The patient is placed in the modified dorsal supine lithotomy position (15° Trendelenburg). The bladder is emptied with a Foley catheter. A thorough bimanual examination is always performed. The abdomen, perineum, and vagina are surgically prepared.

An abdominal incision is made in the midline and extended around the umbilicus. A Foley catheter is left in the bladder and connected to straight drainage.

The abdomen is thoroughly explored. The peritoneum between the cecum and terminal ileum is opened, the common iliac and aortic area are exposed, and any suspicious lymph nodes are removed for biopsy.

The intestine is packed off in the upper abdomen.

A large thyroid clamp is placed on the uterine fundus and used as an elevator. The round ligaments are clamped at both pelvic walls, incised, and tied. The anterior leaf of the broad ligament is opened along with the vesicouterine peritoneal fold.

This view, which is cut through the pelvis in the posterior-anterior plane, demonstrates the pelvic spaces essential for all radical pelvic surgery.

In this view, the presacral space (PSS) is at the top. Advancing anteriorly, the surgeon finds the rectum (R) and the pararectal spaces (PRS). The surgeon can enter this space by displacing the ureter and moving between the ureter and internal iliac artery.

The rectovaginal space (RVS) is the next space anterior to the rectum. This area is entered by incising the peritoneum in the cul-de-sac of Douglas and dissecting the posterior vaginal wall from the perirectal fascia covering the rectum. The next space is the vagina (V).

After the vagina comes the vesicovaginal space (VVS). This is entered by retracting the bladder (B) anteriorly and dissecting this space with sharp dissection along the pubovesical cervical fascia. Note the position of the ureter and its relationship to this space.

The next significant space is the paravesical space (PVS). Between the pararectal space and the paravesical space is the lateral extent of the cardinal ligament, originally described as the "web" by Wertheim. The web contains the venous network of the internal iliac vein. The superior portion of the web contains the sympathetic nerve fibers to the bladder along with the venous plexus. The inferior portion of the web contains the parasympathetic nerve fibers to the bladder.

In between the paravesical space is the bladder. Anterior to the bladder is the space of Retzius (SR), the retropubic space.

Prior to performing a radical Wertheim hysterectomy, the surgeon must completely dissect the paravesical and pararectal spaces.

The round ligaments have been cut and divided. The anterior leaves of the broad ligament have been opened, and the vesicouterine peritoneum has been transected. The vesical peritoneum is grasped with two forceps and elevated. Scissors are used to dissect the vesicovaginal space between the bladder and the anterior vaginal wall. Elevation of the bladder can be facilitated by the placement of two sutures through the vesicoperitoneum to the skin incision above the symphysis pubis.

The posterior leaf of the broad ligament is opened, exposing the infundibulopelvic ligament in the area of the pelvic brim. A finger is inserted under the infundibulopelvic ligament. The ureter is identified and dissected free of the infundibulopelvic ligament. Three clamps are applied to the infundibulopelvic ligament, and it is transected and doubly tied. The same procedure is carried out on the opposite side.

The infundibulopelvic ligament, tubes, ovaries, and round ligaments are all tied to the thyroid clamp placed on the middle of the fundus. The surgical field is kept free of excessive instruments.

The uterus is retracted caudad and medially. The base of the aorta is exposed, and the lymphatic tissue surrounding the common iliac artery and vein is removed with sharp dissection. The ureter is identified, dissected free of the artery, and retracted laterally. All lymphatic tissue surrounding the external iliac and common iliac blood vessels is removed from the bifurcation of the aorta to the inguinal ligament at the femoral canal.

The lymph nodes are carefully isolated in individual specimen containers for precise pathologic analysis.

The common iliac, external iliac and upper hypogastric vessels have been stripped of all lymphatic-bearing tissue. The obturator fossa and the lower branches of the hypogastric artery remain to be dissected.

A vein retractor is used to retract the external iliac artery and vein laterally, and all lymphatic tissue is removed from behind these vessels and from the obturator fossa. The obturator nerve is preserved. Vessels deep in the obturator fossa may be ligated with hemoclips. The uterine artery is identified as it comes off the anterior division of the hypogastric artery before it enters the tunnel. It is transected and tied with 2-0 suture.

The same procedure is carried out on the left side.

The pararectal space (PRS) and the paravesical space (PVS) are shown with the intervening web, which is the lateral extent of the cardinal ligament. The uterine artery on both sides has been transected and deviated medially. The distal stump of the uterine artery is seen as it enters the tunnel. Its relationship to the ureter within the tunnel is ghosted in this view. The ureter is seen as it enters the tunnel.

The relationship of the ureter to the uterine artery is shown in the tunnel. The uterine artery has been transected as it branches from the anterior division of the hypogastric artery. It enters the tunnel laterally and crosses the ureter. Two horizontal curved clamps are inserted on top of the ureter beneath the roof of the tunnel to include the uterine artery and vein. The tissue in the roof of the tunnel, consisting of the uterine artery and vein, is clamped, incised, and tied. In some patients, this may be performed in one step; in others, two to three successive bites with horizontal curved clamps on the roof of the tunnel are needed.

The ureter is elevated with a small retractor. The filmy adhesions between the ureter and the floor of the tunnel connecting the ureter to the superior portion of the web are gently lysed and dissected laterally. The pararectal and the paravesical spaces, with the web in between, are visualized. The hypogastric artery and vein, along with the external iliac artery and vein, are retracted laterally. Note that in this particular patient the roof of the tunnel has been taken down in three successive bites between the horizontal curved clamps and been incised and tied.

The external iliac artery and vein and the hypogastric artery and vein are retracted medially. The pararectal and the paravesical spaces are exposed. After the ureter has been dissected laterally (Fig. 12), the floor of the tunnel can be visualized. Two horizontal curved clamps are placed across the floor of the tunnel and excised. This completely frees the ureter from any attachment to the web.

The uterus and the stumps of the tunnel, roof, and floor are seen on the right. The ureter is retracted laterally with a vein retractor.

Both portions of the web are noted. The superior portion of the web, containing the hypogastric venous plexus and sympathetic nerves to the bladder, is separated from the lower portion containing the parasympathetic nerves to the bladder. In most cases, transection of only the upper portion is required to achieve the goal of the radical Wertheim hysterectomy.

We prefer to place a straight vascular clamp medial to the ureter on the medial portion of the web. A curved clamp can be placed on the lateral portion of the web at the pelvic wall. The superior portion of the web is transected and tied. The lower portion is left intact.

The uterus is retracted upward and caudad. The incision in the posterior leaf of the broad ligament is extended across the cul-de-sac and peritoneum overlying the cul-de-sac between the cervix and rectum.

The uterus is retracted cephalad, a finger is inserted between the uterosacral ligaments, and the posterior wall of the vagina is dissected off the anterior rectal wall. Retraction on the uterus is changed to the anterior caudad position, placing the uterosacral ligaments on tension. The upper portion of the uterosacral ligaments is clamped, incised, and tied. The lower portion of the uterosacral ligaments, containing the parasympathetic nerves to the bladder, is left.

The lateral, posterior, and anterior attachments of the uterus and its parametria have all been transected and tied. Two right-angle Heaney clamps are placed on the paravaginal tissue on each side, and a scalpel is used to transect the remaining paravaginal tissue and vagina between these clamps. The paravaginal tissue pedicle is tied with a 0 synthetic absorbable suture.Approximately 5 cm of vagina should be removed.

The Sakamoto sling suspends the ureters medially, out of the dissected pararectal and paravesical spaces. Several 0 synthetic absorbable sutures are used for this maneuver, which prevents the ureter from forming adhesions deep in the lateral pelvic wall spaces.

This view shows, on the patient's left, the Sakamoto sling shown in Figure 18. If in younger patients following radical Wertheim hysterectomy in which 4-5 cm of upper vagina were excised a longer vagina is desired, the following steps can be performed. The vesical peritoneum coming off the bladder can be sutured to the anterior vaginal cuff. The serosa from the rectosigmoid colon can be sutured to the posterior vaginal cuff.

On the patient's right, the Sakamoto sling is completed from the serosa of the rectum to the vesical peritoneum. Synthetic absorbable sutures are being placed in a row in the serosa of the rectum 5 cm from the posterior vaginal cuff to a site chosen on the vesical peritoneum 5 cm from the anterior vaginal cuff. When this row of sutures is completed, there will be an extension of the vagina from the vaginal cuff up to the new apex of the vagina that initially will be lined by mesothelium. After several months, this mesothelium will undergo squamous metaplasia, and the upper vaginal extension will be similar to the traditional vagina.

This sagittal view shows the 5-cm extension to the vagina lined initially by mesothelium from the vesical peritoneum and the serosa of the colon. We insert a soft foam rubber form covered with condoms to keep this extension open for 6 weeks following Wertheim hysterectomy. Sexual intercourse is allowed after the form has been removed in 6 weeks.

In young women, one or both ovaries can be preserved by dissecting out the infundibulopelvic ligament with its ovarian artery and vein and suspending the ovary to the psoas muscle high in the abdomen under the inferior pole of the kidney. This removes the ovary from any potential field of radiation that may be utilized postoperatively.

The third portion of the duodenum is seen at the top. The ovary is suspended under the inferior pole of the right kidney to the psoas muscle by several interrupted absorbable sutures. The pelvic peritoneum has been closed with interrupted absorbable sutures. Note that Silastic Jackson-Pratt closed suction drains are inserted into the paravesical and pararectal spaces on each side. These are brought retroperitoneally to the anterior abdominal wall.

The Silastic closed suction drains are brought out, respectively, through the right and left lower quadrants of the abdominal wall. The midline incision, extended around the umbilicus, is closed in layers.