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Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery

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Abstract

Background

Efforts to improve approaches to the so called “parametrium” with minimally invasive and less dangerous techniques have led to a better study of the anatomic location and composition of that region. Nevertheless, many misconceptions and confusions about the anatomy of the posterior parametrium and its structures still remain. This study aimed to review anatomic and surgical data and to identify several clear landmarks and surgical steps for a nerve-sparing approach to posterior parametrectomy in the course of radical pelvic surgery with or without rectal resection.

Methods

The literature and anatomic dissections of fresh, embalmed, and formalin-fixed female pelvis cadavers were reviewed. The authors’ laparotomic and laparoscopic case series also was reviewed for deep-infiltrating endometriosis as well as uterine, ovarian, and rectal cancer.

Results

The anatomic entity commonly termed the “posterior parametrium” can be identified as the conjunction of three important anatomic structures (ligaments): the cranial structure (uterosacral ligaments), the caudad structure (rectovaginal ligaments), and the laterocaudad structure (lateral rectal ligaments). Identification of these structures (containing autonomic innervations for pelvic viscera) may allow an accurate nerve-sparing surgical approach in many radical pelvic operations.

Conclusions

The incidences of urinary, rectal, and sexual morbidity after radical pelvic surgical procedures for oncologic diseases (rectal/ovarian cancer, advanced endometrial/cervical cancer, posterior pelvic recurrences) and deep severe endometriosis can be reduced by better knowing and dissecting the right embryo-anatomic planes of the so-called “posterior parametrium.”

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Acknowledgments

The authors acknowledge Professor Luciano Bovicelli from Department of Obstetrics and Gynecology at the University of Bologna, School of Medicine for his human example as well as his precious assistance and support in the surgical study design and in supervision of the manuscript writing. This report is dedicated with love to his memory. We gratefully acknowledge Mr. Adolfo Bigioni for his accomplished anatomic illustrations.

Disclosures

Marcello Ceccaroni, Roberto Clarizia, Giovanni Roviglione, and Giacomo Ruffo have no conflicts of interests or financial ties to disclose.

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Authors and Affiliations

  1. Gynecologic Oncology and Minimally-Invasive Pelvic Surgery Unit, International School of Surgical Anatomy, Sacred Heart Hospital, Ospedale Sacro Cuore-Don Calabria, Via Don A. Sempreboni No. 5, 37024, Negrar, Verona, Italy

    Marcello Ceccaroni, Roberto Clarizia & Giovanni Roviglione

  2. Department of Obstetrics and Gynecology, European Gynaecology Endoscopy School, Sacred Heart Hospital, Negrar, Verona, Italy

    Marcello Ceccaroni, Roberto Clarizia & Giovanni Roviglione

  3. Division of General Surgery, Sacred Heart Hospital, Negrar, Verona, Italy

    Giacomo Ruffo

Authors
  1. Marcello Ceccaroni
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  2. Roberto Clarizia
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  3. Giovanni Roviglione
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  4. Giacomo Ruffo
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Corresponding author

Correspondence to Marcello Ceccaroni.

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Ceccaroni, M., Clarizia, R., Roviglione, G. et al. Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery. Surg Endosc 27, 4386–4394 (2013). https://doi.org/10.1007/s00464-013-3043-z

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  • DOI: https://doi.org/10.1007/s00464-013-3043-z

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