**4. The connective-vascular pedicles of the uterus**

Vaginal hysterectomy consists of disconnection from below of all elements that maintain the uterus in anatomical position.

From the vaginal point of view, the uterus suspension-supporting system consists of three main connective-vascular pedicles; lower, middle, and upper pedicles.

like abdominal hysterectomy, where the lower pedicle is most difficult to approach, vaginal hysterectomy solves this operative step as the first maneuver of the disconnection of the uterus.

## a. Lower Pedicle

On the caudal side, the cervix and uterine isthmus provide insertion for two fibrous-connective structures: anteriorly, *the vesicouterine ligaments* (bladder pillars), and posteriorly, the *uterosacral ligaments*. In the sagittal plane, the two ligaments are located approximately at the same level. When the uterus is not prolapsed, it can be treated as a single pedicle with an anterior division and a posterior one, the superior vagina remaining anchored even after its disconnection. The natural connections of these pedicles with the superior vagina must be preserved regardless of the hysterectomy method because this is the most efficient method to prevent post-hysterectomy vaginal vault prolapse.

*The vesicouterine ligaments* join the bladder walls with the anterolateral edges of the cervix. During the vaginal hysterectomy, the bladder pillars can be visualized by cranial retraction of the bladder with a Breisky-Navratil retractor after the *cervicovesical ligament* has been sectioned and the bladder has been detached from the cervix, opening the vesicouterine space.

The juxta vesical ureter, surrounded by fatty tissue, is located in the thickness of each pillar. The *vesicouterine* ligaments have a medial and a lateral part. To be able to release the ureter, the two parts must be sectioned at the level of their cervical insertion. The vesicouterine ligaments contain the superior vascular-nervous pedicles of the urinary bladder.

The *uterosacral ligaments* are the most robust structures supporting the uterus. The confluence of the uterosacral ligaments on the uterus forms a small depression known as the *torus uterinus,* always situated at the level of uterine isthmus regardless of the length of the cervix. Torus uterinus marks the area where the visceral uterine peritoneum conjoins with the rectum at the level of the pouch of Douglas. Before the opening of the rectouterine peritoneal fold, we will see a variable amount of fatty tissue, which forms the *yellow line* that announces to the surgeon the dissection layer and the imminent appearance of the underlying rectum. *The fat belongs to the rectum and not to the vaginal wall.*

The uterosacral ligaments on the lateral sides, towards their sacral insertion, are flanked by the hypogastric nerve, which, along with the pelvic nerves, will be part of the inferior hypogastric plexus. For this reason, sectioning the uterosacral ligaments in radical vaginal hysterectomy as close as possible to the sacral insertion bears the risk of urinary disorders occurring through bladder denervation. Laterally and caudally, the uterosacral ligaments continue with the superior paracolpium, and a division of them achieves the upper level of suspension of the vagina (Delancey).

Campbell identified three distinct histologic regions of the uterosacral ligament. At the cervical attachment, the ligament was made up of carefully packed bundles of smooth muscle, abundant medium-sized and small blood vessels, and small nerve bundles. The intermediate third of the ligament was composed of predominantly connective tissue and only a few scattered smooth muscle fibers, nerve elements, and blood vessels. The sacral third was almost entirely composed of loose strands of connective tissue and intermingled fat, few vessels, nerves, and lymphatics.

The mechanical strength of the uterosacral ligaments is remarkable. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure. (Nichols) (**Figure 4**).

b. Middle Pedicle

The middle connective-vascular pedicle consists of the cardinal ligaments and a variable contingent of fibers that are part of the uterosacral ligaments. Vaginally, each cardinal ligament has a fibrous-connective segment consisting of inferior fibers of the uterosacral ligament and a cranially located vascular segment, which consists of the superior bundle of the cardinal ligament and uterine vascular pedicle. The two segments can be surgically treated as a single pedicle or as separate depending on the thickness and insertion area of the uterine edge (Shiff).

On its cranial aspect, the cardinal ligament is crossed by the ureter under the crossing-point with the uterine artery. The distance between the lateral side of the cervix and isthmus and the wall of the pelvis is approximately 4–5 cm. The ureter crosses the cardinal ligament halfway, approximately 2–2.5 cm from the cervix. The ureteral risk is reduced in vaginal hysterectomy because, once the lower pedicle is cut, the cardinal ligament is elongated, removing the ureter from the operator's field. (Kovak) (**Figure 5**).
