Nerve-Sparing Radical Abdominal Hysterectomy "Muallem Technique"

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In Type C radical hysterectomy, which is indicated to stage IB1 with deep invasion of cervical stroma, IB2–IIA or early IIB according to the old version of the International Federation of Gynecology and Obstetrics classification of cervical cancers (FIGO 2009), a total resection of the vesicouterine (ventral parametrium) and vesicovaginal ligaments (ventral paracolpium) combined with a resection of adjusted length of the vaginal vault and its surrounding paracolpium is essential for sufficient removal of large and/or deep- infiltrating tumors. It is well known that the more extensive the vaginal and surrounding tissue ablation, the greater the resultant bladder denervation. As a result, in majority of radical resection (type C) the ventral part of the inferior hypogastric plexus, the bladder branches, and probably the pelvic splanchnic nerves (leading to type C2) are sacrificed inadvertently. Preservation of the bladder branches and inferior hypogastric plexus requires direct visualisation.

In our experience, understanding the precise three-dimensional anatomy of paracolpium and its close anatomical relationship to the components of the pelvic autonomic nervous system is most vital key to perform successful nerve-sparing radical hysterectomy. In our technique, we described in detail the three-dimensional anatomy of paracolpium and the essential role of vaginal vessels in the anatomy of radical hysterectomy. We routinely identify all branches of the pelvic autonomic nervous system and transect only the uterine branches in order to preserve the hypogastric nerves, the pelvic splanchnic nerves, and the bladder branches of the inferior hypogastric plexus.

The operation performed in the lithotomy position. For visual illustration of the autonomic nervous system, we used ultrasonic liposuction SonoSurg (Olympus Deutschland GmbH, Hamburg, Germany).

Preparation: Retroperitoneal Spaces
  1. After preparing the paravesical and pararectal space, we identified the lateral parametrium (uterine artery and vein and their accompanying lymph tissue), the dorsal parametrium (sacrouterine ligament) and the ventral parametrium (vesicouterine ligament).
  2. Subsequently, we identified the hypogastric nerves bilaterally and the superior hypogastric plexus at the lateral side of rectum about 2-3 cm caudal from the ureter.
  3. After isolating and lateralising the hypogastric nerves bilaterally, we resected the dorsal parametrium (sacrouterine ligament) and the dorsal paracolpium (sacrovaginal ligament) to the tendinous arch of the pelvic fascia (fascia pelvis visceralis).
Resection Lateral & Ventral Parametrium
  1. We resected the uterine artery and vein (lateral parametrium) at the internal iliac artery and vein and prepared them to the middle point above the ureter.
  2. We prepared the ventral parametrium by entering the ureter tunnel medial from the ureter and rolling the ureter itself laterally and ventrally to the pelvic sidewall and pubic symphysis. Here we identified a small artery arising from the uterine artery and ending in the ureter (the ureteral branch of uterine artery) and a small vein going from the ureter to the uterine vein (ureteral vein). In 50% of cases, medial from these two small vessels, we observed an arterial branch of uterine artery which crossover the proximal ureter and goes along the lateral vaginal wall. It is in our experience the vaginal branch of the uterine artery. After isolation and cutting all these three branches, the resection of the ventral parametrium is completed and the ureter is now completely unroofed.
Resection of Lateral & Ventral Paracolpium
  1. At the internal iliac vessels, we identified two groups of vessels: the inferior vesical artery and vein (the last medial branch of internal iliac vessels), the vaginal vein (often wrongly called as deep uterine vein) and in 50% of cases the vaginal artery.
  2. By cutting the vaginal vessels (lateral paracolpium) only and directly at the level of internal iliac vessels, we could reveal the pelvic splanchnic nerves. These nerves ran directly from the sacral roots in front of the common trunk of the internal pudendal and inferior gluteal vessels at the dorsal edge of the lesser sciatic foramen and then medial from the inferior vesical vein cranially to merge in the inferior hypogastric plexus behind the ascending vaginal vessels.
  3. The vaginal vein showed two vein anastomoses with the inferior vesical vein. We called these two connected veins: the lateral vaginovesical vein and the medial vaginovesical vein. These two veins with the accompanying lymph tissue build the vesicovaginal ligament (ventral paracolpium). Isolating these two veins and resecting them directly beneath the bladder reveal the bladder branches of the inferior hypogastric plexus
Liposuction & Identification of Inferior Hypogastric Nerve Branches
  1. Mediodorsal from the bladder branches, lateral from the vaginal wall and above the level of hypogastric nerve, we could develop a small space (hollow), which we called Fujii space honoring Prof. Shingo Fujii who described it for the first time [12]. This space allowed us to isolate the inferior hypogastric plexus from the lateral vaginal wall and to isolate uterine branches of inferior hypogastric plexus to be resected from the pelvic autonomic nervous system.
  2. At this point, the uterus was only connected to the vagina. The vaginal vessels go along the vaginal wall, medial from the inferior hypogastric plexus and could be cut and ligated at the adjusted length of vaginal vault appropriate to the tumor size and infiltration.
Final Surgical Specimen & Literature

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