**8.5 Disconnection of lower connective-vascular pedicle**

The lower pedicle is represented by the uterosacral ligament posteriorly and the vesicouterine ligament anteriorly. For the disconnection of the inferior pedicle, it is not mandatory to open the rectouterine pouch, and the maneuver can be done extra-peritoneally.

The bladder is removed cranially with a Briesky-Navratil retractor, placing the two vesical pillars under tension, and the rectum is depressed with a posterior Sims retractor (**Figures 15** and **16**).

Using a Wertheim clamp, one of the uterosacral ligaments and the homologous bladder pillar are loaded together, after which, the pedicle is cut and ligated. The maneuver is repeated on the opposite side. In many situations, after cutting the pedicle, the pouch of Douglas opens spontaneously near the uterine edge.

#### **Figure 15.**

*Right lower pedicle. A dotted line separates the bladder pillar (blue arrow) from the uterosacral ligament (blue light arrow). Clamping the inferior part of the bladder pillar and uterosacral ligament together form the right lower pedicle.*

**Figure 16.** *A. Right lower pedicle secured by Vicryl 2/0. B. the left lower pedicle is clamped prepared to cut.*

#### **Figure 17.**

*Right middle pedicle formed by cardinal ligament and uterine artery and veins clamped and cut. Left middle pedicle clamped. Arrow mark the uterine artery. In our technique, the pediculisation of uterine vessels is not useful as long as the clamping of the pedicle is done strictly parallel to the uterine side. The risk to the ureter's damage is reduced if the lower pedicle is previously sectioned. (see chapter 2).*
