title: A historical perspective and evolution of our knowledge on the cardinal ligament.
abstract: OBJECTIVE
  The objective of our review is to provide a critical appraisal of the literature on the anatomy, structure and roles of cardinal ligaments (CL) in pelvic organ support, in conjunction with the currently evolving evidence based mainly on imaging and biomechanical modeling studies. We aim to contribute to the understanding of the pathophysiology of pelvic organ prolapse (POP) and stimulate new insights in research and development of novel surgical approaches for POP.
  
  
  METHODS
  PubMed, Embase, Scopus-Elsevier, and Cochrane Databases were searched in English and German. Studies from 1870 to 2012 were identified. The keywords used were "cardinal ligament," "transverse cervical ligament," "Mackenrodt ligament," "parametrium," and "paracervix." Cross check and Google search of the reference lists were used for missing articles.
  
  
  RESULTS
  We identified 35 related articles. Located at the base of the broad ligament, the CL is a supportive structure that attaches the cervix and upper vagina to the pelvic wall. The ligament contains the uterine vessels and hypogastric plexus. It conducts most of the pelvic loading forces. On MRI, it appears as a web-like structure around the axis of the internal iliac vessels. Their clinical importance is based on the apical supportive role and lymphatic-rich structure, involved in dissemination of cervical cancer.
  
  
  CONCLUSIONS
  The structure and role of the CL have been long studied, but remained unclear. Recent studies on imaging and biomechanics have improved our understanding and provide new insights which may enable the development of new techniques in prolapse surgery.
authors.affiliation: Department of Obstetrics and Gynaecology, Urogynaecology/Female Pelvic Medicine and Reconstructive Surgery Unit, St George's Healthcare Trust, London, United Kingdom.
authors.forename: George
authors.initials: G
authors.lastname: Iancu
authors.forename: Stergios K
authors.initials: SK
authors.lastname: Doumouchtsis
mesh_terms: D002584:Cervix Uteri / Q000033:anatomy & histology* / Q000098:blood supply / Q000294:innervation / Q000502:physiology / Q000601:surgery; D005260:Female; D013509:Gynecologic Surgical Procedures; D049672:History, 19th Century; D049673:History, 20th Century; D049674:History, 21st Century; D006801:Humans; D008022:Ligaments / Q000033:anatomy & histology* / Q000098:blood supply / Q000502:physiology; D014572:Urology / Q000266:history*
keywords: anatomy; cardinal ligament; pelvic connective tissue