T H E TECHNIQUE OF RADICAL HYSTERECTOMY
FOR CARCINOMA OF T H E CERVIX
GRAYH. TWOMBLY,
M.D.
I N T H E last ten years, there has been a
marked increase in the popularity of sur-
gery as a method of treating carcinoma of
the cervix uteri. Led by many sur-
geons have returned to the methods of
Wertheim and Latzko with, on the whole,
some encouraging results. I t has be.en
found immediately that the high mortality
rates reported by Wertheim,lo and more
recently by Bonney, are entirely unneces-
sary with present methods of anesthesia,
blood replacement, antibiotic therapy,
intestinal intubation, and early ambula-
tion. For instance, in the first year’s experi-
ence, Wertheim reported an operative
mortality of 46 per cent.10 This was later
cut to 15 to 18 per cent, which still is
almost prohibitively high from the modern
point of view. I n contrast to this, Meigs has
done ninety-one radical hysterectomies
without a single death.6 I n the forty-five
cases in the author’s series, there has been
only one death (from status asthmaticus
on the fifth postoperative day).
While it is still not apparent whether
radical surgery will ever be able to give as
many definitive cures of cancer of the
cervix as does skillful and well-administered
roentgen-ray and radium therapy, it is more
than clear that certain cases can be saved
by no other means-the early tumor that
has not responded satisfactorily to radio-
therapy, for instance. It behooves the
gynecologist who is treating many cases to
become thoroughly familiar with the tech-
nique of radical hysterectomy so that he
may perform such operations, when they
are indicated, with skill and dispatch.
Wertheim’s original operation from his
From the Department of Obstetrics and Gyne-
cology, College of Physicians and Surgeons of Co- and therefore unobtainable by the average
lumbia University, and the Sloane Hospital for gynecologist. Perhaps the most useful illus-
Women, New York, New York.
Received for publication, May g, 1950.
own description would not be considered
today to be good cancer surgery. Since it
was done in days before prolonged anes-
thesia was safe and at a time when blood
transfusion or blood banks were unheard
of, it had to be rapid. He says that at first
the procedure took him as much as two
and a half hours, but later when he became
more skillful, this was cut to an hour for an
uncomplicated case or an hour and fifteen
minutes for a difficult one! Even allowing
for the great skill he must have developed
in doing so many operations (he reported
270 in 1905),9 still the operation was ob-
viously not one employing sharp, careful
dissection or meticulous hemostasis, but
was rather one done largely, as his illustra-
tions show, by rough, rapid, blunt finger
dissection. T h e principle of removing the
regional nodes en bloc and in continuity
with the diseased cervix was not followed
at all. T h e regional nodes were palpated
after the hysterectomy had been completed
and any that seemed to be enlarged were
dissected out and removed.
Bonney’s description of his operation is
quite similar to Wertheim’s, though one
,would judge it a little less rapid and a little
more meticulous. Bonney dissected out the
regional nodes routinely by blunt and
finger dissection, but as specimens separate
from the uterus and cervix.
If one endeavors to find detailed descrip-
tions of radical hysterectomy for cervix
cancer, they are hard to locate. Either the
illustrations are poor or the technique very
bad from the point of view of removal of
nodes with care and in continuity with the
tumor, or they have been published in
books that are expensive and out of print
trations are those in Peham and Amreich
 CANCER November 1950
(now out of print), although these authors
hardly show clearly the dissection of the
nodes. Doderlein and Kronig in their
Operative Gynukologie, a German text,
have very fine illustrations at least pictur-
ing the distribution of the regional nodes
and how they appear during radical
liysterectomy.
Because it was necessary for us to learn
what appears to be a satisfactory technique
for the surgical removal of cervical cancer
by hard experience and trial and error,
with suggestions from Dr. Meigs and others
who had done various kinds of radical
operations, it seems worth while to illus-
trate and describe in detail the steps of this
procedure so that others may learn it more
rapidly or use our description as a pro-
cedure to be improved upon. T h e opera-
tion has been worked out with the intent
constantly in mind of (1) gentle, complete
dissection of the lymph nodes draining the
cervix, (2) a minimum of cutting across of
lymphatics or direct extensions from the
tumor toward the nodes, (3) a minimum of
squeezing and kneading of the cancer by
rough technique. T o do a radical hysterec-
tomy in an hour, or even in two, would
seem almost ips0 facto evidence that the
procedure had been done too carelessly or
roughly. Time is cheap. T h e surgeon
usually gets only one opportunity to be
thorough enough. Four hours or longer is
not too long to do a proper job.
SELECTION
O F , CASES
I t has become increasingly apparent that
obesity is a contraindication to radical hys-
terectomy. T h e difficulties of working with
inadequate exposure in a deep pelvis may
be overcome somewhat by a transverse inci-
sion cutting the recti muscles just above
their insertions, but the dissection of the
walls of the pelvis when these are heavily
padded with fat is very unsatisfactory. One
is occasionally tempted to do such surgery
for one reason or another, but such pro-
cedures usually end with the sensation that
one has really been engaging in surgical
gymnastics and that the patient would have
been better off with some localized form of
radium therapy.
T h e ideal case for radical surgery is, of
course, the thin patient with a League of
Nations Stage-I or -11 lesion. Old age of
itself does not seem to be a serious contra-
indication. Certainly, severe hypertension
or a history of cardiac decompensation
would make one hesitate to venture upon
the strain of prolonged and radical surgery.
PREOPERATIVE
PREPARATION
T h e most important study that should
precede radical hysterectomy is investiga-
tion of the genitourinary tract. This should
include, first, cystoscopy and pelvic exam-
ination with the cystoscope in the bladder.
If the tumor invades the base of the blad-
der as evidenced by induration, edema of
the mucosa, or loss of bladder-base mobil-
ity, the type of operation about to be
described is not suitable. Possibly more
radical surgery is the treatment of choice,
but this question has not been studied ade-
quately as yet and will not be discussed
here.
T h e second genitourinary study that
should be done is an intravenous pyelo-
gram. Cases showing partial or complete
ureteral obstruction have not done well
with radical hysterectomy in our experience.
Perhaps transplantation of the ureter will
give better results.
A preoperative cystometric examination
is of value in dealing intelligently with the
most common postoperative complication
-difficulty in voiding and a large residual
urine.
Some sort of estimation of the adequacy
of kidney function should be a n important
part of the general medical work-up. Non-
protein nitrogen or blood-urea-nitrogen
determinations are done routinely.
T h e question of the possible involvement
of the rectal wall by carcinoma of the
cervix should be considered. Usually, simple
rectal palpation is sufficient to give one a
fairly good idea of how far posteriorly the
 TECHNIQUE OF RADICAL HYSTERECTOMY FOR CANCER OF THE CERVIX . Twombly [977
tumor invades. Occasionally, proctoscopy is very little packing or retraction. but makes
indicated. As with cystoscopy, edema and the operator crouch off balance, straining
hyperemia usually indicate microscopic in- the leg on the side toward the patient and
vasion. tiring him unnecessafily. Also, the light is
T h e general condition of the patient is apt to be very poor deep in the pelvis with
of great importance and should be investi- this arrangement. We have gradually come
gated carefully. T h e studies usually done to feel that a moderate Trendelenburg
preoperatively include a chest roentgeno- position is better. One depends then on
gram, electrocardiograph, prothrombin packing to expose the pelvis and the
time, blood count, and particularly a deter- overhead light can be used easily to get
mination of the blood volume. Since it has good general illumination without the use
been appreciated that a patient may have of spotlights, devices that are always only
a normal blood count and hemoglobin but temporarily satisfactory. Time spent in ar-
a greatly reduced blood volume, multiple ranging the table and overhead light so
transfusions have made it possible to re- that the latter will shine into the exposed
store the red-cell mass to normal levels pelvis is apt to be time saved in the end.
preoperatively. T h e ease with which pa- T h e incision is usually a mid-line one
tients withstand major surgery when their from symphysis to a few centimeters above
blood volume is normal makes the extra the umbilicus. T h e well-known adage that
trouble of such studies and controlled pre- a centimeter longer incision near the
operative transfusions well worth the effort. symphysis is worth five at the umbilicus is
A “red cell mass” of 34 ml. per Kg. is pertinent. Skin, fat, fascia, and muscles
thought to be normal for most women with should be separated down to the symphysis.
cancer of the cervix. As has been mentioned already, in the
slightly obese patient, a transverse incision
T E C H N I Q U E OF RADICAL HYSTERECTOMY
through all layers gives a greatly improved
exposure. T h e rectus fascia is divided as in
E x p o s m e . One cannot do an adequate the classical Pfannenstiel incision, but the
dissection of the pelvis without good light- rectus muscles are cut from their insertions
ing and exposure. One must see without at the pubic rami.
effort all the structures to be dissected. T o T h e wound edges should be held apart
obtain such exposure, one must have good with a self-retaining retractor such as the
anesthesia. T o have intestinal loops ex- Balfour. We cover the wound edges with
truded into the operative field in the saline-soaked gauze pads and use the an-
middle of a meticulous pelvic lymph-node terior blade of the retractor to keep the
dissection is destructive of time, patience, bladder flap of peritoneum out of the way.
and delicacy of technique. T h e anesthesia Assistants with abdominal retractors get
most likely to give proper relaxation for tired. Self-retaining retractors do not.
the entire duration of the operation is con- Lately it has been found most advanta-
tinuous spinal, supplemented by intra- geous in exposing the pelvic organs to roll
venous pentothal. If one has a sufficiently up large wet abdominal gauze pads to form
expert anesthetist who thoroughly under- cylinders measuring 6 x 2y2 inches. These
stands the importance of uninterrupted are placed u p under the abdominal wall,
relaxation, other agents such as gas- one transversely in the mid-line to hold u p
oxygen-ether, cyclopropane, etc. may be the small bowel, one to the right to push
used, but in general spinal anesthesia is up the cecum, and one on the left behind
more satisfactory. which are packed any redundant loops of
T h e patient’s position on the table is sigmoid.
important. A high Trendelenburg position Having followed these simple directions,
keeps the intestines out of the wound with the operator ought to have in clear sight
9781 CANCER November 1950

FIG. 1. T h e pelvic organs as viewed f r o m the patient’s left side at t h e start of

radical hysterectomy. T h e wound edges ure blocked off with wet saline pads and
held apart with a Balfozrr self-retaining retractor. T h e intestines have been
packed up out of the operative field with cylinders of saline-soaked gauze. T h e
uterus is drawn forward and out of the pelvis by means of straight clamps
placed across the round ligaments and tubes at the cornua. T h e drawing is made
as though the broad laganaent and peritonewti were transparent, showing the
ureter, uessels, and nodes through them. Actually in a thin patient occasionally
the ureter can be seen and in rore instances the start of the hypogastric artery.
T h e nodes are not visible. T h e y may be palpable if enlarged.

all the pelvic organs, well illuminated,
with no troublesome loops of rectosigmoid
obscuring the fundus. (Fig. 1.) This should
be the case with no assistant pulling on any
retractor. One should be able to forget
anesthesia, bowels, light, and normal re-
traction and concentrate entirely on pelvic
lymph-node dissection. Our first illustra-
tion shows the location of the most impor-
tant of these.
Lymph-Node Dissection. If the operator
stands at the patient’s left side, thc right
pelvis is dissected first. After palpation of
the uterus and pelvic walls, the uterus is
picked u p with two straight Pean hysterec-
tomy clamps across tubes and broad liga-
ments, a procedure that stops back bleeding
from branches of the uterine arteries when
the round ligaments are cut. T h e bladder
flap of the peritoneum is picked up with
forceps and cut across from side to side
with scissors. By gentle blunt dissection,
the cervix and vagina can be separated
from the under side of the bladder. This is
often a bloodless procedure and tells one
at once whether there is any extension of
the cervical carcinoma into the bladder
 TECHNIQUE OF RADICAL HYSTERECTOMY FOR CANCER OF THE CERVIX T w o m b l y [979

FIG. 2 . T h e peritoneum between the uterus and bladder has been cut across
from round ligament t o round ligament and the ceroix and trigone separated
by gentle blunt dissection. If the carcinoma infiltrates the base of the bladder,
this will become apparent at tliis stage and will Preclude further carrying out
of this type of operation. T h e right round ligament has been ligated near the
anterior abdominal wall and cut. Traction on the suture helps t o expose the
external iliac artery for the subsequent node dissection.

base. It should take less than a minute.
T h e forefinger is pushed down to about 2
cm. below the cervix in the mid-line. (See
Fig. 2.)
If no carcinoma is encountered, the right
round ligament is ligated close to the ab-
dominal wall and cut. T h e infundibulo-
pelvic ligament is picked u p where it
crosses the pelvic brim and doubly ligated.
At this point, care is taken not to include
the ureter, which crosses the pelvic brim
very close to the vessels but slightly medial
to them. I n most patients, one can readily
see it shining through the peritoneum. T h e
distal end of the infundibulopelvic liga-
ment is clamped. It is our practice to use
00 silk for ties on these ligaments and 000
for smaller vessel ties.
Having tied and cut the right infundib-
ulopelvic ligament, the peritoneum be-
tween it and the round ligament is incised.
This exposes the fat, lymph nodes, and
9801 CANCER November 1950

FIG. 3. T h e right infundibulopelvic ligament has been doubly ligated as it

crosses the peluic brim, care being taken to a-c~oidthe ureter and to free it u p by
an extension of the incision in the peritoneum upward along the iliac artery.
T h e peritoneum between the round ligament and infundibulopelvic ligament
has been cut. A l l areolar and fatty tissue and whatever lymph nodes are present
have been dissected off the psoas muscle and external iliac artery as a sheet from
the lateral side toward the mid-line.

areolar tissue over the right external iliac
artery. Starting lateral to this artery, these
structures are dissected medially as a sheet,
exposing psoas muscle and the bare wall of
the artery. As one proceeds around the
artery, the external iliac vein and the base
oE the hypogastric artery come into view.
Frequently one finds a fairly large node
nestled into the bifurcation of the conimon
iliac artery, usually somewhat medial to
the vein. This is the hypogastric node and
must be removed by careful dissection. T h e
appearance of the operation at this stage is
shown in Fig. 3.
How far up to carry the dissection at this
stage is something of a question. Lymph
nodes surround the common iliac artery to
the bifurcation and extend on u p the ab-
dominal aorta. It has been our practice to
make a clean dissection from the round
ligament to the bifurcation of the common
iliac artery, take any obviously enlarged
nodes lying just above the brim of the
pelvis along the common iliac artery, but
leave higher nodes undisturbed. Just
medial to the ureter is a lateral sacral node,
usually not seen. (See Fig. 1.) I n one opera-
tion in which the nerve supply was being
dissected for demonstration, this node was
found enlarged. It was removed and found
FIG. 4. Inset: T h e dissection of nodes,
fat, and areolar tissue is being carried
around the external iliac uessels by
sharp dissection, exposing the contents
of the obturator fossa and the hypo-
gastric node nestled an the bifurcation
of t h e common iliac artery. M a i n Illus-
tration: T h e obturator fossa has been
dissected out completely, exposing the
obturator neriie from where it emerges
behind the hypogastric uein to its disap-
pearance in the obturator canal. T h e
hypogastric node has been dissected free,
exposing the hypogastric artery and the
uterine artery. T h e obliter-ated vitelline
artery rontinues anteriorly toward the
femoral canal. All nodes o n the right
wall of the peluis haue been gently dis-
sected free and reflected toward the
specimen (mid-line). T h e ureter is still
adherent to the medial leaf of the
peritoneum.
9821 CANCER November 1950
to contain cancer. T h e patient has re-
mained well now three and a half years.
Perhaps this node should be removed more
often. As a practical matter, if all the iliac
nodes below the bifurcation, the hypogas-
tric nodes, and the nodes in the obturator
fossa are removed cleanly and en bloc, we
feel that the first stage in metastasis has
been removed and that we have done as
adequate a dissection as is practical.
Having dissected all nodes, fat, and
areolar tissue off the external iliac artery
and vein, a Cushing vein retractor is
hooked over these vessels and they are
drawn gently to the side by an assistant.
This exposes the obturator fossa from
which, in turn, the nodes and areolar tissue
are dissected by sharp dissection toward
the mid-line. (Fig. 4.)At this point, retrac-
tion of the tissues on the medial side of the
dissection with a gauze sponge on a sponge
holder is very helpful. T h e obturator nerve
is exposed two thirds of the way down the
fossa. It is stripped of its surrounding fat
from the hypogastric vein to its entrance
into the obturator foramen, a distance of
about 4 cm. Occasionally, particularly if
an enlarged node is present, there may be
some bleeding from the dissection of the
fossa. If this cannot be stopped by careful
clamping, a small hot pack and pressure
will control it. T h e bleeding is usually
venous and from small branches going
from the lymph nodes. This stage of the
dissection is finished by reflecting all iliac,
hypogastric, and obturator nodes toward
the mid-line and dissecting downward
from the stump of the round ligament and
the femoral ring toward the ureter until the
bladder is separated from the anterior leaves
of the broad ligament and the obliterated
hypogastric artery is exposed.
Dissection of the Ureter. T h e ureter
should have been visualized first when the
infundibulopelvic ligament and ovarian
vessels were cut. It is closely adherent to
the medial leaf of the peritoneum. As the
hypogastric artery is freed of the surround-
ing fat and lymph nodes and the perito-
neum pulled toward the mid-line, the ureter
will go with it. T h e first branch of the hy-
pogastric artery to become clearly defined
in the dissection is the uterine. T h e supe-
rior gluteal and obturator arteries come
off on the posterolateral aspects of the
hypogastric and are not seen for that
reason. T h e uterine artery is freed at its
origin from the hypogastric, doubly ligated
with 00 silk on a ligature carrier, and cut
between the ties. ,4clamp on the distal cut
end serves as a convenient guide and re-
tractor in the subsequent dissection of the
ureter.
It is our observation that catheterization
of the ureters is not necessary and may be
harmful. T h e ureters can be located easily
and safely where they cross the brim of the
pelvis. They lie medial and posterior to
the ovarian vessels and are closely adherent
to the medial layer of the peritoneum.
While catheterization allows them to be
distinguished by palpation, it increases con-
siderably the possibility of trauma. It was
observed that postoperative hematuria was
very rare in those cases operated upon by
the technique being described. O n the
other hand, radical hysterectomies done in
the same hospital by other surgeons who
placed catheters in the ureters have almost
invariably shown blood in the urine. Of
forty-five cases done by the presently de-
scribed technique, only two have devel-
oped ureterovaginal fistulas.
Meigs says that the ureter is supplied in
the pelvis by three small arteries, any two
of which may be cut with impunity.5 Cut-
ting all three, he believes, leads to ureteral
necrosis and ureterovaginal fistulas. S a m p
son years ago studied very carefully the
anatomy of the ureter and his diagrams
show the circulation to be somewhat vari-
able. He emphasized that one must be very
gentle with the vascular sheath of the
ureter. I n Sampson’s mind, stripping this
structure is responsible for ureteral slough-
ing. We have endeavored to combine these
viewpoints and cut as little of the blood
supply as possible and at the same time
treat the ureter with the utmost gentleness.
 TECHNIQUE OF RADICAL HYSTERECTOMY FOR CANCER OF THE CERVIX - Twombly [983

FIG. 5. T h e middle third of the ureter has been freed, with as little trauma as
possible, from the surrounding structures and retracted with an empty Penrose
drain. T h e uterine artery has been ligated and cut where it arises from the
hypogastric artery. T h e uterine i~einsare being ligated by passing a ligature
carrier down along the top of the ureter in several bites.

We believe it important never to pick u p
the ureter with forceps. If tension must be
used in dissecting it free from its bed, this
is done by picking u p the areolar tissue
around it or by passing a piece of empty
Penrose rubber tubing around it and
gently retracting with that.
At first, the ureter is left attached to the
peritoneum for about one third of its
course between pelvic brim and bladder.
It. must be freed from its bed as it ap-
proaches the cervix, however. Long Matz-
enbaum dissecting scissors are of great
value in this procedure. T h e ureter can be
freed quickly and gently until it dives
under the mass of fat, areolar tissue, and
veins that connect the back of the bladder
with the parametrium. This structure has
been called the vesico-uterine ligament.
T h e uterine artery lies posterior to it and
is easily retracted out of the way. However,
the uterine veins form a plexus in this
bundle where they join u p with veins from
the back of the bladder. T o dissect down
from the top is like cutting down between
the arms of many letter “Y”s-one is
bound to cut into the main vein as one gets
deeper into the pelvis and into the more
inaccessible parts of the dissection.
Hemorrhage at this stage of the opera-
tion may be troublesome or often exasper-
ating. T h e veins are large enough to pour
9841 CANCER Nonember 1950

FIG. 6. T h e right ureter has been freed completely f r o m its bed f r o m 3 cm.
below the pelvic brini t o the trigone. Paranaetriu and pelvic l y m p h nodes are
seen attached t o the site of the uterus. A similar dissection will be carried out
at this point o n the left wall of the pelvis and left ureter, the operator changing
sides and standing at the patient’s right side.

out considerable blood if unclamped. On
the other hand, they collapse with slight
pressure or tension and their open ends
may be very hard to see.
Wertheim’s technique at this stage was
blunt finger dissection along the course of
the ureter to the bladder base, with ligation
of the bundle so defined. This is a trauina-
tic and crude maneuver. We believe that
passing a threaded ligature carrier along
the course of the ureter a little at a time
and cutting between the subsequent suture
and a clamp placed on the uterine side is
the most satisfactory procedure. (Fig. 5.)
T h e ureter must be exposed and freed
from its bed all the way to where it disap-
pears into the trigone. I t is certainly i n this
maneuver that most of the accidents to the
ureter occur. It should be re-emphasized
that picking u p or stripping it in this dis-
section may result in necrosis and fistula.
When all the lymph nodes have been
dissected from the right pelvic wall and the
ureter carefully freed froin the pelvic brim
to the trigone as just described (Fig. 6), the
same procedure is carried out o n the other
side, the operator changing sides with the
first assistant for this procedure.
Division of the Uterosacral and Macken-
rodt’s Ligaments-Znneroation of the Blad-
 TECHNIQUE OF RADICAL HYSTERECTOMY FOR CANCER OF THE CERVIX . Twombly [985

FIG. 7. B o t h sides of the pelvis h a m been dissected. T h e uterus is being pulled

strongly forward and upward t o @it the medial leaves of the peritoneum on the
stretch and expose the bottom of the posterior cul-de-sac. T h e ureter on the
right is being drawn laterally t o prevent injury as the peritoneum is cut on that
side. T h e dotted line shows the proposed incision in the peritoneum. T h e
posterior cul-de-sac is usually more di@ilt to expose than is shown in this
illustration.

der. Figure 7 shows both sides of the
pelvis completely dissected and the uterus
strongly drawn upward and forward, put-
ting the peritoneum on the stretch. T h e
dotted line shows where the peritoneum is
to be incised. Note that the ureter must be
carefully retracted and that the bottom of
the peritoneal incision is in the extreme
bottom of the posterior cul-de-sac well
below the uterosacral ligaments. T h e expo-
sure is not usually nearly so clear or simple
as is shown in the figure. T h e posterior cul-
de-sac is apt to be very deep and obscured
by the falling back of the cervix. Pulling
up sharply on the rectum is a help in ex-
posing it. If the incision is much too high
on the rectum, troublesome bleeding will
be encountered from the anterior rectal
wall. If the peritoneum is incised just
where it should be, where rectum and
vagina meet, the two may be separated
bloodlessly by very gentle blunt dissection,
often with the finger. It should be re-
marked that the anterior rectal wall turns
at right angles just at the floor of the pos-
terior cul-de-sac and runs forward to the
vagina. A possible accident that may occur
quite easily at this stage is perforation of
the anterior rectal wall. It is to be avoided
by remembering that the rectum is not in
9861 CANCER November 1950

FIG. 8. T h e uterosacral ligaments on the lelt are being clamped. T h e posterior

clamp is a Moynihan gull-duct clamp, whzle the clamp toward the uterus is a
large curved Pkan hysterectomy clamh. T h e clamps are really applied in a more
vertical position than is shown, being drawn toward the right side in the picture
f o r clarity. Moynihan’s clamp is very useful. It has long handles and therefore
can be applied easily deep tn the peluis. T h e cunie of the tips is just right to
carry the dissection naturally acroAs the pelvic floor to the posterolateral aspects
of the vagina. T h e diflerence i n cuive between the Moynihan clamp and the
Pian allows easy division of the uterosacral ligament with long (12-inch) dissect-
ing scissors. After division, t h e tissues held in the Moynihan clamp are secured
with suture ligatures.

the position one would expect it, as judged
by the position of the rectosigmoid one
sees descending into the pelvis, but is run-
ning anteriorly below the pelvic perito-
neum.
Having separated the rectum from the
vagina for 5 to 6 cm. in the mid-line, it
becomes apparent that the cervix is being
held in the pelvis by strong fibrous bands
surrounding the rectum on either side.
These are a continuation of the uterosacral
ligaments extending downward into the
pelvis. They are shown being clamped in
Fig. 8. For this purpose, the gall-duct
 TECHNIQUE OF RADICAL HYSTERECTOMY FOR CANCER OF THE CERVIX - T w o m b l y [987

FIG. 9. T h e uterosacral and cardinal ligaments have been clamped, divided,

and tied o n both sides, leaving the uterus, tubes, ovaries, parametria, and pelvic
lymph nodes attached only by the skeletonized vagina 3 to 4 cm. below the
cervix. A Wertheim right-angle clamp closes 08 the upper part of the vagina
and prevents gross contamination of the dissected pelvis by cancer. T h e lower
part of the vagina is supported by Moynihan clamps o n each side. A deep right-
angle retractor lifts the base of the bladder out of the way. T h e vagina will be
cut across between the clamps.
clamps designed by Moynihan and known Lateral to the uterosacral ligaments lie
by his name are invaluable. They are potential spaces filled with areolar tissue,
placed quite far posteriorly on the utero- called the pararectal spaces. Anterior to
sacral ligaments and long curved PCan these spaces, and between them and similar
clamps are used between them and the cer- areas known as the paravesical spaces, lie
vix. T h e difference in curve between the the structures known variously as the cardi-
two kinds of clamps allows easy cutting of nal ligaments or Mackenrodt’s ligaments.
the ligament between them. As the utero- They contain vessels that are branches of
sacral ligaments are severed, the uterus, the hypogastric arteries and veins running
cervix, and vagina are abruptly freed and to the vagina. These ligaments are clamped
can be pulled forward and u p out of the and cut as far laterally as possible toward
pelvis. It is our opinion that these struc- the walls of the pelvis. If one uses Moyni-
tures form one of the most important sup- han’s clamps, the line of dissection nat-
porting structures of the uterus in the urally takes a course toward the back of the
pelvis. vagina about 4 cm. below the cervix. T h e
9881 CANCER N o v e m b e r 1950

FIG. 10. T h e sympathetic nerues supplying t h e peluic viscera come f r o m t h e

presacral nerues and t h e sympathetic cord. T h e s e u n i t e t o f o r m a m u l t i p l e
stranded nerue band, t h e inferior hyi()ogastric plexus. T h i s is cut in radical
hysterectomy since it runs in the deeper portions of t h e uterosacral ligaments.
T h e parasympathetic n e w e s ?ise f r o m t h e Zd, 3 d , and 4 t h sacral roots a n d pass
forward and j o i n t h e deeper parts of t h e infeyior h y p o p s t r i c plexus. T h e s e
nerves (riervi eiigentes) control t h e e m p t y i n g of t h e bladder. T h e sensations of
heat, cold, and p a i n for t h e most part are carried in their fibers. M a n y are un-
doubtedly c u t , or traumatized during radical hysterectomy, this accounting for
postoperative urinary retention and frequent failure t o e m p t y t h e bladder com-
pletely.
dissection is carried toward the vagina, I t should be noted that the commonest
care being taken not to clamp or injure the postoperative complication of radical hys.
ureters, until the uterus, tubes, ovaries, terectoniy is paresis of the bladder. Almost
parametriums, and nodes are held in the invariably the patient has difficulty in com-
body by the vaginal tube alone, and this is pletely emptying her bladder for several
skeletonized at a point 4 cin. below the weeks or even months after such an opera-
posterior fornix and about 3 cm. below the tion, and, in some of these cases, evidence
anterior fornix. (Fig. 9.) of very considerable denervation is present,
F'IG. 11. T h e specz-
men has been re-
moved and the vaginal
c u f is being closed
with chromic 0 figure-
of-eightstitches. These
are placed in such a
way as to inuert the
mucosa. N o drains
are used. Inset: T h e
raw areas are covered
by sewing t h e peri-
toneal edges together.
9901 CANCER Nouember 1950
often with loss of ability to differentiate
heat and cold in the bladder. A brief con-
sideration of the innervation of the bladder
shows why this is so. T h e sympathetic
fibers supplying the pelvic viscera come
from two sources, the presacral nerves, of
which there are two too many, that pass
over the bifurcation of the aorta and into
the pelvis over the promontory of the
sacrum, and the sympathetic cord that lies
alongside the promontory. A prominent
ganglion of the latter can usually be seen
if one attempts to dissect out the lateral
sacral node. T h e presacral nerves divide
into two main bundles sweeping to right
and left around the rectum, unite with
branches from the sympathetic cords and
come to lie in the deeper parts of the utero-
sacral ligaments as the inferior hypogastric
plexuses. (See Fig. 10.) Of necessity, one
cuts these nerves in doing a radical hyster-
ectomy. It is generally agreed that the
sympathetic nerves are not necessary for
normal voiding. They contain some sensory
fibers, send motor fibers to the ureters and
probably the vessels of the bladder, but
have minimum motor function. T h e plex-
uses are joined in their deeper parts by
fibers from the 2d, 3d, and 4th sacral
nerves. These are the parasympathetic fi-
bers or nervi erigentes. If they are severed
at the corda equina, bladder sensation is
lost and voluntary voiding is interfered
with. They are probably not usually com-
pletely cut, since they arise very deep in
the pelvis and extend toward the neck of
the bladder below the usual line of dissec-
tion. T h e hypogastric plexus and the
pelvic nerves (nervi erigentes) are said to
form a series of ganglia, the largest of
which (Frankenhauser’s ganglion) lies on
the anterior surface of Mackenrodt’s liga-
ment lateral to the cervix. This ganglion
can usually be found by careful search of
the specimen after radical hysterectomy. I n
thirteen of sixteen specimens examined by
multiple sections by A. Wong in our clinic,
ganglia of varying size were found in the
parametrial tissues.
It is hardly surprising that difficulties
with bladder function occur after such
marked interference with bladder innerva-
tion. Indeed, the difficult thing to under-
stand is why all patients do not have
complete bladder denervation. T h e fact is,
however, that they do not, and that normal
function has returned in all cases observed,
although in some only after a prolonged
interval, such as a year. N o way of avoiding
nerve injury and still preserving the radical
nature of the operation seems to be con-
ceivable.
Remoual of Specimen-Closure. A so-
called Wertheini clamp is placed across the
skeletonized vagina to close the part of the
vagina containing the cancer and so pre-
vent gross contamination of the operative
field with cancer cells. T h e corners of the
vagina are held with Moynihan clamps on
either side. (Fig. 9.) T h e vagina is cut across
and the specimen removed. It should con-
tain in one piece uterus, tubes, ovaries,
parametriums, pelvic lymph nodes, and a
vaginal cuff of one third to one half the
length of the vagina. T h e vagina is closed
with figure-of-eight stitches of 0 chromic
catgut. These are placed in such a way as
to invaginate the mucosal edges. (Fig. 11.)
T h e stumps of the uterosacral and Mack-
enrodt’s ligaments are ligated with suture
ligatures of 00 silk. T h e pelvis is perito-
nealized with a running stitch of 0 chromic
catgut. We like to fill the space below the
peritoneal floor with sulfamylon.3 N o
drains are placed either in the vagina or
through the abdominal wound.
POSTOPERATIVE
CARE
T h e patient is placed on constant blad-
der drainage with an indwelling catheter
for a week. I n many instances tidal drain-
age was used, but this does not seem to be
of any advantage either in preventing in-
fection or in hastening a return to normal
function. When the catheter is removed,
the patient usually is able to void spon-
taneously but is apt to have a large residual
urine. She is catheterized at first twice a
day and later once a day after voiding and
 TECHNIQUE OF RADICAL HYSTERECTOMY FOR CANCER OF THE CERVIX
the residual urine measured. This is con-
tinued until the amount is less than 100 cc.,
or until the patient is deemed able to go
home, and some satisfactory arrangement
can be made for supervision of her bladder
disability or for self-catheterization.
Penicillin, 400,000 units, is given twice
daily and 0.5 gm. streptomycin every six
hours for a week. Antibiotics are usually
discontinued thereafter.
T h e patient is made to get out of bed
briefly the first day and for longer intervals
thereafter, emphasis being placed on walk-
ing and standing rather than sitting in a
chair. Of course the usual examinations for
phlebothrombosis and thrombophlebitis
are carried out, and treatment with anti-
coagulants instituted if indicated. When
one considers the extent to which the iliac
veins are denuded of their surrounding
tissues, it is surprising that no case of ob-
vious thrombosis in these large vessels has
been encountered.
One cannot help but be impressed by the
general good health of patients who have
had radical surgery if they remain free of
recurrence. T h e late bladder sclerosis and
hemorrhage and similar difficulties with
the rectum that one sees after radiation
therapy of course are absent. T h e vagina is
apt to be very short after the operation,
REFERENCES
1. BONNEY, V.: T h e treatment of carcinoma of the
cervix by Wertheini’s operation. A m . J. Obst. &
Gynec. 30: 815-830, 1935.
2. DODERLEIN, A. S. G., and KRONE, B.: Operative
Gynakologie. Leipzig. G. Thiema. 1912.
3. HOWES,E. L.: Local chemotherapy of wounds;
tissue toxicity of certain antihacterial substances.
Surg., Gynec. & Obst. 83: 1-14, 1946.
4. MEICS,J. V.: Carcinoma of the cervix-Wer-
theim operation. Surg. Gynec. & Obst. 78: 195-199,
1944.
5 . MEIGS,J. V.: T h e Wertheim operation for car-
cinoma of the cervix. Am. 7. Obst. & Gynec. 49: 542-
553, 1945.
6. MEIGS,J. V.: T h e radical operation of cancer
. Twombly [ Y Y I
perhaps not more than half its normal
length, but the patients seem to complain
not at all about this defect.
SUMMARY
T h e details of radical hysterectomy for
carcinoma of the cervix have been de-
scribed and pictured. T h e operation
should include meticulous dissection of the
pelvic lymph nodes in continuity with the
uterus and cervix. It should be gentle,
avoiding blunt dissection or the squeezing
or massaging of tumor. Early ambulation
is advocated.
T h e most frequent complications are
genitourinary ones. Ureteral fistulas may
be avoided usually by care in not squeez-
ing, clamping, or picking u p the ureters
with forceps or stripping their vascular
sheaths. Ureteral catheterization is not
necessary and may be harmful. Difficulty
in voiding, together with large quantities
of residual urine, follows the almost com-
plete denervation of the bladder that seems
necessary in doing a complete cancer oper-
ation. This difficulty is usually only of brief
duration. Precautions should be taken,
however, to avoid or clear up urinary in-
fections that may result from stasis and
catheterization.
of the cervix. Am. J. Roentgenol. 57: 679-684, 1947.
7. PEHAM,H. VON,and AMREICH,I.: Operative
Gynecology. (Transl. by L. K. Ferguson.) Philadel-
phia. J. B. Lippincott Co. 1934.
8. SAMPSON, J. A.: T h e efficiency of the periure-
teral arterial plexus, and the importance of its
preservation in the more radical operations for
carcinoma cervicis uteri. Johns Hopkins Hosp. Bull.
15: 39-46, 1904.
9. WERTHEIM. ET AL.: A discussion on the diae-
nosis and treatment of cancer of the uterus. B r z .
M . J. 2: 689-704, 1905.
10. WERTHEIM, E.: Zur Frage der Radicalopera-
tion beim Uteruskrebs. Arch. f. Gynaek. 61: 627-668,
1900.