Operative anatomy and technique of radical parametrial resection in the surgical treatment of cervical cancer.

Wertheim's radical operation aimed, by removing the parametrial tissue far from the tumour, to achieve margins free of disease. The paratissues contain the lymphatic channels draining the cervix. They run to the pelvic wall and are interspersed by lymph nodes scattered throughout the parametrium. If lymphadenectomy is to be curative then the entire parametrium must be removed. To this end the resection of the cardinal ligament was pushed to its limit by dissection directly at the pelvic wall. The surgical technique is guided by the anatomy of the pelvic fascia. The gaine hypogastrique lies just beneath the peritoneum and facilitates the opening of the paravesical space. The following are discussed: the condensations of the pelvic fascia; the composition of the cardinal ligament; the division into a venous, an arterial, and a neurovegetative root; and the anatomy of the connective tissue planes. The order in which the surgical steps are carried out is important. The paraspaces are opened first. The ureter is identified, and lymphadenectomy is performed. The rectum is dissected off the vagina, and the uterosacral ligaments are identified and removed. Only then is the vesico-uterine fold opened. The bladder is dissected off the vagina, and the anterior parametrium is clamped and divided. Now the cardinal ligament is completely exposed. The bladder, rectum and ureter have been mobilized so that the parametrium can be divided sharply directly at the pelvic wall, clipping the vessels step-by-step. The paracolpium is clamped and divided according to the proposed vaginal cuff. Thus, the entire lymphatic drainage can be removed. The value of this extension of radical abdominal hysterectomy lies especially in the treatment of large, voluminous tumours.