A Vascular Centered Surgical Approach to Radical Hysterectomy: Laparoscopic Anatomy of Pelvic Vascular System Revisited

Objective As a standard therapy for locally invasive cervical cancer, radical hysterectomy (RH) has been in routine medical practice for more than a century [ 1 Wertheim E. Die Erweiterte Abdominale Operation bei Carcinoma Colli Uteri (auf Grund von 500 Fallen). Urban, Berlin1911 Google Scholar ]. However, challenges still exist due to the troublesome bleeding during parametrium dissection and resection, which could increase the risk of surgical complications and may probably affect surgical outcomes ultimately [ 2 Fujii S Takakura K Matsumura N et al. Precise anatomy of the vesico-uterine ligament for radical hysterectomy. Gynecol Oncol. 2007; 104: 186-191 Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar ]. This video illustrated the three-dimensional anatomy of the pelvic vascular system with particular emphasis on “deep uterine vein” and further introduced a vascular-centered surgical approach to performing RH, which could facilitate parametrium dissection with less blood loss and obtain enough resection margins. Design A step-by-step, narrated video demonstration Setting A university hospital Interventions After systemic pelvic lymphadenectomy, ureter was then identified along the medial leaf of the broad ligament. By continuously exploring the pelvic cavity along the ureter, communicating branches of the uterine artery to the ureter, urinary bladder, corpus uteri, uterine cervix, and upper vagina were clearly identified in a cranial to caudal direction, demonstrating the arterial network surrounding the urinary system. Coagulating and cutting these blood vessels could free the ureter from retroperitoneum and subsequently excavate the ureteral tunnel easily. Next, a precise dissection of the area below the ureter revealed the whole distribution of currently named “deep uterine vein”. Originated from an internal iliac vein, it is much more like a venous confluence than an accompanying vein, with branches crossing directly into the bladder, dorsally to the rectum, and traveling caudally to the anterolateral side of the uterus and vagina in a crisscross fashion, which mandates us to describe it as pampiniform-like venous plexus instead of “deep uterine vein” due to its anatomical distribution and function. Finally, after complete exposure of venous network, enough extent of parametrium could be adequately separated and resected by accurate coagulation of blood vessels on an individualized requirement. Conclusion Recognizing the precise anatomy of pelvic vascular system, especially the entire distribution of currently named “deep uterine vein” and isolating the venous branches connecting to all three parts of parametrium, are key to the RH procedure. Careful attention to the complex vascular anatomy is critical to reducing intraoperative bleeding and avoiding complications in RH.