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460 Nerve-Sparing Surgery in Cervical Carcinoma

Figure 10. (A). Separation and division of the inferior vesical vein reveals the bladder branch from the cross-shaped inferior hypogastric
plexus. The nerves composing the inferior hypogastric plexus is residing in the same connective tissue of the pelvic nerve plane (B).
Between the uterine branch and the upper-vagina above the level of the hypogastric nerve and bladder branch, Pean’s forceps is insinu-
ated in order to isolate only the uterine branch in the pelvic nerve plane.

side wall, if we trace the pelvic splanchnic nerve toward 9: Division of The Uterine Branch From the
the uterus, we can appreciate the cross-shaped inferior Inferior Hypogastric Plexus (Figure 11A) and
hypogastric plexus formed by the pelvic splanchnic Division of The Uterosacral Ligament (Figure
nerve, the hypogastric nerve, the uterine branch and 11B)
the bladder branch from the inferior hypogastric plexus.
These nerves reside in the same connective tissue plane The uterine side of the pelvic nerve plane including the
that we call the pelvic nerve plane (4) (Figure 10A). uterine branch from the inferior hypogastric plexus is
clamped, divided, and ligated. When we cut the uterine
On the same level of the hypogastric nerve, the branch of the pelvic nerves, there is a feeling resembling a
bladder branch from the inferior hypogastric plexus can stretched string breaking with a snap (Figure 11A). After
be separated from the blood vessels of the paracolpium. the division of the uterine branch, the hypogastric nerve,
Then Pean’s forceps is insinuated from the v-shaped the pelvic splanchnic nerve and the bladder branch of
depression created between the bladder branch and the the inferior hypogastric plexus forms the T-shaped nerve
blood vessels of the paracolpium into the connective plane. The remaining uterosacral ligament residing
tissue between the pelvic nerve plane and the cervix/ between the uterus and the rectum is divided (Figure
upper vagina at the level a little bit ventral side of the 11B). Then, the connective tissue between the lower
hypogastric nerve and a little bit dorsal side of the cut uterus/vagina and the rectum is appreciated. This is the
end of the deep uterine vein (Figure 10B). rectovaginal ligament (Figure 11B).

Figure 11. (A). Illustrating the figure of the division of the only uterine branch and the remaining uterosacral ligament. The cross-shaped
inferior hypogastric plexus turned into the T-shaped one. (B). Division of the remaining the uterosacral ligament reveals the rectovaginal
ligament.