ABSTRACT

Background:

The cardinal ligaments insert onto the anterior surface of cervix and pubocervical fascia. They support the bladder base, preventing cystocele, and are a key support for the uterus, helping to prevent prolapse. Many cadaveric studies doubt the existence of the cardinal ligament.

Objective:

To define the live anatomy of the cardinal ligament (CL).

Patients and Methods:

A live anatomical study during routine surgical dissection involving 3 groups of patients. Group1: 61 women with cystocoele and/or uterine/apical prolapse. Group 2: 30 women with uterine pathology undergoing vaginal hysterectomy. Group 3: 3 women undergoing abdominal hysterectomy. The course of the CLs was assessed during surgery using the Tissue Fixation System (TFS), by rectal palpation under traction, by approximating them medially using Allis forceps to monitor the effect on the cystocoele and uterine prolapse.

Results:

The CLs attach onto the anterior surface of the cervix and are laterally displaced in patients with high cystocoele. The cardinal ligament is attached to a point 2cm above the ischial spine. Approximation of the laterally displaced CLs (“simulated operation”) in the operation room prior to commencing surgery restored a high cystocoele, anteverted the uterus, and partially restored a 3rd or 4th degree uterine prolapse.

Conclusions:

As well as inserting into the lateral part of the cervix, the cardinal ligaments also insert into the anterior part of the cervix. This insertion plays a major role in retaining the uterus in an anteverted position, in preventing a high cystocele, and to assist in uterine/apical support.