c. Upper Pedicle

The upper pedicle consists of *round ligaments*, *uterine tubes*, and *utero-ovarian ligaments*. The tubes and ovaries are indirectly supported by the *infundibulopelvic ligament*, which offers support to the pelvic wall. The upper

#### **Figure 4.**

*A. Lower connective-vascular pedicle (cardinal uterosacral complex -CUSC the first pedicle in vaginal hysterectomy). 1 = cervicovesical ligament, 2 = uterosacral ligaments, 3 = cardinal ligament. Redline mark where the same pedicle might secure bladder pillar, uterosacral ligaments, and cardinal ligaments. B. Lower connective pedicle at vaginal hysterectomy with distinct uterosacral ligament (USL) and cardinal ligament (CL) in the same pedicle.*

#### **Figure 5.**

*Middle pedicle. 1 = uterine artery, 2 = cardinal ligament, 3 = inferior pedicle cut, 4 = parametrial ureter. Once cut, the uterosacral ligament's traction on the cervix makes the cardinal ligament elongated and removes the ureter from the surgical field.*

pedicle, which does not have a significant supporting role, maintains the uterus in anatomical position and stands against the force that tends to push it through the pelvic opening. During the vaginal hysterectomy, the upper pedicle is the most problematic one in terms of strategy regarding the extraction of the uterus from the pelvic cavity.

The primary vascular element of the upper pedicle is the *Tubo ovarian arch*, contained in the thickness of the *mesosalpinx*. The infundibulopelvic pedicle becomes the main vascular element when an adnexectomy is an option. The resistance of the superior pedicle to traction is due to the intrinsic elasticity of the connective elements in the ligament structures and the resistance of the

leaf of broad ligaments. Chronic inflammatory processes may cause the adhesion of ovaries to the posterior leaf of broad ligament or parietal peritoneum of fossa ovaries, which leads to the fixation of the adnexa to the walls of the pelvis. Vaginal adnexectomy is difficult in these cases.
