesical veins that start Plexus and Isolation of The Bladder Branch and
from the urinary bladder and drain into the deep uterine The Uterine Branch
vein (13) (Figure 8B). Division of these veins reveals the
inferior hypogastric plexus. After removal of the fatty tissues residing between the
dorsal portion of the urinary bladder and the rectal

Figure 9. (A). A view of the posterior leaf of the vesicouterine ligament (B). Separation and division of the middle vesical vein in the
posterior leaf of the vesicouterine ligament.