Fig. 1.

Paracervical resection in Wertheim and Latzko & Schiffmann procedures. Shown are schematic illustrations of an LP excision. The drawings are based on Wertheim and Latzko methods described in Operative Gynecology by Peham-Amreich (1934; original German publication in 1930). The Wertheim method involved excising the bladder pillar and uterorectal ligament, lateralizing the ureter and exposing the CL, followed by its excision on the medial aspect to the ureter (A). Latzko method entailed excavation of the paravesical and pararectal spaces on the lateral aspect to the ureter, followed by excision of the separated TCL (dotted black line in A). However, unlike the Wertheim method, as perpendicular excavation of both the paravesical and pararectal spaces progressed, this excavation terminated at the iliococcygeus muscle and on the sacral aspect, i.e. in the vicinity of S2-3 (vertical cylinder in A) (Yabuki et al.,1991, Höckel et al., 2003). A septum, i.e. the Mackenrodt ligament, then appears between the two aforementioned spaces (B). A perspective view of the sagittally sliced septum is shown in B, which is demonstrated by a dotted red line on A. To solve this ‘dead end’ problem caused by appearance of the septum, L&S created a new artificial space or the lower portion of the pararectal space between the capsule and levator ani muscle by incising this capsule that forms the base of the paravesical space (B). This capsule corresponds to the horizontal connective tissue ground bundle of P&A (1934) or the deep investing fascia (TA, 1998) or superior fascia of the pelvic diaphragm (TA, 1998). They then unified this new space and upper portion of the aforementioned pararectal space by breaking the septum with the fingertip at the level of the sacrospinous ligament (double-headed black arrow in A and black arrow in B) (P&A, 1934). They concluded that longitudinal clamping and excision of the origin of Mackenrodt ligament could be successfully carried out. a; uterus, b; bladder, c; rectum, d; uterine cervix, e; vagina, f; ureter, l; TCL, n; Latzko’s pararectal space (upper portion), q; paravesical space, r; CL, s; pararectal space (lower portion), t; levator ani muscle, u; septum or Mackenrodt ligament or perpendicular connective tissue ground bundle, v; uterine broad ligament, w; paracolpium, uu; pelvic sidewall, vv; capsule or deep investing fascia or horizontal connective tissue ground bundle, ww; sacrospinous ligament, mn; Wertheim’s dorsal space, mq; Wertheim’s ventral space.