During radical hysterectomy, the pararectal space should be developed to excise the
cardinal ligament entirely.
Use the lap salt sponge covering the Kocher clamps on the
cardinal ligament pedicles to wipe the surgical field clean.
Central defects are often associated with the loss of Level I support at the
cardinal ligaments, and patients may present with a concomitant enterocele.
This trial compared McCall culdoplasty, simple purse-string closure of the peritoneum, and vaginal Moschcowitz-type closure (which involves purse-string closure of the posterior peritoneum with fixation to the distal uterosacral and
cardinal ligaments) in 100 women undergoing hysterectomy.
When the stitch is placed high at the level of the cervicoisthmic junction--or even higher--and above the level of the
cardinal ligaments, the stitch is less likely to slip down along the cervix.
A vessel-sealing device is used to coagulate and transect the uterine arteries and the
cardinal ligaments. At that point--and not any sooner--the vagina is transected immediately distal to the cervix and the uterus is detached and removed, along with the ovaries in most cases, through the vaginal opening.
The latter represents a deficiency in the level I supporting structures described by DeLancey(2)--primarily the uterosacral and
cardinal ligaments (FIGURE 1).