Long Kocher forceps are placed close to the bilateral uterine body including the round ovarian ligaments as well as the fallopian tubes. The Kocher forceps are tied by a ribbon to use as a uterine retractor.
6.1.5 Ligation and Division of the Round Ligament (Figure 6.2)
The uterus is drawn cranially left, then the right round ligament becomes tense. The ligament is picked up and two ligatures, one to the uterine side and the other to the inguinal side, are placed on the round ligament through the broad ligament. The round ligament is divided between the two ligatures. Then an incision to the anterior peritoneal layer of the broad ligament is made toward the urinary bladder and cranially toward the common iliac artery to expose the loose connective tissue in the broad ligament (the retroperitoneal connective tissue).
6.1.6 Ligation and Division of the Suspensory Ligament of the Ovary (Ovarian Vessels) (Figure 6.3)
With the uterus held over to the left side, long Kocher forceps are already placed to clamp the uterine side of the ovarian ligament and fallopian tube. The suspensory ligament of the ovary (ovarian vessels) is isolated, doubly ligated, and divided. (For the preservation of the ovary and the fallopian tube, ovarian side of the ovarian ligament and fallopian tube is ligated, then dissected between the long Kocher forceps and the ligature.)
Usually, in the connective tissue of the dorsal side of the cut-end of the suspensory ligament of the ovary, a long tubular structure can be appreciated running toward the urinary bladder. Tapping the tubular structure stimulates a vermiculation movement. This is a characteristic feature of the ureter. Manually, firmly press the tubular structure between the thumb and middle finger, which should lead to the tubular structure slipping from your fingers with a “snapping sensation.” The snapping sensation is characteristics of the ureter.
The ureter running along the posterior peritoneal layer of the broad ligament is separated from the connective tissue of the retroperitoneal side of the peritoneum. The ureter is easier to isolate from the surrounding connective tissue, when approached as cranially at the level of the common iliac artery and caudally at the level where the ureter crosses the uterine artery.
6.1.9 Application of a Vessel Tape for a Marker of the Ureter (Figure 6.6)
A vessel tape is applied to act as a marker of the isolated ureter. It is very important to maintain the ureter with a marker during a radical hysterectomy. There are many opportunities to divide or damage the ureter as a result of a careless mistake during surgery. The marker of the vessel tape can help to avoid injuries to the ureter.
6.1.10 Tentative Development of the Pararectal Space (Figure 6.7)
Between the posterior peritoneal layer and internal iliac vein/artery, the retroperitoneal connective tissue is dissected. This allows the loose connective tissue to be easily separated toward the pelvic floor along the pelvis axis between the rectum and the internal iliac artery/vein. This is the loose connective tissue of the pararectal space (Latzko’s pararectal space).
6.1.11 Definition of the Pararectal Space (Figures 6.8 and 6.9)
The pararectal space is a space surrounded by rectal sidewall (uterine side), internal iliac blood vessels (pelvic sidewall), sacral bone (cranial side), and blood vessels and connective tissue of cardinal ligament (inguinal side). The pararectal space is filled with the loose connective tissue to the base of the pelvis. The development of the pararectal space can be undertaken by inserting fingers into the loose connective tissue between the rectum and the internal iliac artery/vein. The direction of insertion is toward the pelvic axis. Separation of the connective tissue between the internal iliac artery and the ureter reveals a space called as Latzko’s pararectal space.
In contrast, Okabayashi opened the pararectal space by the division of the uterosacral ligament and usually divided the hypogastric nerve. Therefore, Okabayashi’s pararectal space is developed just close to the rectal sidewall retracting the isolated ureter to the pelvic sidewall (Figure 6.9a, b). In order to increase the mobility of the uterus, Okabayashi preferred to open the space from the uterosacral ligament. Between Latzko’s and Okabayashi’s pararectal space, the hypogastric nerve is appreciated parallel to the ureter as shown in Figure 6.8b. In order to extend Okabayashi’s pararectal space toward Latzko’s pararectal space, it is necessary to divide the hypogastric nerve, which in turn increases the mobility of the uterus.
6.1.12 The Ureter and the Hypogastric Nerve Are on the Same Connective Tissue Plane (Figure 6.10)
As shown in the photos during surgery (Figure 6.10a, b), if the two spaces are developed separately, the connective tissue plane containing the ureter is created between Okabayashi’s pararectal space and Latzko’s pararectal space. The hypogastric nerve runs at a level 2–4 cm dorsal to the ureter in the same connective tissue plane. Usually, the ureter is already isolated from the connective tissue plane. The division of the connective tissue plane with the hypogastric nerve can expand Okabayashi’s pararectal space to reach Latzko’s pararectal space. The expanded pararectal space is very wide and deep. When performing nerve-sparing radical hysterectomy, the development of Latzko’s pararectal space is enough and development of the Okabayashi’s pararectal space is not required.
6.1.13 Division of the Peritoneum at Pouch of Douglas (Figure 6.11)
The uterus is drawn toward the pubic arch and the rectum with its peritoneal surface is stretched with the hand toward the cranial side. The peritoneum between the uterus and the rectum is lifted from the base of the Pouch of Douglas. The incision is made on the elevated peritoneum and extended with scissors across the dorsal side (back) of the cervix. This step connects the retroperitoneal spaces of the broad ligament on both sides.
6.1.14 Separation of the Peritoneum of the Vesicouterine Pouch (Figure 6.12)
The peritoneum is divided across the ventral side of the cervix, just 1–2 cm below the vesicouterine fold where scissors can insinuate and divide the peritoneum easily without any damage to the urinary bladder.
Major lymph nodes in the pelvic cavity are illustrated in the Figure 6.13. We usually start the dissection of lymph nodes from the supra-inguinal area and finish cranially by the common iliac area. If we find positive nodes in the pelvic lymph nodes, we undertake paraaortic lymphadenectomy above the bifurcation of the aorta either till the level of the inferior mesenteric artery or till the level of the renal vein.
6.2.2 Exposure of the Adipose Tissue in the Supra-Inguinal Area (Figure 6.14)
The adipose tissues are distributed in the retroperitoneal space of the pelvis on the external iliac/internal iliac/common iliac vessels as shown in Figure 6.14a. Including the incised abdominal wall and the cut-end of the round ligament, a retractor is applied to the abdominal wall on the inguinal side. Then, the retractor is pulled caudally, to expose the adipose tissue of the supra-inguinal area. Figure 6.14b shows a cross-sectional view of the retroperitoneal structures in the pelvis at the level of a two-directional arrow drawn in the Figure 6.14b. A dotted arrow line in Figure 6.14b shows the separation point of connective tissue from the iliopsoas muscle. In the following illustrations of cross-sectional view of lymphadenectomy, the dotted arrow line indicates the separation line of the connective tissue from muscle, blood vessels, or nerve.
6.2.3 Exposure of the Iliopsoas Muscle (Figure 6.15)
By retracting the incised abdominal wall laterally from the supra-inguinal region to the region of the common iliac artery, the ventral side of the iliopsoas muscle is revealed. The connective tissue with adipose tissue is dissected from the surface of the iliopsoas muscle toward the ventral surface of the external iliac artery (Figure 6.15a). The genitofemoral nerve runs parallel to the external iliac artery. Usually, the genitofemoral nerve is preserved. A dotted arrow line in Figure 6.15b indicates the direction of separation of the adipose tissue on the external iliac artery.
6.2.4 Separation of the External Supra-Inguinal Nodes from the Ventral Surface of the External Iliac Artery (Figure 6.16)
Retraction of the abdominal wall of the supra-inguinal area distally (arrow in Figure 6.16a) exposes the adipose tissue of the supra-inguinal region. Picking up the adipose tissue on the external iliac artery, the adipose tissue including supra-inguinal node is separated from the ventral surface of the external iliac artery. In the supra-inguinal region, usually the deep circumflex iliac vein runs across the external iliac artery. Avoiding a deep circumflex iliac vein, the adipose tissue with lymph nodes is dissected up from the ventral surface of the external iliac artery. A dotted arrow line in Figure 6.16b indicates the direction of separation that reaches to the ventral surface of the external iliac vein. Paying attention to the deep circumflex iliac vein, the adipose tissues with the external supra-inguinal nodes are removed.
6.2.5 Tentative Development of the Paravesical Space (Figure 6.17)
By the separation of the connective tissue between the obliterated umbilical artery and the external iliac vein at a point 2–3 cm cranial to the pubic bone, the cobweb-like loose connective tissue becomes visible. This is the entrance of the paravesical space. The paravesical space is surrounded by the obliterated umbilical artery (urinary bladder side), rectal/vaginal wall (rectal side), external iliac vein (inguinal side), public bone (caudal side), the connective tissue of the cardinal ligament (cranial side), and pelvic floor (dorsal side). In the base of the pelvis, a yellow-white string running from the foramen obturatum is appreciated. This is the obturator nerve. The obturator nerve can be traced along the dorsal side of external iliac vein by the lateral side of the common iliac vein.
6.2.6 Separation of the Connective Tissue Between the External Iliac Artery and Iliopsoas Muscle (Figure 6.18)
The connective tissue surrounding the external iliac artery is separated by insertion of a small retractor and medial traction of the external iliac artery as shown in Figure 6.18. Giving tension to the connective tissue between the external iliac artery and iliopsoas muscle, the loose connective tissue sheath on the surface of the external iliac artery is dissected. This procedure opens the space between the iliopsoas muscle and external iliac vessels. It is possible to continue the dissection along the medial surface of the iliopsoas muscle deep into the obturator fossa.
6.2.7 Separation of the Uterine Side Connective Tissue of the External Iliac Artery and Vein (Figure 6.19)
The dissection proceeds toward the medial side of the external iliac artery and continues to the sheath of the medial side of the external iliac vein.
6.2.8 Lymphadenectomy of the External Iliac Nodes of the Uterine Side (Figure 6.20)
Picking up the adipose tissue on the medial side, the external iliac lymph nodes are dissected from the external iliac artery and vein. The direction of the separation is illustrated using a dotted arrow line in Figure 6.20b.
6.2.9 Separation of the Connective Tissue Between the Iliopsoas Muscle and the External Iliac Vessels Toward the Pelvic Floor (Figure 6.21)
The ventral side of the adipose tissue on the iliopsoas muscle is already removed. The connective tissue of the external iliac artery side is picked up and scissors are advanced into the connective tissue along the medial side of the iliopsoas muscle (Figure 6.21a). The scissors are advanced dorsally into the obturator fossa. Moreover, the dissection should be extended deep enough to reach the base of the pelvic wall as shown in Figure 6.21b using a dotted arrow line.
6.2.10 Dissection of the External Iliac Nodes (Figure 6.22)
Drawing the external iliac artery medially by a small retractor, the loose connective tissue sheath on the external iliac vein is separated toward the dorsal surface of the external iliac vein (Figure 6.22a). During this step, the connective tissue sheath with adipose tissue including the external iliac lymph nodes is separated from the external iliac vein (Figure 6.22b). The separated adipose tissues with lymph nodes are reflected medially to the obturator fossa or can be dissected at this point.
6.2.11 Separation of the Connective Tissue on the Internal Iliac Artery (Figure 6.23)
The same kind of dissection is extended to both cranial side and caudal side of the external iliac vein. The adipose tissues with external iliac lymph nodes are separated from the external iliac vein and are collected in the obturator fossa (Figure 6.23a). Once the common iliac artery is identified, the internal iliac artery is found medially and the adipose and connective tissues are separated from the ventral side of the internal iliac artery (Figure 6.23b). The uterine artery and the obturator arteries often branch from the internal iliac artery. In order to avoid injuries to these arteries, it is better to start dissection from the ventral surface of the internal iliac artery.
6.2.12 Confirmation of the Obturator Nerve in the Obturator Fossa (Figure 6.24)
In the dorsal level of the external iliac vein, we usually appreciate a yellow-white solid string running in the obturator fossa. This is the obturator nerve. The obturator nerve becomes a landmark of the obturator fossa (Figure 6.24a). As shown in Figure 6.24b, the connective tissue with lymph nodes is separated toward the obturator nerve.
6.2.13 Lymphadenectomy of the Obturator Fossa  (Figure 6.25)
Using a small retractor to lift up both the external iliac artery and vein at the pelvic wall side opens the space of the obturator fossa as widely as possible. Picking up the adipose tissues of the dorsal side of external iliac vein, the connective/adipose tissues surrounding the obturator nerve are separated. The obturator nerve is easily stripped from the adipose tissues (Figure 6.25a). It is better to trace the obturator nerve from the foot/caudal side (obturator canal) to the cranial side (between the common iliac vein and iliopsoas muscle). In the dorsal side of the obturator nerve, the obturator artery and vein are usually running parallel to the obturator nerve (Figure 6.25b). In order to avoid unnecessary hemorrhage, attention should be paid to these vessels.
6.2.14 Lymphadenectomy of the Obturator Fossa  (Figure 6.26)
In the inguinal side of the external iliac vein, the internal supra-inguinal node is residing between the accessory obturator vein and iliopsoas muscle/pubic bone. From the foot side, the lymph node is separated and passed to the dorsal side of the accessory obturator vein. If this step is difficult, the accessory obturator vein can be divided and ligated. At this stage, the adipose tissues with lymph nodes on the side of the iliopsoas muscle can be separated from both the external iliac artery and vein.
6.2.15 Lymphadenectomy of the Obturator Fossa  (Figure 6.27)
After the separation of the internal supra-inguinal node, the lymph nodes of the external iliac artery/vein are passed into the obturator fossa. Lifting up the passed internal supra-inguinal node, the adipose tissues with lymph nodes are separated from the obturator nerve. The denuded obturator nerve can be traced cranially along the external iliac vessels to the dorsal space between the iliopsoas muscle and the common iliac vessels.