Surgical anatomy of the uterosacral ligament

Introduction and hypothesis This study aims to elucidate and expand current knowledge of the uterosacral ligament (USL) from a surgical viewpoint. Methods Studies were performed on 12 unembalmed cadaveric pelves and five formalin-fixed pelves. Results The USL, 12-14-cm long, can be subdivided into three sections: (1) distal (2-3 cm), intermediate (5 cm), and proximal (5-6 cm). The thick (5-20 mm) distal section, attached to cervix and upper vagina, is confluent laterally with the cardinal ligament. The proximal section is diffuse in attachment and generally thinner. The relatively unattached intermediate section is wide, and thick, well defined when placed under tension, more than 2 cm from the ureter and suitable for surgical use. The strength of the USL is perhaps derived not only from the ligament itself, but also from the addition of extraperitoneal connective tissue. Conclusions The USL can be subdivided into three sections according to thickness and attachments with the intermediate section suitable for surgical use, particularly for vaginal vault support.