Discrepancies between classic anatomy and modern gynecologic surgery on pelvic connective tissue structure: Harmonization of those concepts by collaborative cadaver dissection  Yoshihiko Yabuki, MD, DMSc, Hiromasa Sasaki, MD, DMSc, Noboru Hatakeyama, MD, DMSc, Gen Murakami, MD, DMSc  American Journal of Obstetrics & Gynecology  Volume 193, Issue 1, Pages 7-15 (July 2005) DOI: 10.1016/j.ajog.2005.02.108 Copyright © 2005 Mosby, Inc. Terms and Conditions

Figure 1 Vesicohypogastric fascia and Mackenrodt ligament. Photograph showing development of the left paravesical space followed by lifting of the uterus with forceps and upward retraction of the lateral umbilical ligament by the use of a thread. The vesicohypogastric fascia originating from the lateral umbilical ligament and the transverse cervical ligament forms a continuity. There is a hollow (arrowhead 1) between the transverse cervical ligament and the short fibrous bundle, leading to the caudal chamber of the pararectal space. In the supine position, the vesicohypogastric fascia and the transverse cervical ligament lie vertical to the bladder and uterine cervix, and the short fibrous bundle is situated horizontally. The area around the genital hiatus (arrowhead 2) is the true pelvic floor. U, Uterus; B, bladder; II, internal iliac artery; Ur, ureter; LU, lateral umbilical artery/ligament; VH, vesicohypogastric fascia; CL, transverse cervical ligament; SB, short fibrous bundle; TL, tendinous arc of levator ani muscle; TP, tendinous arc of pelvic fascia; PS, pubic symphysis; SP, sacral promontory; BS, paravesical space. American Journal of Obstetrics & Gynecology 2005 193, 7-15DOI: (10.1016/j.ajog.2005.02.108) Copyright © 2005 Mosby, Inc. Terms and Conditions

Figure 2 Lateral ligament of the pelvis and cranial chamber of the pararectal space. This photograph shows a view of Figure 1 from the cranial aspect, which presents the lateral ligament of the pelvis with its anterior fascia and vessels preserved, and only its posterior fascia excised. Also shown is the exposed cranial chamber of the pararectal space. The paravesical space is seen here filled with paper clay, showing the border between the paravesical space and the caudal chamber of the pararectal space (arrowhead). The excised lateral ligament of the pelvis forms a plate from the lateral umbilical ligament to the fascia of the piriformis muscle, which is a complex consisting of the vesicohypogastric fascia, transverse cervical ligament, and lateral ligament of the rectum. The visceral terminus of this complex crosses the pelvic autonomic nerves. The direction of the inserted forceps indicates Okabayashi's space. A large opening via Latzko's space is ‘the so-called pararectal space.’ The deep uterine vein and pelvic splanchnic nerve (S3) are shown here being suspended by a black thread. An asterisk indicates the paper clay filling of the paravesical space. II, Internal iliac artery; CPG, common trunk of internal pudendal and inferior gluteal artery; LU, lateral umbilical ligament; SV, superior vesical artery; UA, uterine artery; DV, deep uterine vein; MV, middle vesical vessels; MR, middle rectal vessels; SN, pelvic splanchnic nerve; HN, hypogastric nerve; NP, pelvic nerve plexus; Ur, ureter; D, pouch of Douglas; U, uterus; VF, vesicohypogastric fascia; SU, sacrouterine ligament. American Journal of Obstetrics & Gynecology 2005 193, 7-15DOI: (10.1016/j.ajog.2005.02.108) Copyright © 2005 Mosby, Inc. Terms and Conditions

Figure 3 Paravesical space and cranial chamber of the pararectal space. Shown here is the right side of the pelvic cavity, which has been divided by the lateral ligament of the pelvis, which indicates the so-called surgical pelvic floor. In the paravesical space (right photograph), the short fibrous bundle is separated from the tendinous arc of the levator ani muscle with a part of the muscle exposed (large arrowhead). On the cranial aspect there is the cranial chamber of the pararectal space opened via Latzko's space. The pelvic splanchnic nerves (S3-4) and the hypogastric nerve then form a pelvic nerve plexus, which, after crossing the lateral ligament of the pelvis, radiates to the vesical branch facing the paravesical space (small arrowhead). SB, Short fibrous bundle; LM, levator ani muscle; ML, Mackenrodt ligament; Ur, ureter; SN, pelvic splanchnic nerve; NP, pelvic nerve plexus; HN, hypogastric nerve; U, uterus; B, bladder; R, rectum; A, aorta. American Journal of Obstetrics & Gynecology 2005 193, 7-15DOI: (10.1016/j.ajog.2005.02.108) Copyright © 2005 Mosby, Inc. Terms and Conditions

Figure 4 Okabayashi's space for entry into the cranial chamber of the pararectal space: findings of the right pelvic cavity. Photograph shows the visceral endopelvic fascia that lines the broad ligament being separated from the serosa of the broad ligament, together with the ureter and hypogastric nerves. A further separation in a dorsal direction results in reaching the cranial chamber of the pararectal space (Figure 6) (large arrowhead). The membranous tissue in the photograph shows the mesoureter formed by a union of the visceral endopelvic fascia of the broad ligament, and the hypogastric sheath separated from the internal iliac vessels. The ureter and hypogastric nerves descend within it (small arrowhead). M, Mesoureter; Ur, ureter; HN, hypogastric nerves; IF, infundibulopelvic ligament; BL, posterior leaf of broad ligament; OS, Okabayashi's space; U, uterus; R, rectum; LS, Latzko's space; BS, paravesical space; EI, external iliac artery; II, internal iliac artery. American Journal of Obstetrics & Gynecology 2005 193, 7-15DOI: (10.1016/j.ajog.2005.02.108) Copyright © 2005 Mosby, Inc. Terms and Conditions

Figure 5 Paravaginal space and cranial chamber of the pararectal space: findings of the right pelvic cavity. The paravaginal space formed between the uterine cervix and ureter and its continuing caudal chambers of the pararectal space are developed. An asterisk indicates the peripheral branch of the pelvic nerve plexus. The cranial space is the cranial chamber of the pararectal space, developed by entering Okabayashi's space. The fascia of the transverse cervical ligament has already been reflected in a cranio-caudal direction, with the photograph showing the parametrium lacking visceral fascia. OS-Cr, Okabayashi's space and cranial chamber of the pararectal space; VS-Ca, paravaginal space and caudal chamber of the pararectal space; PM, parametrium; Ur, ureter; U, uterus; B, bladder; AV, superficial layer of the vesicouterine ligament; UA, uterine artery; LS, Latzko's space; SP, sacral promontory; AN, pelvic autonomic nerve. American Journal of Obstetrics & Gynecology 2005 193, 7-15DOI: (10.1016/j.ajog.2005.02.108) Copyright © 2005 Mosby, Inc. Terms and Conditions

Figure 6 Separation of the caudal reflection of the lateral ligament of the pelvis: right pelvic cavity seen from the pubic aspect. Entrance into the paravaginal space and caudal chamber of the pararectal space (Figure 4) is made by inserting scissors between the uterine cervix and ureter. The tip of the scissors pierces the tendinous arc of the pelvic fascia, protruding into the paravesical space. The superior aspect of the caudal reflection is the deep layer of the vesicouterine ligament, and the inferior aspect being the bundle that covers the paracolpium. In addition, with excavation of the paravesical and pararectal spaces, we can conjecture that there is a change in direction of the lateral ligament of the pelvis from ventrocranial-to-dorsocaudal to lateral-to-medial during observation of the hypogastric and pelvic visceral nerves. CaR, Caudal reflection of the lateral ligament of the pelvis; UA, uterine artery; DV, deep uterine vein; U, uterus; Ur, ureter; HN, hypogastric nerves; SN, pelvic splanchnic nerve; SB, short fibrous bundle; R, rectum; B, bladder. American Journal of Obstetrics & Gynecology 2005 193, 7-15DOI: (10.1016/j.ajog.2005.02.108) Copyright © 2005 Mosby, Inc. Terms and Conditions

Figure 7 Schematic illustration of the pelvic connective tissue. The pelvic connective tissue is classified into a musculofascial bundle, or the suspensory system (X) and a fasciovascular bundle or the supporting system (Y). The supporting system is further divided into a cranially reflected bundle (Y-1) and a caudally reflected bundle (Y-2). The ureter and pelvic autonomic nerves pass within this suspensory system. U, Uterus; B, bladder; R, rectum; Ur, ureter; SN, pelvic splanchnic nerve; HN, hypogastric nerve; VN, vesical nerve branch; SB, short fibrous bundle; LS, Latzko's space; BS, paravesical space; VF, vesicouterine space; RF, rectouterine space; X, pubovesical ligament, superficial layer of the vesicouterine ligament, rectouterine ligament, and rectococcygeal ligament; Y-1, mesoureter, etc; Y-2, deep layer of the vesicouterine ligament, etc. American Journal of Obstetrics & Gynecology 2005 193, 7-15DOI: (10.1016/j.ajog.2005.02.108) Copyright © 2005 Mosby, Inc. Terms and Conditions

Figure 8 Fascial capsule of the uterus and uterine vessels: the frontal section seen through the uterine cervix and the anterior margin of the uterine body. A group of small arrowheads show merging of the fascial capsule of the uterus covering the uterine artery/vein (AB, VB) into the fascial capsule of the rectum via the sacrouterine ligament (SU). Also observed are the middle rectal vessels that pierce the pelvic nerve plexus passing within the paraproctum (MR). The surrounding tissue that covers the visceral fascia is probably the longitudinal section of the supporting system. AB, Branches of uterine artery; VB, branches of uterine vein; SU, sacrouterine ligament; MR, middle rectal vessels; NP, pelvic nerve plexus; Ur, ureter; UB, uterine body; UC, uterine cervix; R, rectum. American Journal of Obstetrics & Gynecology 2005 193, 7-15DOI: (10.1016/j.ajog.2005.02.108) Copyright © 2005 Mosby, Inc. Terms and Conditions