Table 1 Steps of the adapted nerve-sparing operation

Transect the round ligaments and open the peritoneum of the broad ligament above the level of the common iliac arteries

Identify and dissect the ureters from as cranially as possible up to the entrance of the ureteral canal

Lymphadenectomy along the external iliac vessels, the common iliac artery, the hypogastric artery, from the obturator fossa and the presacral area, clearing all of the lymph node-bearing fatty tissue. Also, the area lateral to and underneath the superior vesical arteries (“lateral parametrium”) is cleared from the lymphatic tissue

Develop the parietal spaces (see [14] for a more extensive description) by blunt dissection of the loose connective tissue lateral to the superior vesical arteries up to the bifurcation of the iliac vessels

Identify the origin of the uterine vessels from the pelvic side wall and dissect along the distal border of the vessels to separate the uterine vessels (“mesometrium”) from the underlying bladder mesentery. The bladder mesentery consists of the inferior vesical artery and veins, lymphatic vessels, fatty tissue and the distal part of the inferior hypogastric nerve plexus, with branches to the ureter, bladder, vagina and clitoris

Transect the uterine vessels at their origin and dissect this tissue (containing blood vessels, lymph vessels, fatty tissue and loose connective tissue) down along the pelvic side wall, then turn upwards in a medial direction, over the ureter to its medial side, using haemoclips or LigaSure sealing (Fig. 3)

Develop the presacral space by blunt dissection between the rectum medially and the ureters laterally

Put the peritoneum flap attached to the rectum under tension in a clamp and identify the hypogastric nerve system attached to the subperitoneal and dense connective tissue, grasp it in a Babcock clamp and dissect it laterally. The hypogastric nerve can be identified best at the entrance of the ureteral tunnel. At this level, the autonomous nerves run parallel to and closely dorsally to the ureter

Open the pouch of Douglas peritoneum and develop the prerectal space

Cut the peritoneal flap that has been separated from the hypogastric nerve halfway round the circumference of the rectum and continue the dissection to include all of the uterosacral ligaments close to where the ureters enter the ureteral canal

Open the bladder peritoneum, cut the supravaginal septum and dissect the bladder down from the cervix and the vagina

Open the rest of the ureteral canal (anterior leaf of the vesico-uterine ligament) using an Oberholt clamp or Uchida’s ureter spoon

Remove the ureter from the posterior leaf of the vesico-uterine ligament by dissecting the loose connective tissue embedding the ureter. The ureters are now completely freed up to their entrance into the bladder

Place clamps or LigaSure on the thin sheath of dense connective tissue along the cervix and vagina. This tissue has been called the medial part of the posterior leaf of the vesico-uterine ligament, paracolpium or vesico-vaginal ligament. It is almost continuous to the distal attachment of the uterosacral ligaments

Place Burke clamps on the vagina and cut the vagina below these clamps

Remove the uterus with the mesometrium wings and the long-tailed uterosacral ligaments

Close the vaginal cuff with interrupted resorbable sutures

Rinse the operating field with sterile water to detect persistent venous bleeding and provide for adequate haemostasis

Close the abdomen