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The gross and microscopic anatomy of the transverse cervical ligament
The gross and microscopic anatomy of the transverse ROBERT RUSSELL Ann
Arbor,
L. T.
cervical ligament RANGE,
M.D.*
WOODBURNE,
PH.D.
Michigan
?’ H E c LA s s IC A L description of the transverse cervical ligament and its function was published by Mackenrodt” in 1895. His concept was based upon his clinical observations and the gross dissection of a number of cadavers of stillborn female infants and one adult. Though subject to criticism throughout the years, this original contribution has become rather generally accepted. Medical students have been taught that “Mackenrodt’s ligament is the chief supporting strucand some texts contain ture of the uterus,” this unqualified statement. ,4 superficial appraisal of investigations since Mackenrodt’s time reveals a gross lack of agreement concerning the function of the transverse cervical ligament and varied conclusions regarding its structure, contents, and attachments to the uterus and the lateral pelvic wall. Gross dissection of this structure has been the basis for differing reports by a number of individuals. In 1917 Fothergill,7 with whose name the Manchester procedure is closely linked, stated that he did not know the exact nature of the paracervical tissues, but that the surgical utility of this tissue in the treatment of prolapse could not be denied. In 1933 Sears13 described a “main sheet” of fascia arising from and continuous with the
From the Departments of Obstetrics Gynecology and Anatomy, Unirlersity Michigan.
superior fascia of the pelvic diaphragm which completely encircled the vagina and cervix, giving rise to a prevaginal and prerectal supporting layer. His diagrams show a definite reflection of the superior levator fascia to form the main sheet of connective tissue which he terms “fascia” because of this origin. His findings have not been confirmed. In 1939 and 1940 Anson, Curtis and McVay’ published their beautifully illustrated articles on the anatomy of the female pelvis. They concluded that the transverse cervical ligament arises near the origin of the hypogastric artery and is attached to the endopelvie fascial compartment, arising from the superior layer of fascia of the pelvic diaphragm surrounding the vagina and cervix. They stated that the main bulk of the ligament is composed of blood vessels, chiefly veins, and that the entire mass of retroperitoneal connective tissue, incIuding the ligament, can be shelled away from the superior fascia of the pelvic diaphragm. Power,l? in 1945, described the transverse cervical ligament as an inverted U-shaped structure which arises along the arcus tendineus of the pelvic fascia and inserts into the cervix and upper vagina. In a later article he attributed a very definite function to this tissue. He stated that the inferior surface of the ligament was attached to the superior fascia of the pelvic diaphragm, but did not enlarge upon the nature of this attachment. In 1931 Gaffs published a description of the histologic structure of the tissues between the anterior vaginal wall and the bladder
and of
“Present address: 5120 J Street, Sacramento l.g, Cnlifornin. 460
Anatomy
and urethra, stating that there was nothing which could be called fascia in the area, but only loose areolar connective tissue which could not be considered of value as a means of support. Koster,” in 1933, confirmed these findings, and extended the microscopic approach to a study of the transverse cervical ligament. Hc removed the entire retroperitoneal connective tissue mass from the pelvis of a 22-year-old girl who died of an acute disease, prepared microscopic sections from the fixed tissue, and, after detailed study, concluded that there was no ligament present. He stated that the so-called fascia consisted of loose areolar connective tissue, that it had no supportive function, and that there was no justification for its use surgically in the correction of prolapse. Sears” then used this approach to confirm his earlier gross findings, but his study did not support his previous conclusions to a convincing degree. In 1953 Bcrglas and Rubin’ reported a histologic study of the pelvic connective tissue in which an intact pelvis was sectioned and subjected to microscopic examination. They concluded that there is no anatomic basis for ascribing support of the pelvic orsaris to retroperitoneal connective tissue structures. In a later paper based upon x-ray studies of the levator ani muscle injected with opaque media in living subjects, the same authors” concluded that a disturbed anatomic relationship of the uterus to the levator ani muscle, resulting from injury or disease of the pelvic diaphragm, chiefly accounts for loss of pelvic visceral support. While the opinions of Goff, Koster, and Berglas and Rubin indicate a lack of supportive function by the retroperitoneal arcolar connective tissue, and the absence of ligamentous structures in their tissue, operations for uterine prolapse utilizing the transverse cervical ligament remain popular and effective. Some surgeons depend solely upon this tissue to re-establish adequate uterine support without modification of the pelvic diaphragm. Even after subsequent childbearing they claim that uterine support remains adequate.
of transverse
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Because of the variability of gross description and the contradictory histologic findings, the present study, based upon a technique similar to that of Berglas and Rubin, was undertaken with the hope that the true nature and function of the so-called transverse cervical ligament as a supportive structure might be more firmly established. Material
and
methods
Materials for the investigation were made available by the Department of Anatomy of the University of Michigan Medical School, and we were fortunate to obtain a fresh unembalmed specimen for our final study. In all, eighteen cadavers were used. Clinical histories were not available. Ages at death were known, and ranged from 4.5 to 60 years. The cadaver selected for the final preparation was known to have been nulliparous. Fifteen were demonstration specimens in various stages of dissection and, therefore, were utilized only to develop a method of approach to the gross study of the transverse cervical ligament. Two intact specimens were grossly dissected and the removed tissue subjected to histologic study before the final specimen was prepared. Gross
anatomy
With the pelvic organs in their natural position, without distortion, there is no dissectable structure of ligamentous nature in the area occupied by the so-called transverse cervical ligament. The areolar connective tissue surrounding the blood vessels and the pelvic plexus of nerves, arising near the hypogastric artery and sweeping anterior and medially to reach the lateral border of cervix and vagina, contains less fat and is more compact than the rest of the retroperitoneal areolar connective tissues, but blends into them without any natural cleavage plane demonstrable. This condensation is greatest at the lateral margin of the cervix and vagina, extending downward to the level of the pelvic floor (Fig. tA‘, It cannot he separated from the thinner, looser endopelvie fascia, but does not continue around the vagina and cervix in any bulk. Lateral to the
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Fig. 1.4. Sagittal section from left hemipelvis through left vaginal fornix and immediate paracervical structures. This section should include any ligamentous tissue as it attaches to the cervix. The honeycomb appearance of the broad ligament base included between the uterine artery, bladder, vagina, and rectum is produced by the numerous tortuous veins. Contrast the appearance of the paracervical tissue with the loose fat-filled areolar tissue of the space of Retzius.
Fig. 1B. Microscopic slide, sagittal section, identical to Fig. 1A in location, demonstrating the vascular nature of the broad ligament base. The very tortuous veins are readily identified by the dark stained walls. The fairly compact areolar tissue is lighter stained and contains little fat, The compact tissue posterior and superior to the vagina consists of the anterior rectal wall and the partially obliterated Douglas pouch caused by old pelvic adhesions. The rectovaginal septum appears quite broad because of a somewhat tangential section of the rectum apparent in Fig. IA. The pelvic diaphragm is not represented here, but the multiple filaments of areolar tissue leading to it are seen anterior to the vagina at the inferior border of the slide.
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15, 1964 & Gyncc.
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FUSlOff PARf&r& AN0
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OF PEQf TONEWM
ANT&oQ RECTAL WAIL
1 EVATk? musciE
1 EF T UTERINE ARXR!’I
L CF 7,UvRETER
aff/ PELV1C
‘%I PHRAGM
Fig. 2A. Gross sagittal section from left hemipelvis through intersection of left ureter and uterine artery. Compared to Fig. 1A the vessels are larger and less tortuous and the areolar tissues less dense. Veins are more numerous and larger than the thicker walled arteries. The most compact tissue is the anterior rectal wall cut in tangential section. The superior fascia of the pelvic diaphragm and the levator ani muscle are now visible as they sweep inferiorly and medially from the lateral pelvic wall. Note the many fine connections of the areolar fibers to this layer. The pararectal fossa ordinarily visible at this level is obliterated by the rectal ampulla.
Fig.
2B.
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point at which the ureter crossesunder the uterine artery the vessels become larger and the areolar tissue becomes less compact and is connected loosely with the superior fascia of the pelvic diaphragm by multiple fine filaments (Fig. 2A). As the pelvic wall is approached this tissue fans out rapidly to become continuous with the general retroperitoneal connective tissue. At the origin of the uterine artery it differs little from the surrounding fat-filled mesh lining the rest of the pelvic cavity (Fig. 3A). With the uterus pulled to the opposite side, a much more definite and prominent mass of tissue becomes apparent. It can then be more easily dissected from the looser tissue lying anteriorly and the filmy tissue posteriorly surrounding the rectum. The vessels now appear to lie in a space between two thick bands extending from the IateraI border of the cervix and vagina to the lateral pelvic wall near the origin of the hypogastric artery. Most illustrations of a gross dissection of the transverse cervical ligament are made
Microscopic slide from left hemipelvis identical to plane of Fig. to Fig. 1B the vessels are larger and less tortuous, and the areolar tissue is less compact and contains more fat. The rectal wall contains the dense connective tissue. The parietal peritoneum of the lateral pelvic wall and the serosa of the rectum appear fused at the point indicated, but this is because of the tangential section of the slide. The levator ani muscle appears as a horizontal border of dark tissue on the inferior margin of the section and is somewhat distorted, but the connection of the areolar fibers to the superior fascia of the pelvic diaphragm is seen anterior to the rectal wall.
2A. In contrast
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Fig. 3A. Sagittal section from left hemipelvis passing through the terminal portion of the anterior division of the left hypogastric artery at the origin of the left uterine and vesical arteries. The tip of the left ischial spine and a portion of the arcus tendincus of the pelvic fascia are included, as well as the lateral fibers of the obturator intcrnus muscle and the superior portion of .4lcock’s canal containing the pudendal vessels and nerve. The loosely arranged fat-filled areolar tissue is now apparrnt, and the absence of any ligamentous structure is obvious. The vessels are quite large and few are seen here.
Fig. 3B. Microscopic slide corresponding to the exact section grossly represented in Fig. 3A. Here the appearance of the regular dense fascial tissue over the ischial spine and that comprising Alcock’s canal is in sharp contrast to the very filmy areolar tissue about the vessels. Large amounts of fat occupy the only area which is capable of containing a ligamentous structure.
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Fig. 4. On the left a piece of ordinary chicken wire is shown representing diagramatically the undisturbed appearance of pelvic areolar connective tissue as it is distributed throughout the retroperitoneal space of the pelvis. On the right the same wire has been grasped with an instrument and put under traction in its midportion to demonstrate the distortion of the pelvic areolar tissues resulting from traction on the cervix in the Manchester operation. Condensation and obliteration of the interareolar spaces account for the “ligaments” apparent at the operating table.
with the uterus retracted toward the opposite side, which gives the ligament a more convincing appearance. When removed for microscopic study, however, the tissues regain their true configuration, and only blood vessels, nerves, and lymphatic channels embedded in loose areolar tissue regardless of the plane of the section are seen. The chief bulk of this so-called transverse cervical ligament then is blood vessels (chiefly veins), nerves arising from the pelvic plexus, lymphatic channels, and their surrounding loose areolar connective tissue. Microscopic
anatomy
Microscopic section of the transverse cervical ligament removed at gross dissection confirms the findings of Koster. However, the nature of the connection of the ligament to the pelvic floor remains unanswered. While in Koster’s” study the relationship between the ligament and the surrounding looser retroperitoneal tissues was preserved, connections with the pelvic floor were destroyed. In order to preserve the relationship of all the tissue connected with and making up the
transverse cervical ligament, the following preparations were made. The unembalmed body of a 45-year-old nulliparous woman was obtained within 24 hours after death, injected with formalin, and frozen. The trunk was transected at the level of the fourth lumbar vertebra, and the lower extremities divided on a line passing the most dependent portion of the buttocks. While still frozen, the pelvis was reduced to sagittal sections each one-half inch thick, the first division being as near the midline as possible. Following cleansing and thawing, the sections were immersed in alcohol for 1 week to clear. Photographs were taken and blocks removed for preparation of microscopic slides for study. Blocks were cut in coronal, sagittal, and cross-section. Numerous stains were applied to the tissues for proper differentiation. Hematoxylin and eosin were used for general tissue identification. Masson’s trichrome preparations were used to differentiate connective tissue from smooth muscle. Weigert’s elastic connective tissue technique, counterstained with Masson’s, was used to identify the location of the
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elastic elements present. These special stains were necessary because, as was pointed out by Campbell,6 smooth muscle bundles and fibroelastic tissue bundles appear very similar with the common hematoxylin and eosin preparations. ilnterior to the cervix a thin layer of areolar connective tissue separates the posterior vesical and anterior vaginal walls. It extends inferiorly a short distance between the musculature of the urethra and the vagina, but does not meet the superior fascia of the pelvic diaphragm. The collagen bundles are loosely arranged in a haphazard pattern and vascular and cellular elements are minimal in this region. The tissue between the posterior cervical and vaginal walls and the anterior rectal wall appear much the same. However, in most specimens some connection by fine filaments with the superior pelvic diaphragmatic fascia is visible. The thin layers blend indistinguishably with the much more dense areolar tissues lateral to the cervix. The greatest bulk lies inferior to the uterine arteries and invests the vascular tissue constituting the uterine circulation (Fig. 1B). In this area collagen bundles assume a more regular pattern, rougly parallel to the numerous veins. The connections with the pelvic floor are by multiple fine filaments. No fascial compartments can be differentiated from this areolar mass, and no endopelvic fascia sweeping up from the superior diaphragmatic fascia to invest the viscera is found. Smooth muscle fibers are abundant throughout this tissue, but on serial section are found to be associated with the walls and adventitia of the blood vessels. Cellular elements, especially fibroblasts, are numerous. There are few elastic fibers outside the vessel walls, although with special stains occasional isolated elastic fibers are seen. The same type of dense areolar tissue makes up the bulk of the bladder pillar which contains the vesical arteries and veins? and from these fine filaments of collagen sweep inferiorly and laterally to provide myriad connections to the entire superior layer of the pelvic diaphragmatic fascia. The areolar tissue is most dense at the site at
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which the fascia is penetrated by blood vessels. Lateral to the intersection of the uterine artery and ureter the blood vessels are larger and fewer in number and fatty tissues displace the areolar ground substance, forcing the collagen fibers into thin septa between the fat lobules (Fig. 2B). The amount of fat increases as the lateral pelivc wall is approached. At the site of origin of the uterine artery very little areolar tissue is found at any distance from the blood vessels (Fig. 3B). Smooth muscle cells are not found in this tissue and elastic fibers are rare. Myelinated and unmyelinated nerve fibers are numerous and accompany the uterine artery and veins from their origins at the lateral pelvic wall to the lateral margins of the uterus. Comment
With the elimination of the other pelvic ligamentous structures as an adequate means of support and in consideration of its demonstrated surgical value, the transverse cervical ligament has been accepted as the most important tissue for maintenance of the normal uterine position. Mengert*l showed that with traction applied to the cervix of a cadaver, prolapse occurred as soon as the paracervical and parametrial tissues were divided. Cutting of the other uterine ligaments and the muscles of the pelvic floor did not result in the same degree of descent when the same amount of traction was applied. We modified Mengert’s experiment so that the cervical attachment of the transverse cervical ligament was preserved. Separation from the surrounding areolar tissue was then carried out, following which the vessels and nerves were cut at their origin near the lateral pelvic wall and at the sites of penetration of the superior fascia of the pelvic diaphragm. A 1 Kg. weight was attached to the cervix and allowed to hang free over a pulley. Prolapse occurred in both specimens so prepared. Koster has pointed out that no distensible organ such as bowel, bladder, or uterus is surrounded by fixed ligamentous tissue. Their function makes this type of support impractical.
Anatomy
Our study has confirmed the fact that there is no ligament between the cervix and the lateral pelvic wall. What then supports the uterus? It would appear that the entire mass of retroperitoneal areolar connective tissue functions to support the pelvic viscera. While one isolated strand is incapable of preventing prolapse, the intact mass by means of its multitudinous attachments to the fascia lining the pelvis forms an effective and elastic support for the uterus. In the Manchester operation the bases of the broad ligaments are divided with the uterus under traction. The tissue masses which appear thick and strong are overlapped and sutured to the anterior wall of the amputated cervix. They may be compared to a piece of chicken wire, which, in its natural state, appears as a loose mesh similar to the pelvic areolar connective tissue (Fig. 4). When placed under traction, the chicken wire assumes the appearance of a strong cable, a situation which is duplicated by the paracervical tissues when placed under traction and this fact explains the apparent ligaments visible at the time of operation. Summary
and
conclusions
Gross dissection of the transverse cervical ligament was performed upon two intact
2. 3. 4. 5. 6. 7.
Anson, B. J., Curtis, A. H., and McVay, C. B.: Surg. Gynec. & Obst. 68: 161, 1939. Anson, B. J., Curtis, A. H., and Beaton, L. E.: Surg. Gynec. & Obst. 70: 643, 1940. Anson, B. J., Curtis, A. H.: Quart. Bull. Northwestern Univ. M. School 16: 275, 1942. Berglas, B., and Rubin, I. C.: Surg. Gynec. & Obst. 97: 287, 1953. Berglas, B., and Rubin, I. C.: Surg. Gynec. & Obst. 97: 677, 1953. Campbell, R. M.: AM. J. OBST. & GYNEC. 59: 1, 1950. Fothergill, W. E.: In Eden and Lockyer, editors: The New System of Gynecology,
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cadavers, and the removed tissues subjected to histologic study. With the pelvic viscera lying in their normal position, no ligament was demonstrable. With the uterus pulled strongly to the contralateral side, a “ligament” was observed and could be dissected. When fixed, sectioned, and observed microscopically, this “ligament” contained only loose areolar connective tissue enclosing blood vessels, nerves, and lymphatic tissue, With the “ligament” dissected free of the surrounding areolar tissues and the nerves and vessels divided near the lateral pelvic wall, uterine prolapse occurred when traction was applied to the cervices of two fresh autopsy specimens. A cadaver of an adult was specially prepared. The pelvis was removed intact and reduced to one-half inch sagittal sections. This preserved the normal relationship of the pelvic organs to the surrounding connective tissue. Blocks were removed, stained, cut in coronal, sagittal, and cross-section, and studied. Special staining techniques were used for accurate tissue identification. Representative sections are presented in Figs. 1 through 3. An explanation of the function of the retroperitoneal connective tissue in the support of the uterus is given.
REFERENCES
1.
of
8. 9. 10. 11. 12. 13. 14.
London, 1917, The Macmillan Co., vol. 2, p. 637. Goff, B. H.: Surg. Gynec. & Obst. 52: 32, 1931. Koster, H.: AM. J. OBST. & GYNEC. 25: 67, 1933. Mackenrodt, A.: Arch, Gynlk. 48: 393, 1895. Mengert, William F.: AM. J. OBST. & GYNEC. 31: 775, 1936. Power, R. M. H.: Surg. Gynec. & Obst. 79: 390, 1944. Sears, N. P.: AM. J. OBST. & GYNEC. 25: 67, 1933. Sears, N. P.: AM. J. OBST. & GYNEC. 29: 834, 1935.
Arbor,
L. T.
cervical ligament RANGE,
M.D.*
WOODBURNE,
PH.D.
Michigan
?’ H E c LA s s IC A L description of the transverse cervical ligament and its function was published by Mackenrodt” in 1895. His concept was based upon his clinical observations and the gross dissection of a number of cadavers of stillborn female infants and one adult. Though subject to criticism throughout the years, this original contribution has become rather generally accepted. Medical students have been taught that “Mackenrodt’s ligament is the chief supporting strucand some texts contain ture of the uterus,” this unqualified statement. ,4 superficial appraisal of investigations since Mackenrodt’s time reveals a gross lack of agreement concerning the function of the transverse cervical ligament and varied conclusions regarding its structure, contents, and attachments to the uterus and the lateral pelvic wall. Gross dissection of this structure has been the basis for differing reports by a number of individuals. In 1917 Fothergill,7 with whose name the Manchester procedure is closely linked, stated that he did not know the exact nature of the paracervical tissues, but that the surgical utility of this tissue in the treatment of prolapse could not be denied. In 1933 Sears13 described a “main sheet” of fascia arising from and continuous with the
From the Departments of Obstetrics Gynecology and Anatomy, Unirlersity Michigan.
superior fascia of the pelvic diaphragm which completely encircled the vagina and cervix, giving rise to a prevaginal and prerectal supporting layer. His diagrams show a definite reflection of the superior levator fascia to form the main sheet of connective tissue which he terms “fascia” because of this origin. His findings have not been confirmed. In 1939 and 1940 Anson, Curtis and McVay’ published their beautifully illustrated articles on the anatomy of the female pelvis. They concluded that the transverse cervical ligament arises near the origin of the hypogastric artery and is attached to the endopelvie fascial compartment, arising from the superior layer of fascia of the pelvic diaphragm surrounding the vagina and cervix. They stated that the main bulk of the ligament is composed of blood vessels, chiefly veins, and that the entire mass of retroperitoneal connective tissue, incIuding the ligament, can be shelled away from the superior fascia of the pelvic diaphragm. Power,l? in 1945, described the transverse cervical ligament as an inverted U-shaped structure which arises along the arcus tendineus of the pelvic fascia and inserts into the cervix and upper vagina. In a later article he attributed a very definite function to this tissue. He stated that the inferior surface of the ligament was attached to the superior fascia of the pelvic diaphragm, but did not enlarge upon the nature of this attachment. In 1931 Gaffs published a description of the histologic structure of the tissues between the anterior vaginal wall and the bladder
and of
“Present address: 5120 J Street, Sacramento l.g, Cnlifornin. 460
Anatomy
and urethra, stating that there was nothing which could be called fascia in the area, but only loose areolar connective tissue which could not be considered of value as a means of support. Koster,” in 1933, confirmed these findings, and extended the microscopic approach to a study of the transverse cervical ligament. Hc removed the entire retroperitoneal connective tissue mass from the pelvis of a 22-year-old girl who died of an acute disease, prepared microscopic sections from the fixed tissue, and, after detailed study, concluded that there was no ligament present. He stated that the so-called fascia consisted of loose areolar connective tissue, that it had no supportive function, and that there was no justification for its use surgically in the correction of prolapse. Sears” then used this approach to confirm his earlier gross findings, but his study did not support his previous conclusions to a convincing degree. In 1953 Bcrglas and Rubin’ reported a histologic study of the pelvic connective tissue in which an intact pelvis was sectioned and subjected to microscopic examination. They concluded that there is no anatomic basis for ascribing support of the pelvic orsaris to retroperitoneal connective tissue structures. In a later paper based upon x-ray studies of the levator ani muscle injected with opaque media in living subjects, the same authors” concluded that a disturbed anatomic relationship of the uterus to the levator ani muscle, resulting from injury or disease of the pelvic diaphragm, chiefly accounts for loss of pelvic visceral support. While the opinions of Goff, Koster, and Berglas and Rubin indicate a lack of supportive function by the retroperitoneal arcolar connective tissue, and the absence of ligamentous structures in their tissue, operations for uterine prolapse utilizing the transverse cervical ligament remain popular and effective. Some surgeons depend solely upon this tissue to re-establish adequate uterine support without modification of the pelvic diaphragm. Even after subsequent childbearing they claim that uterine support remains adequate.
of transverse
cervical
ligament
461
Because of the variability of gross description and the contradictory histologic findings, the present study, based upon a technique similar to that of Berglas and Rubin, was undertaken with the hope that the true nature and function of the so-called transverse cervical ligament as a supportive structure might be more firmly established. Material
and
methods
Materials for the investigation were made available by the Department of Anatomy of the University of Michigan Medical School, and we were fortunate to obtain a fresh unembalmed specimen for our final study. In all, eighteen cadavers were used. Clinical histories were not available. Ages at death were known, and ranged from 4.5 to 60 years. The cadaver selected for the final preparation was known to have been nulliparous. Fifteen were demonstration specimens in various stages of dissection and, therefore, were utilized only to develop a method of approach to the gross study of the transverse cervical ligament. Two intact specimens were grossly dissected and the removed tissue subjected to histologic study before the final specimen was prepared. Gross
anatomy
With the pelvic organs in their natural position, without distortion, there is no dissectable structure of ligamentous nature in the area occupied by the so-called transverse cervical ligament. The areolar connective tissue surrounding the blood vessels and the pelvic plexus of nerves, arising near the hypogastric artery and sweeping anterior and medially to reach the lateral border of cervix and vagina, contains less fat and is more compact than the rest of the retroperitoneal areolar connective tissues, but blends into them without any natural cleavage plane demonstrable. This condensation is greatest at the lateral margin of the cervix and vagina, extending downward to the level of the pelvic floor (Fig. tA‘, It cannot he separated from the thinner, looser endopelvie fascia, but does not continue around the vagina and cervix in any bulk. Lateral to the
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Fig. 1.4. Sagittal section from left hemipelvis through left vaginal fornix and immediate paracervical structures. This section should include any ligamentous tissue as it attaches to the cervix. The honeycomb appearance of the broad ligament base included between the uterine artery, bladder, vagina, and rectum is produced by the numerous tortuous veins. Contrast the appearance of the paracervical tissue with the loose fat-filled areolar tissue of the space of Retzius.
Fig. 1B. Microscopic slide, sagittal section, identical to Fig. 1A in location, demonstrating the vascular nature of the broad ligament base. The very tortuous veins are readily identified by the dark stained walls. The fairly compact areolar tissue is lighter stained and contains little fat, The compact tissue posterior and superior to the vagina consists of the anterior rectal wall and the partially obliterated Douglas pouch caused by old pelvic adhesions. The rectovaginal septum appears quite broad because of a somewhat tangential section of the rectum apparent in Fig. IA. The pelvic diaphragm is not represented here, but the multiple filaments of areolar tissue leading to it are seen anterior to the vagina at the inferior border of the slide.
Am.
October J. Oh.
15, 1964 & Gyncc.
Volume Numbu
90 4
FUSlOff PARf&r& AN0
Anatomy
OF PEQf TONEWM
ANT&oQ RECTAL WAIL
1 EVATk? musciE
1 EF T UTERINE ARXR!’I
L CF 7,UvRETER
aff/ PELV1C
‘%I PHRAGM
Fig. 2A. Gross sagittal section from left hemipelvis through intersection of left ureter and uterine artery. Compared to Fig. 1A the vessels are larger and less tortuous and the areolar tissues less dense. Veins are more numerous and larger than the thicker walled arteries. The most compact tissue is the anterior rectal wall cut in tangential section. The superior fascia of the pelvic diaphragm and the levator ani muscle are now visible as they sweep inferiorly and medially from the lateral pelvic wall. Note the many fine connections of the areolar fibers to this layer. The pararectal fossa ordinarily visible at this level is obliterated by the rectal ampulla.
Fig.
2B.
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point at which the ureter crossesunder the uterine artery the vessels become larger and the areolar tissue becomes less compact and is connected loosely with the superior fascia of the pelvic diaphragm by multiple fine filaments (Fig. 2A). As the pelvic wall is approached this tissue fans out rapidly to become continuous with the general retroperitoneal connective tissue. At the origin of the uterine artery it differs little from the surrounding fat-filled mesh lining the rest of the pelvic cavity (Fig. 3A). With the uterus pulled to the opposite side, a much more definite and prominent mass of tissue becomes apparent. It can then be more easily dissected from the looser tissue lying anteriorly and the filmy tissue posteriorly surrounding the rectum. The vessels now appear to lie in a space between two thick bands extending from the IateraI border of the cervix and vagina to the lateral pelvic wall near the origin of the hypogastric artery. Most illustrations of a gross dissection of the transverse cervical ligament are made
Microscopic slide from left hemipelvis identical to plane of Fig. to Fig. 1B the vessels are larger and less tortuous, and the areolar tissue is less compact and contains more fat. The rectal wall contains the dense connective tissue. The parietal peritoneum of the lateral pelvic wall and the serosa of the rectum appear fused at the point indicated, but this is because of the tangential section of the slide. The levator ani muscle appears as a horizontal border of dark tissue on the inferior margin of the section and is somewhat distorted, but the connection of the areolar fibers to the superior fascia of the pelvic diaphragm is seen anterior to the rectal wall.
2A. In contrast
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Fig. 3A. Sagittal section from left hemipelvis passing through the terminal portion of the anterior division of the left hypogastric artery at the origin of the left uterine and vesical arteries. The tip of the left ischial spine and a portion of the arcus tendincus of the pelvic fascia are included, as well as the lateral fibers of the obturator intcrnus muscle and the superior portion of .4lcock’s canal containing the pudendal vessels and nerve. The loosely arranged fat-filled areolar tissue is now apparrnt, and the absence of any ligamentous structure is obvious. The vessels are quite large and few are seen here.
Fig. 3B. Microscopic slide corresponding to the exact section grossly represented in Fig. 3A. Here the appearance of the regular dense fascial tissue over the ischial spine and that comprising Alcock’s canal is in sharp contrast to the very filmy areolar tissue about the vessels. Large amounts of fat occupy the only area which is capable of containing a ligamentous structure.
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Fig. 4. On the left a piece of ordinary chicken wire is shown representing diagramatically the undisturbed appearance of pelvic areolar connective tissue as it is distributed throughout the retroperitoneal space of the pelvis. On the right the same wire has been grasped with an instrument and put under traction in its midportion to demonstrate the distortion of the pelvic areolar tissues resulting from traction on the cervix in the Manchester operation. Condensation and obliteration of the interareolar spaces account for the “ligaments” apparent at the operating table.
with the uterus retracted toward the opposite side, which gives the ligament a more convincing appearance. When removed for microscopic study, however, the tissues regain their true configuration, and only blood vessels, nerves, and lymphatic channels embedded in loose areolar tissue regardless of the plane of the section are seen. The chief bulk of this so-called transverse cervical ligament then is blood vessels (chiefly veins), nerves arising from the pelvic plexus, lymphatic channels, and their surrounding loose areolar connective tissue. Microscopic
anatomy
Microscopic section of the transverse cervical ligament removed at gross dissection confirms the findings of Koster. However, the nature of the connection of the ligament to the pelvic floor remains unanswered. While in Koster’s” study the relationship between the ligament and the surrounding looser retroperitoneal tissues was preserved, connections with the pelvic floor were destroyed. In order to preserve the relationship of all the tissue connected with and making up the
transverse cervical ligament, the following preparations were made. The unembalmed body of a 45-year-old nulliparous woman was obtained within 24 hours after death, injected with formalin, and frozen. The trunk was transected at the level of the fourth lumbar vertebra, and the lower extremities divided on a line passing the most dependent portion of the buttocks. While still frozen, the pelvis was reduced to sagittal sections each one-half inch thick, the first division being as near the midline as possible. Following cleansing and thawing, the sections were immersed in alcohol for 1 week to clear. Photographs were taken and blocks removed for preparation of microscopic slides for study. Blocks were cut in coronal, sagittal, and cross-section. Numerous stains were applied to the tissues for proper differentiation. Hematoxylin and eosin were used for general tissue identification. Masson’s trichrome preparations were used to differentiate connective tissue from smooth muscle. Weigert’s elastic connective tissue technique, counterstained with Masson’s, was used to identify the location of the
466
Range
and
Woodburne Am.
elastic elements present. These special stains were necessary because, as was pointed out by Campbell,6 smooth muscle bundles and fibroelastic tissue bundles appear very similar with the common hematoxylin and eosin preparations. ilnterior to the cervix a thin layer of areolar connective tissue separates the posterior vesical and anterior vaginal walls. It extends inferiorly a short distance between the musculature of the urethra and the vagina, but does not meet the superior fascia of the pelvic diaphragm. The collagen bundles are loosely arranged in a haphazard pattern and vascular and cellular elements are minimal in this region. The tissue between the posterior cervical and vaginal walls and the anterior rectal wall appear much the same. However, in most specimens some connection by fine filaments with the superior pelvic diaphragmatic fascia is visible. The thin layers blend indistinguishably with the much more dense areolar tissues lateral to the cervix. The greatest bulk lies inferior to the uterine arteries and invests the vascular tissue constituting the uterine circulation (Fig. 1B). In this area collagen bundles assume a more regular pattern, rougly parallel to the numerous veins. The connections with the pelvic floor are by multiple fine filaments. No fascial compartments can be differentiated from this areolar mass, and no endopelvic fascia sweeping up from the superior diaphragmatic fascia to invest the viscera is found. Smooth muscle fibers are abundant throughout this tissue, but on serial section are found to be associated with the walls and adventitia of the blood vessels. Cellular elements, especially fibroblasts, are numerous. There are few elastic fibers outside the vessel walls, although with special stains occasional isolated elastic fibers are seen. The same type of dense areolar tissue makes up the bulk of the bladder pillar which contains the vesical arteries and veins? and from these fine filaments of collagen sweep inferiorly and laterally to provide myriad connections to the entire superior layer of the pelvic diaphragmatic fascia. The areolar tissue is most dense at the site at
October J. Oht.
15, 1964 & (:yrwr.
which the fascia is penetrated by blood vessels. Lateral to the intersection of the uterine artery and ureter the blood vessels are larger and fewer in number and fatty tissues displace the areolar ground substance, forcing the collagen fibers into thin septa between the fat lobules (Fig. 2B). The amount of fat increases as the lateral pelivc wall is approached. At the site of origin of the uterine artery very little areolar tissue is found at any distance from the blood vessels (Fig. 3B). Smooth muscle cells are not found in this tissue and elastic fibers are rare. Myelinated and unmyelinated nerve fibers are numerous and accompany the uterine artery and veins from their origins at the lateral pelvic wall to the lateral margins of the uterus. Comment
With the elimination of the other pelvic ligamentous structures as an adequate means of support and in consideration of its demonstrated surgical value, the transverse cervical ligament has been accepted as the most important tissue for maintenance of the normal uterine position. Mengert*l showed that with traction applied to the cervix of a cadaver, prolapse occurred as soon as the paracervical and parametrial tissues were divided. Cutting of the other uterine ligaments and the muscles of the pelvic floor did not result in the same degree of descent when the same amount of traction was applied. We modified Mengert’s experiment so that the cervical attachment of the transverse cervical ligament was preserved. Separation from the surrounding areolar tissue was then carried out, following which the vessels and nerves were cut at their origin near the lateral pelvic wall and at the sites of penetration of the superior fascia of the pelvic diaphragm. A 1 Kg. weight was attached to the cervix and allowed to hang free over a pulley. Prolapse occurred in both specimens so prepared. Koster has pointed out that no distensible organ such as bowel, bladder, or uterus is surrounded by fixed ligamentous tissue. Their function makes this type of support impractical.
Anatomy
Our study has confirmed the fact that there is no ligament between the cervix and the lateral pelvic wall. What then supports the uterus? It would appear that the entire mass of retroperitoneal areolar connective tissue functions to support the pelvic viscera. While one isolated strand is incapable of preventing prolapse, the intact mass by means of its multitudinous attachments to the fascia lining the pelvis forms an effective and elastic support for the uterus. In the Manchester operation the bases of the broad ligaments are divided with the uterus under traction. The tissue masses which appear thick and strong are overlapped and sutured to the anterior wall of the amputated cervix. They may be compared to a piece of chicken wire, which, in its natural state, appears as a loose mesh similar to the pelvic areolar connective tissue (Fig. 4). When placed under traction, the chicken wire assumes the appearance of a strong cable, a situation which is duplicated by the paracervical tissues when placed under traction and this fact explains the apparent ligaments visible at the time of operation. Summary
and
conclusions
Gross dissection of the transverse cervical ligament was performed upon two intact
2. 3. 4. 5. 6. 7.
Anson, B. J., Curtis, A. H., and McVay, C. B.: Surg. Gynec. & Obst. 68: 161, 1939. Anson, B. J., Curtis, A. H., and Beaton, L. E.: Surg. Gynec. & Obst. 70: 643, 1940. Anson, B. J., Curtis, A. H.: Quart. Bull. Northwestern Univ. M. School 16: 275, 1942. Berglas, B., and Rubin, I. C.: Surg. Gynec. & Obst. 97: 287, 1953. Berglas, B., and Rubin, I. C.: Surg. Gynec. & Obst. 97: 677, 1953. Campbell, R. M.: AM. J. OBST. & GYNEC. 59: 1, 1950. Fothergill, W. E.: In Eden and Lockyer, editors: The New System of Gynecology,
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cervical
ligament
467
cadavers, and the removed tissues subjected to histologic study. With the pelvic viscera lying in their normal position, no ligament was demonstrable. With the uterus pulled strongly to the contralateral side, a “ligament” was observed and could be dissected. When fixed, sectioned, and observed microscopically, this “ligament” contained only loose areolar connective tissue enclosing blood vessels, nerves, and lymphatic tissue, With the “ligament” dissected free of the surrounding areolar tissues and the nerves and vessels divided near the lateral pelvic wall, uterine prolapse occurred when traction was applied to the cervices of two fresh autopsy specimens. A cadaver of an adult was specially prepared. The pelvis was removed intact and reduced to one-half inch sagittal sections. This preserved the normal relationship of the pelvic organs to the surrounding connective tissue. Blocks were removed, stained, cut in coronal, sagittal, and cross-section, and studied. Special staining techniques were used for accurate tissue identification. Representative sections are presented in Figs. 1 through 3. An explanation of the function of the retroperitoneal connective tissue in the support of the uterus is given.
REFERENCES
1.
of
8. 9. 10. 11. 12. 13. 14.
London, 1917, The Macmillan Co., vol. 2, p. 637. Goff, B. H.: Surg. Gynec. & Obst. 52: 32, 1931. Koster, H.: AM. J. OBST. & GYNEC. 25: 67, 1933. Mackenrodt, A.: Arch, Gynlk. 48: 393, 1895. Mengert, William F.: AM. J. OBST. & GYNEC. 31: 775, 1936. Power, R. M. H.: Surg. Gynec. & Obst. 79: 390, 1944. Sears, N. P.: AM. J. OBST. & GYNEC. 25: 67, 1933. Sears, N. P.: AM. J. OBST. & GYNEC. 29: 834, 1935.