American Journal of Obstetrics and Gynecology (2005) 193, 7–15

www.ajog.org

EDITORS’ CHOICE

Discrepancies between classic anatomy and modern

gynecologic surgery on pelvic connective tissue
structure: Harmonization of those concepts by
collaborative cadaver dissection
Yoshihiko Yabuki, MD, DMSc,a,* Hiromasa Sasaki, MD, DMSc,b
Noboru Hatakeyama, MD, DMSc,c Gen Murakami, MD, DMScd

Department of Obstetrics and Gynecology, Hokuriku Central Hospital, Oyabe, Japana; Department of Obstetrics
and Gynecology, Ishikawa Prefectural Central Hospital, Kanazawa, Japanb; Department of Anesthesiology,
Toyama Medical and Pharmaceutical University, Toyama, Japanc; and Department of Anatomy, Sapporo
Medical University School of Medicine, Sapporo, Japand

Received for publication September 14, 2004; revised January 27, 2005; accepted February 22, 2005

KEY WORDS Objective: The purpose of this study was to solve a disagreement regarding the anatomy of the
Mackenrodt and pelvic connective tissue in 19th and 20th century, and to establish new surgical anatomy.
cardinal ligaments Study design: The study involved the dissection 26 female cadavers. The ligamentous structure of
Pelvic connective the pelvis was examined by developing the paravesical and pararectal spaces, using our standard
tissue procedure of radical hysterectomy.
Paravesical and Results: The lateral ligamentous structure of the pelvis was a plate complex, which consisted of
pararectal spaces the vesicohypogastric fascia, the transverse cervical ligament, and lateral ligament of the rectum.
Pelvic autonomic The 3-dimensional relationship of this complex and the pelvic organs was sagittaly perpendicular.
nerves The pelvic connective tissue was classified into 2 systems, musculofascial and mesentery-like
Radical hysterectomy structures.
Conclusion: The authors examined the discrepancies in 19th century anatomy for the pelvic
connective tissue that is widely accepted in today’s medical field, therewith proposing a new
surgical anatomy for this structure.
Ó 2005 Mosby, Inc. All rights reserved.

The condensation in the base of the broad ligament

* Reprint requests: Yoshihiko Yabuki, MD, DMSc, Department of
Obstetrics and Gynecology, Hokuriku Central Hospital, 123 Nodera,
Oyabe, Toyama 932-8503, Japan.
E-mail: hirosasa@coral.plala.or.jp
was first depicted by Savage.1 Later, it was described as
the cardinal ligament by Kocks,2 and as the ligamentum
transversale colli by Mackenrodt.3 The lateral parame-
trium and paracolpium, known as the Mackenrodt
ligament,3,4 has been described as an anatomic structure
in which the transverse cervical ligament connects the
short fibrous bundle in an L-like fashion at the level of

0002-9378/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved.
doi:10.1016/j.ajog.2005.02.108
8 Yabuki et al
the ischial spine. Incidentally, the transverse cervical
ligament was referred to by Mackenrodt as a stout
bundle of fibers emanating from the iliac fossa and
inserting into the sidewall of the cervix. Further, the
short fibrous bundle (superior fascia of the levator ani
muscle) has also been described as a kind of inferior
continuation of the transverse cervical ligament that
arises from the tendinous arc of the levator ani muscle
and attaches to the side of the connective tissue sheath
surrounding the vagina.
Surgery for cervical cancer during the 20th century
was characterized by an extensive dissection of the
connective tissue bundle, or the so-called cardinal liga-
ment, which appeared following development of the
paravesical and pararectal spaces. Latzko-Schiffmann5
incised the short fibrous bundle to develop the caudal
chamber of the pararectal space,6,7 and dissected the
ligamentous structure that emerged between the caudal
and cranial chambers of the pararectal space.6,7 In
addition, Okabayashi performed a more extensive dis-
section of the vesicouterine ligament by dividing it into
superficial and deep layers following excavation of the
paravaginal space.8,9 Their operative techniques, which
became mainstream during the 20th century, obviously
contained a component that departed from the concept
of 19th century anatomy. However, during this time,
there was no discussion of any new anatomic concept
that accommodated these new operative techniques.10-12
In addition, a large discrepancy is apparent between
systemic anatomy and clinical anatomy. In Nomina
Anatomica, only the pelvic connective tissue bundle
covered with the peritoneum is given any terminology,
eg, Ligamentum terues uterii (Processus vaginalis peri-
tonei), Lig latum uteri, Lig suspensorium ovarii, and Plica
rectouterina. There is, however, no terminology what-
soever for spaces and the connective tissue bundles
exposed by surgical maneuvers. Consequently, surgeons
have developed different concepts and nomenclature of
their own. A precise understanding of surgical morphol-
ogy is required in order to solve this problem.
In this paper, we attempted to establish a new pelvic
connective tissue anatomy by cadaver dissection in view
of our practical surgical theory.13-16
Material and methods
Study subjects
Topographic dissection of the pelvic connective tissue
was carried out on 17 fixed Japanese female cadavers,
and 9 fresh Japanese female cadavers aged 76 to 90 years.
Procedure
The following intrapelvic dissection of tissue was based
on previous knowledge from the surgical morphology of
93 patients who had undergone radical hysterectomy for
cervical cancer.13-16 As carried out in current radical
hysterectomy, the following 6 spaces were developed16:
the paravesical space, paravaginal space, caudal and
cranial chambers of the pararectal space,6,7 vesicouter-
ine space, and rectouterine space. We investigated the
6 connective tissue bands16 that appeared between
the spaces, namely, the superficial and deep layers of the
vesicouterine ligament,9 transverse cervical ligament of
Mackenrodt, mesoureter, and the sacrouterine/rectou-
terine ligaments. These maneuvers were followed by
simultaneous observation of the fasciae, blood vessels,
and nerves, which were dissected while preserving the
anatomic relationship between the fascial structure and
the pelvic viscera.
Terminology
In this article, we defined anatomy as practical anatomy
or surgical morphology the same as that referred to by
surgeons such as Mackenrodt, Peham and Amreich; for
example, a term ligament does not denote skeletal liga-
ment. The parametrium (Virchow, 1864), cardinal liga-
ment (Kocks2), transverse cervical ligament (Mackenrodt3),
retinaculum uteri (Martin17), or the web (Meigs18) is the
bundle that connects the pelvic brim and uterine cervix,
and we generically defined this bundle as the lateral
uterine ligament. The neurovascular stalk (Pern-
kopf19,20), hypogastric sheath (Uhlenhuth21), or pelvic
connective tissue ground bundle (Peham and Amreich6,7)
is the bundle that connects the lateral border of the pelvic
organs to the pelvic brim, and we generically defined this
bundle as the lateral ligament of the pelvis. The short
fibrous bundle of Mackenrodt (kurzere Faserbundel3)
denotes the superior fascia of the levator ani muscle or a
part of the superior fascia of the pelvic diaphragm. The
cranial and caudal chambers of the pararectal space6,7 are
2 chambers Peham and Amreich divided. The deep layer
of the vesicouterine ligament8,9: Okabayashi divided this
ligament into superficial and deep layers that roughly
correspond to the sagittal bladder septum (Pfeiler,6 pillar)
and ascending bladder septum of Peham and Amreich.6,7
The paravaginal space9,16 is a space that was created on
the lateral aspect of the uterine cervix by Okabayashi to
separate the deep layer of the vesicouterine ligament. The
vesicohypogastric fascia or lamina ligamenti umbilica-
lis6,7 is a bundle that connects the lateral umbilical
ligament and lateral border of the bladder, or the para-
cysticum. A pseudonym for this is the vesicoumbilical
stalk (Pernkopf).19,20 The lateral ligament of the rectum is
referred to as the bundle that connects the pelvic side wall
and the lateral aspect of the rectum, or the lateral
paraproctum.22,23 We defined the double-layered fascia
of the pelvic lateral ligament as the anterior fascia and the
posterior fascia, respectively. The terminology used by
Peham and Amreich was referred to from the English
translation by L. K. Ferguson.7
Yabuki et al 9

Figure 1 Vesicohypogastric fascia and Mackenrodt ligament.

Photograph showing development of the left paravesical space
followed by lifting of the uterus with forceps and upward
retraction of the lateral umbilical ligament by the use of a
thread. The vesicohypogastric fascia originating from the
lateral umbilical ligament and the transverse cervical ligament
forms a continuity. There is a hollow (arrowhead 1) between
the transverse cervical ligament and the short fibrous bundle,
leading to the caudal chamber of the pararectal space. In the
supine position, the vesicohypogastric fascia and the transverse
cervical ligament lie vertical to the bladder and uterine cervix,
and the short fibrous bundle is situated horizontally. The area
around the genital hiatus (arrowhead 2) is the true pelvic floor.
U, Uterus; B, bladder; II, internal iliac artery; Ur, ureter; LU,
lateral umbilical artery/ligament; VH, vesicohypogastric fas-
cia; CL, transverse cervical ligament; SB, short fibrous bundle;
TL, tendinous arc of levator ani muscle; TP, tendinous arc of
pelvic fascia; PS, pubic symphysis; SP, sacral promontory; BS, Figure 2 Lateral ligament of the pelvis and cranial chamber
paravesical space. of the pararectal space. This photograph shows a view of
Figure 1 from the cranial aspect, which presents the lateral
ligament of the pelvis with its anterior fascia and vessels
preserved, and only its posterior fascia excised. Also shown is
the exposed cranial chamber of the pararectal space. The
Results paravesical space is seen here filled with paper clay, showing
the border between the paravesical space and the caudal
Mackenrodt ligament and cardinal ligament chamber of the pararectal space (arrowhead). The excised
The Mackenrodt ligament was first observed following lateral ligament of the pelvis forms a plate from the lateral
umbilical ligament to the fascia of the piriformis muscle, which
the development of the paravesical and pararectal spaces
is a complex consisting of the vesicohypogastric fascia, trans-
(Figures 1 and 2). The transverse cervical ligament3,4 verse cervical ligament, and lateral ligament of the rectum. The
was shown to be a mesentery-like structure covered on visceral terminus of this complex crosses the pelvic autonomic
its anterior and posterior aspects with visceral endo- nerves. The direction of the inserted forceps indicates Oka-
pelvic fascia that was an extension of the perivascular bayashi’s space. A large opening via Latzko’s space is ‘the so-
sheath of the internal and external iliac artery/vein. In called pararectal space.’ The deep uterine vein and pelvic
contrast to the transverse cervical ligament, the short splanchnic nerve (S3) are shown here being suspended by a
fibrous bundle3,4 proved to be a part of the superior black thread. An asterisk indicates the paper clay filling of the
fascia of the pelvic diaphragm, or the superior fascia of paravesical space. II, Internal iliac artery; CPG, common
the levator ani muscle, which was stretched between the trunk of internal pudendal and inferior gluteal artery; LU,
tendinous arc of the levator ani muscle and the tendi- lateral umbilical ligament; SV, superior vesical artery; UA,
uterine artery; DV, deep uterine vein; MV, middle vesical
nous arc of the pelvic fascia (white line). In other words,
vessels; MR, middle rectal vessels; SN, pelvic splanchnic nerve;
the short fibrous bundle united, via the tendinous arc of HN, hypogastric nerve; NP, pelvic nerve plexus; Ur, ureter; D,
the pelvic fascia, or indirectly, with the rectovaginal pouch of Douglas; U, uterus; VF, vesicohypogastric fascia;
ligament (deszendierende Rektumpfeiler,6 descending SU, sacrouterine ligament.
rectal septum or pillar), lateral aspect of the vagina,
and pubovesical ligament (Figures 1 and 3).
10
Figure 3 Paravesical space and cranial chamber of the
pararectal space. Shown here is the right side of the pelvic
cavity, which has been divided by the lateral ligament of the
pelvis, which indicates the so-called surgical pelvic floor. In the
paravesical space (right photograph), the short fibrous bundle
is separated from the tendinous arc of the levator ani muscle
with a part of the muscle exposed (large arrowhead). On the
cranial aspect there is the cranial chamber of the pararectal
space opened via Latzko’s space. The pelvic splanchnic nerves
(S3-4) and the hypogastric nerve then form a pelvic nerve
plexus, which, after crossing the lateral ligament of the pelvis,
radiates to the vesical branch facing the paravesical space
(small arrowhead). SB, Short fibrous bundle; LM, levator ani
muscle; ML, Mackenrodt ligament; Ur, ureter; SN, pelvic
splanchnic nerve; NP, pelvic nerve plexus; HN, hypogastric
nerve; U, uterus; B, bladder; R, rectum; A, aorta.
There was found to be a hollow buried in abundant
adipose tissue at the junction of the short fibrous bundle,
and the anterior fascia of the transverse cervical ligament
communicating to the caudal, or anterior, chamber of the
pararectal space (Figure 1, arrowhead 1). These findings
negated the existence of any structural continuity of the
transverse cervical ligament and the short fibrous bundle.
The lateral ligament of the pelvis was observed as 1
continuous plate from the lateral umbilical ligament to
the surface of the sacrum (Figures 2 and 3). This plate was
then dissected in the area between the space created by a
combination of the paravesical space and the caudal
chamber of the pararectal space, and the cranial chamber
of the pararectal space. Further, the caudal chamber of
the pararectal space was exposed by incision of the short
fibrous bundle, and its cranial chamber by separation of
the posterior fascia of the lateral ligament of the pelvis
(Figures 2 and 3). The exposed vessels within the plate, in
descending order, were from the ventral to the dorsal
aspect, the lateral umbilical artery/ligament, superior
vesical artery, uterine artery, deep uterine vein, middle
vesical vessels, and middle rectal vessels (Figure 2).
A septum was developed between the cranial and
caudal chambers of the pararectal space. This septum
was a continuation of the transverse cervical ligament,
Yabuki et al
Figure 4 Okabayashi’s space for entry into the cranial
chamber of the pararectal space: findings of the right pelvic
cavity. Photograph shows the visceral endopelvic fascia that
lines the broad ligament being separated from the serosa of the
broad ligament, together with the ureter and hypogastric
nerves. A further separation in a dorsal direction results in
reaching the cranial chamber of the pararectal space (Figure 6)
(large arrowhead). The membranous tissue in the photograph
shows the mesoureter formed by a union of the visceral
endopelvic fascia of the broad ligament, and the hypogastric
sheath separated from the internal iliac vessels. The ureter and
hypogastric nerves descend within it (small arrowhead). M,
Mesoureter; Ur, ureter; HN, hypogastric nerves; IF, infundib-
ulopelvic ligament; BL, posterior leaf of broad ligament; OS,
Okabayashi’s space; U, uterus; R, rectum; LS, Latzko’s space;
BS, paravesical space; EI, external iliac artery; II, internal iliac
artery.
within which ran the middle rectal artery/vein piercing
the pelvic nerve plexus, which proved to be the lateral
ligament of the rectum.22,23 As for the transverse cervi-
cal ligament, it was continuous with the vesicohypogas-
tric fascia, which did not correspond with the accepted
opinion of it being the condensation in the base of the
broad ligament (Figure 1).
In summary, the lateral ligament of the pelvis was
a complex in which the lateral paracysticum, or the
vesicohypogastric fascia,5,6 lateral parametrium, or the
transverse cervical ligament3 and lateral paraproctium
or the lateral ligament of the rectum22,23 lay side by side
in a ventro-dorsal direction. From these findings, it was
reasonable to conjecture that the superior part of the
transverse cervical ligament was composed of the uterine
artery, and the inferior part was composed of the deep
uterine vein or the middle vesical artery/vein. Further,
this complex proved to be in either a frontal or perpen-
dicular relationship, and not parallel to the sagittal
plane of each pelvic organ (Figures 2 and 3).
Two pelvic floors
Traditional anatomic understanding of the pelvic
floor3,23,24 is conceived as that of the pubic part of the
Yabuki et al
Figure 5 Paravaginal space and cranial chamber of the
pararectal space: findings of the right pelvic cavity. The
paravaginal space formed between the uterine cervix and
ureter and its continuing caudal chambers of the pararectal
space are developed. An asterisk indicates the peripheral
branch of the pelvic nerve plexus. The cranial space is the
cranial chamber of the pararectal space, developed by entering
Okabayashi’s space. The fascia of the transverse cervical
ligament has already been reflected in a cranio-caudal direc-
tion, with the photograph showing the parametrium lacking
visceral fascia. OS-Cr, Okabayashi’s space and cranial cham-
ber of the pararectal space; VS-Ca, paravaginal space and
caudal chamber of the pararectal space; PM, parametrium; Ur,
ureter; U, uterus; B, bladder; AV, superficial layer of the
vesicouterine ligament; UA, uterine artery; LS, Latzko’s space;
SP, sacral promontory; AN, pelvic autonomic nerve.
pelvic diaphragm or the pubococcygeus through which
the vagina pierces the genital hiatus (Figure 1). But the
pelvic floor5-9,11,12 in contemporary pelvic surgery is
found to be the iliac part of the pelvic diaphragm
or the iliococcygeus and the fascia of the piriformis
muscle to which the lateral ligament of the pelvis attaches
(Figure 3).
Surgically developed cavities and the
connective tissue bundle
Within the pelvic cavity there exist the paravesical and
pararectal spaces as physiologic or potential spaces. The
paravesical space takes part in micturition and forms the
parturient canal, and the pararectal space aides in
performance of defecation. We developed these 2 spaces
in our radical hysterectomy, and severed the connective
tissue bundle that emerged between these spaces.
There were found to be 2 routes to enable excavation
of the cranial chamber of the pararectal space. One
route was constructed by separation of the visceral
pelvic fascia that lines the broad ligament from the
serous membrane (Figures 2, 4, and 5).8,9 We named this
space Okabayashi’s space, created for the development
of the visceral attachment of the cardinal ligament
(Figure 4).16 The other route was by entering a space
11
Figure 6 Separation of the caudal reflection of the lateral
ligament of the pelvis: right pelvic cavity seen from the pubic
aspect. Entrance into the paravaginal space and caudal cham-
ber of the pararectal space (Figure 4) is made by inserting
scissors between the uterine cervix and ureter. The tip of the
scissors pierces the tendinous arc of the pelvic fascia, protrud-
ing into the paravesical space. The superior aspect of the
caudal reflection is the deep layer of the vesicouterine ligament,
and the inferior aspect being the bundle that covers the
paracolpium. In addition, with excavation of the paravesical
and pararectal spaces, we can conjecture that there is a change
in direction of the lateral ligament of the pelvis from
ventrocranial-to-dorsocaudal to lateral-to-medial during ob-
servation of the hypogastric and pelvic visceral nerves. CaR,
Caudal reflection of the lateral ligament of the pelvis; UA,
uterine artery; DV, deep uterine vein; U, uterus; Ur, ureter;
HN, hypogastric nerves; SN, pelvic splanchnic nerve; SB, short
fibrous bundle; R, rectum; B, bladder.
following separation of the posterior fascia of the
transverse cervical ligament and the internal iliac vessel
sheath from the main body.6,7 This space for the
development of the origin of the cardinal ligament was
so named Latzko’s space (Figures 2 and 3).16
There were also 2 routes by which to develop the
caudal chamber of the pararectal space. One was the
route invented by Latzko, through which we entered via
the paravesical space (Figures 1 and 3).6,7,16 The other
was the route by which we entered the space following
separation of the uterine cervix and the ureter (Figures
5–7).8,9,16 This space was named Okabayashi’s para-
vaginal space.16
As a result, the connective tissue bundle that emerged
between the paravesical space and Latzko’s space was
found to be a fasciovascular complex that lacked pos-
terior fascia, as shown in Figure 2, and we called it the
cardinal ligament. The connective tissue bundle that
emerges between Okabayashi’s and Latzko’s spaces is
the so-called mesoureter (or Ureterblatt or ureteral
leaf25) (Figures 4 and 7). This mesoureter is the one in
which 2 visceral pelvic fasciae are fused, and between
which the ureter, hypogastric nerve, and ureteral branch
12
Figure 7 Schematic illustration of the pelvic connective
tissue. The pelvic connective tissue is classified into a muscu-
lofascial bundle, or the suspensory system (X) and a fascio-
vascular bundle or the supporting system (Y). The supporting
system is further divided into a cranially reflected bundle (Y-1)
and a caudally reflected bundle (Y-2). The ureter and pelvic
autonomic nerves pass within this suspensory system. U,
Uterus; B, bladder; R, rectum; Ur, ureter; SN, pelvic splanch-
nic nerve; HN, hypogastric nerve; VN, vesical nerve branch;
SB, short fibrous bundle; LS, Latzko’s space; BS, paravesical
space; VF, vesicouterine space; RF, rectouterine space; X,
pubovesical ligament, superficial layer of the vesicouterine
ligament, rectouterine ligament, and rectococcygeal ligament;
Y-1, mesoureter, etc; Y-2, deep layer of the vesicouterine
ligament, etc.
of the internal iliac vessels pass (Figure 4). The connec-
tive tissue bundle that emerges between the paravesical
space and Okabayashi’s paravaginal space is the deep
layer of the vesicouterine ligament advocated by Oka-
bayashi (Figures 3, 6, and 7).8,9,20 This deep layer of the
vesicouterine ligament was found to be a neurovascular
bundle that connected the bladder and the lateral
ligament of the pelvis.14,15
The structure of the pelvic connective tissue
The pelvic connective tissue was classified into 2, the
suspensory system and the supporting system (Figure
7).16 The suspensory system was found to be a group of
true ligaments that had a musculofascial consistency,
Yabuki et al
Figure 8 Fascial capsule of the uterus and uterine vessels: the
frontal section seen through the uterine cervix and the anterior
margin of the uterine body. A group of small arrowheads show
merging of the fascial capsule of the uterus covering the uterine
artery/vein (AB, VB) into the fascial capsule of the rectum via
the sacrouterine ligament (SU). Also observed are the middle
rectal vessels that pierce the pelvic nerve plexus passing within
the paraproctum (MR). The surrounding tissue that covers the
visceral fascia is probably the longitudinal section of the
supporting system. AB, Branches of uterine artery; VB,
branches of uterine vein; SU, sacrouterine ligament; MR,
middle rectal vessels; NP, pelvic nerve plexus; Ur, ureter; UB,
uterine body; UC, uterine cervix; R, rectum.
and connected the fascial capsules of the pelvic viscera in
a chain-like fashion from the pubis to the sacrum/
coccyx. It consisted of the pubovesical ligament, super-
ficial layer of the vesicouterine ligament, rectouterine
or sacrouterine ligament, and rectococcygeal ligament,
which suspended and anchored the pelvic organs to the
pubis, sacrum/coccyx (Figure 8).
The supporting system was found to be a more specif-
ically conceptualized entity of the lateral ligament of the
pelvis. That is, the supporting system was a neurovascular
fascial complex consisting of the vesicohypogastric fascia,
transverse cervical ligament, and lateral ligament of the
pelvis (Figures 1 and 2). This supporting system crossed in
front, or on the lateral aspect, of the ureter and pelvic
nerve plexus and, consequently, divided into 3, namely,
the core, cranial reflection, and caudal reflection. The core
was found to be a stalk consisting of blood vessels, lymph
vessels, and nerves, and with no termed fascia. This
areolar tissue pierced through the proper fascia and
fanned out underneath it.
The cranial reflection was found to be the mesoureter,
or posterior fascia, of the supporting system reflected in
a cranial direction accompanied with a small part of the
areolar tissue. The caudal reflection was found to be a
neurovascular bundle that included the deep layer of the
vesicouterine ligament, or the anterior fascia, of the
supporting system that reflected in a caudal direction
accompanied with a small part of the areolar tissue.
Yabuki et al
Table Dease pelvic connective tissue of Peham and Amreich
Mackenrodt ligament Bladder septum
Vaginal-cervical septum
Rectal septum
These tissues enveloped the suspensory system, thereby
pulling and anchoring the pelvic organs en masse.
Pelvic autonomic nerves
The pelvic nerve plexus positioned itself a little dorsal or
deeper to the deep uterine vein, with the middle rectal
vessels piercing almost its center (Figures 3 and 8). The
hypogastric nerve, pelvic splanchnic nerves, pelvic nerve
plexus, and vesical nerve branch created a potential
plane along the reflected parts of the supporting system,
which, in turn, crossed the potential plane formed by the
vessels of the stem (Figures 2 and 3). As for the passage
of the vesical nerve, please refer to Yabuki et al.14
Comment
Gray’s anatomy defines Mackenrodt ligament as ‘‘the
fascia over the ventral and dorsal walls of the vagina and
cervix come together at the lateral border of these organs,
and the resulting sheet extends across the pelvic floor as a
deeper continuation of the broad ligament.’’24 Peham and
Amreich,6 having analyzed the relationship between the
adjacent organs and connective tissue bands, classified the
Mackenrodt ligament into bladder, vaginal-cervical, and
rectal septa (Table). These 2 concepts show that the
vesicohypogastric fascia, transverse cervical ligament,
and lateral ligament of the rectum are independent
bundles that are parallel to the longitudinal axis of each
corresponding organ, and do not cross each other. How-
ever, this theory cannot explain contemporary surgical
dissection of the cardinal ligament, in which the bottom of
the Mackenrodt ligament is separated from the coccygeus
and piriformis fasciae.
In order to answer this question we proposed that the
vesicohypogastric fascia, transverse cervical ligament,
and lateral ligament of the rectum form 1 plate. How-
ever, this proposition alone was insufficient to fully
explain contemporary radical hysterectomy. Accord-
ingly, we meticulously carried out and investigated
Okabayashi and Latzko’s surgery, and conceived a
structure of a plate that becomes divided into 3 at its
periphery. Our hypothesis is not a duplicate of Peham
and Amreich’s, but rather reference to the hypogastric
wing of Uhlenhuth,21 and the neurovascular stalk of
Pernkopf.19,20 The difference between Peham/Amreich/
Reiffenstuhl’s (who belonged to the Amreich school)25,29
and our concepts is that they classified the 3 septa of the
13
Horizontal ground bundle Frontal ground bundle
Ascending bladder septum Sagittal bladder septum
Vaginal septum Cervical septum
Descending rectal septum Sagittal rectal septum
Mackenrodt ligament into the horizontal and frontal
ground bundles, whereas our concept has nothing akin
to the horizontal ground bundle. In addition, our
structure is stacked from the top to bottom, while their
septa lay parallel to each other.
However, our concept has many common denomi-
nators with other theories. The sketches drawn by
Rieffenstuhl25,29 and us are, in appearance, very similar.
Our caudal reflection corresponded conceptually with
Okabayashi’s deep layer of the vesicouterine ligament,
together with the ascending bladder septum of Peham
and Amreich,6,7 and the inferior hypogastric wing of
Uhlenhuth.21 Further, the cranial reflection was found
to resemble both the mesoureter25 and sagittal rectal
septum.6,7 In addition, the neurovascular stalk of
Pernkopf substantiated our concept of the supporting
system. We can state confidently that our results clar-
ified the relationship between the pathway of both the
pelvic autonomic nerves and ureter and the ligaments,
and enabled the preservation of the vesical nerve branch
by selective dissection of the vesicouterine ligament.14-16
In many past studies the existence of the cardinal
ligament has come into question.26-28 Our answer to this
question is that this is caused by the lack of visceral
terminal fascia. Further, we easily lose sight, during
surgical maneuver, of the posterior fascia of the cardinal
ligament, which is an extension of the internal iliac
vessel’s sheath, as shown in Latzko’s space.
In recent years an increase in research and reports on
surgery concerning nerve-sparing radical hysterectomy
has been evident.30-33 Our surgical technique,32 and that
of others,30,31,33 aim to preserve the parasympathetic
nerve by dividing the cardinal ligament into vascular and
neural portions. However, their articles are saturated with
classic clinical anatomy. It is anatomically contradictory
to divide the continuation consisting of the transverse
cervical ligament of Mackenrodt and the paracolpium
into vascular and neural portions, which cannot explain
the exact pathway of the parasympathetic nerves. We do
not deny the existence of the accessory nerve of McCrea,34
but it is likely that most of the parasympathetic nerves
may be distributed to the bladder via the pelvic nerve
plexus. Particularly, effort on our part has been made to
establish a surgical procedure to preserve the pelvic nerve
plexus and its vesical branch.13-16
If the authors were to describe the Mackenrodt liga-
ment and the present-day cardinal ligament in one
phrase, we would say that: the lateral parametrium, or
14
Mackenrodt ligament, of the 19th century is a conception
observed from the paravesical space (Figure 1), whereas
the lateral parametrium of the 20th century, or the
present-day cardinal ligament, is a conception primarily
observed from ‘the so-called pararectal space (Figure 2).’
In other words, the former is a continuation consisting of
the transverse cervical ligament and the short fibrous
bundle, and the latter a complex consisting of the
transverse cervical ligament and the lateral ligament of
the rectum. To be precise, both of these have to be
distinguished, and even Peham and Amreich in their
surgical textbook apply to the former structure in regards
to anatomy and the latter for surgery.6 The description of
the cardinal ligament (of Mackenrodt) by Reiffenstuhl29
and Gray’s anatomy24 add to this confusion.
Many surgeons, past and present, have believed that,
because each of the lateral supports of the bladder,
uterus, and rectum is independent and parallel to each
other, the lateral parametrium can be separated from
the lateral paracysticum and lateral paraprocticum, the
same way as in the separation of the uterus from the
bladder and rectum. With this concept in mind, it is
reasonable to see why the lateral ligament of the rectum
in radical hysterectomy is ignored. However, massive
bleeding and/or dysfunction of the bladder and rectum
may occur because the lateral ligament of the rectum is
dissected without any reference.13-16
The advantage of our interpretation of the pelvic
connective tissue as a mass that is common to the fields
of gastroenterology, gynecology, and urology makes its
observation possible from a common viewpoint of these
3 disciplines. Specifically, we are confident to say that
our conception of the reflected part of the lateral
support systematizes the pathway for the autonomic
nerves and ureter, and makes a nerve-sparing operation
possible.13-16 If spontaneous laxity in the union between
the suspensory and supporting systems is clinically
verified, then advent of an etiology that differs from
that of the traditional theory for uterine prolapse may
emerge. Furthermore, if this new concept of the sup-
porting system is introduced to the surgical procedure
for rectal cancer,35 we can also expect a new develop-
ment for the lateral dissection of the pelvis.
This study was an attempt to establish a new surgical
anatomy of the pelvis by a collaboration of the 2
concepts developed during the past one and a half
centuries. We believe that radical hysterectomy born out
of this new concept will become one of the effective
treatment methods for cancer of the uterine cervix in the
21st century.
Acknowledgments
We are indebted to Dr Osamu Ohtani, Professor and
Chair of the Department of Anatomy, Toyama Medical
Yabuki et al
and Pharmaceutical University, and Dr Yoshiaki
Nojoh, Professor and Chair of the Department of
Anatomy, Fukui Medical University School of Medi-
cine for providing us with the opportunity to dissect
cadavers. The authors also wish to acknowledge Dr
Shimpachiro Ogiwara, Professor of Physical Therapy,
University of Kanazawa, and Mrs Sandra M. Ogiwara
in preparing this manuscript.
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