Which ligaments are ligated during a total abdominal hysterectomy?

Ligaments Ligated During Total Abdominal Hysterectomy

During a total abdominal hysterectomy, the following ligaments are systematically ligated and divided: the round ligaments, the infundibulopelvic ligaments (if oophorectomy is performed) or utero-ovarian ligaments (if ovaries are preserved), the cardinal ligaments, and the uterosacral ligaments.

Sequential Order of Ligament Ligation

The procedure follows a systematic anatomical approach moving from superior to inferior structures:

1. Round Ligaments

• These are the first ligaments encountered and divided
• Located anteriorly, extending from the uterine cornua toward the inguinal canal
• Coagulated and cut to enter the retroperitoneum 1

2. Infundibulopelvic Ligaments OR Utero-ovarian Ligaments

• If bilateral salpingo-oophorectomy (BSO) is performed: The infundibulopelvic (IP) ligaments are ligated, which contain the ovarian vessels
• If ovaries are preserved: The utero-ovarian ligaments are ligated instead, preserving the IP ligaments and ovarian blood supply
• This decision depends on patient age, menopausal status, and indication for surgery 2, 3

3. Uterine Vessels

• The uterine arteries and veins are identified, ligated, and divided
• These branch from the internal iliac vessels and run along the lateral aspect of the uterus
• Critical step requiring identification of the ureter, which runs beneath the uterine artery ("water under the bridge")
• May be ligated at their origin from the hypogastric vessels in some techniques 4

4. Cardinal Ligaments (Mackenrodt's Ligaments)

• These are the primary lateral support structures of the uterus and cervix
• Contain significant vascular and neural structures in their intermediate and proximal portions
• The distal (cervical) section (approximately 2.1 cm) attaches to the lateral cervix and is the safest portion for surgical manipulation 5
• Posteriorly confluent with the uterosacral ligaments to form the cardinal-uterosacral confluence (CUSC) 5
• This confluence represents the "first pedicle" in vaginal hysterectomy but a later pedicle in abdominal approach 5

5. Uterosacral Ligaments

• Provide posterior support to the uterus and cervix
• Extend from the posterior cervix to the sacrum
• Ligated together with or just after the cardinal ligaments
• Form part of the CUSC, which is critical for subsequent vaginal vault support 5, 6

Critical Anatomical Considerations

Cardinal-Uterosacral Ligament Complex

The cardinal and uterosacral ligaments merge at their attachment to the cervix, forming the CUSC. When performing the final pedicles, incorporating these structures into bilateral "angle stitches" at the vaginal cuff margins significantly reduces the risk of subsequent vaginal vault prolapse 6. Studies demonstrate that methodical incorporation of the cardinal-uterosacral ligaments into the vaginal cuff reduces apical descent under traction by approximately 10% (p=0.026) 6.

Safety Zones

• Only the distal section of the cardinal ligament (nearest the cervix) is free of significant neural or vascular components and safe for surgical manipulation 5
• The intermediate section (average 3.4 cm) contains the ureter
• The proximal section (average 4.6 cm) is triangular, thick, and attached to the pelvic sidewall with major vascular branches 5

Common Pitfalls to Avoid

1. Ureteral injury: The ureter must be identified before ligating the uterine vessels and cardinal ligaments, as it runs beneath the uterine artery and through the intermediate cardinal ligament 7, 5

2. Inadequate vaginal vault support: Failure to incorporate the cardinal-uterosacral ligament complex into the vaginal cuff closure increases risk of subsequent vault prolapse 6

3. Vascular injury: The proximal cardinal ligament contains branches of the internal iliac vessels and should not be aggressively manipulated 5

4. Bladder injury: The vesicouterine ligament (anterior peritoneal reflection) must be incised carefully to mobilize the bladder away from the cervix before dividing the cardinal ligaments 7

Sequence Summary

The systematic order is: Round ligaments → IP/utero-ovarian ligaments → Uterine vessels → Cardinal ligaments → Uterosacral ligaments, with the cardinal-uterosacral confluence representing the final critical pedicle that should be incorporated into the vaginal cuff for optimal long-term support 1, 5, 6.