Surgeons Corner

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Parametrial dissection during laparoscopic

nerve-sparing radical hysterectomy
A new approach aims to improve patients postoperative quality of life
Marcello Ceccaroni, MD, PhD; Giovanni Pontrelli, MD; Emanuela Spagnolo, MD;
Marco Scioscia, MD; Francesco Bruni, MD; Amelia Paglia, MD; Luca Minelli, MD

Problem: postoperative dysfunctions

In recent years, nerve-sparing radical
hysterectomy for cervical cancer has
proven successful in reducing postoperative bladder, colorectal and sexual dysfunction. At our institution, we perform
this procedure using a magnified laparoscopic view to better identify fibers and
surgical landmarks; this improves dissection of the pars vasculosa from the
pars nervosa of the parametrium.
Typically, the medial pararectal space
(Okabayashis space) is developed between the mesoureter and the rectouterine ligament by opening up a space between the posterior leaf of the broad
ligament (medial) and the ureter (lateral). In contrast, the lateral pararectal
space (Latzkos space) is developed between the mesoureter and pelvic wall by
opening up the space between the internal iliac artery (lateral) and the ureter
(medial).

From the Gynecologic Oncology Division

(Drs Ceccaroni, Pontrelli, and Bruni) and
the Department of Obstetrics and
Gynecology (Drs Ceccaroni, Pontrelli,
Scioscia, Bruni, and Minelli), European
Gynecology Endoscopy School, Sacred Heart
Hospital, Negrar, Verona; the Department of
Obstetrics and Gynecology, University
Hospital, Bologna (Dr Spagnolo); the
Department of Perinatal Medicine, Tor
Vergata University (Dr Scioscia); and the
Department of Obstetrics and Gynecology,
Catholic University of the Sacred Heart (Dr
Paglia), Rome, Italy.
Cite this article as: Ceccaroni M, Pontrelli G, Spagnolo
E, et al. Parametrial dissection during laparoscopic
nerve-sparing radical hysterectomy: a new approach
aims to improve patients postoperative quality of life.
Am J Obstet Gynecol 2010;202:320.e1-2.
0002-9378/free
2010 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2009.12.019

320

FIGURE

Pars nervosa of the parametrium

A panoramic view of the left pelvis shows the pars nervosa of the parametrium during nerve-sparing
radical hysterectomy. After developing the medial Okabayashis pararectal space, the middle rectal
artery can be identified at the level of the rectal wings. This step allows isolation and preservation of
the parasympathetic pelvic splanchnic nerves and the fibers of the inferior hypogastric plexus during
transection of the cardinal ligament.
Ceccaroni. Parametrial dissection during laparoscopic nerve-sparing radical hysterectomy. Am J Obstet Gynecol 2010.

Our solution
In our procedure, blunt opening of the
medial and lateral pararectal spaces at the
level of the rectal wings allows preservation
of the mesoureter, as well as identification
of the middle rectal artery and the origin of
the parasympathetic pelvic splanchnic
nerves at the sacral roots. The posterior
parametrial planes can then be safely dissected, and the cardinal ligament can be
completely transected while sparing the fibers distributed within the rectovaginal
ligament (Figure). Subsequent visualization of the inferior hypogastric plexus at its

American Journal of Obstetrics & Gynecology MARCH 2010

origin permits preservation of the visceral

afferent and efferent fibers that are directed
to the uterus, the vagina, and the bladder.
Unroofing of the ureter and dissection
of the deep layer of the vesicouterine ligament toward the mesorectal planes
opens additional anatomical space, facilitating complete dissection of the vesicouterine ligament and the paravaginal
portion of the paracervix. At the same
time, the neural portions of the anterior
parametrium are protected even when
more than one-third of the vagina is removed during colpectomy.
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