The cardinal (Mackenrodt, transverse cervical) ligament is the main lateral support of the cervix and upper vagina, a condensation of connective tissue at the base of the broad ligament that runs to the pelvic sidewall alongside the uterosacral ligaments. It carries the uterine vessels, the parametrial venous plexus and autonomic nerves of the inferior hypogastric plexus. Its laxity after vaginal delivery or with collagen weakness contributes to uterine prolapse. The ureter passes through its upper part about 1-2 cm lateral to the cervix, directly beneath the uterine artery ('water under the bridge').
| Origin | Lateral cervix and upper vaginal wall |
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| Insertion | Lateral pelvic wall over the obturator internus fascia and internal iliac vessels |
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Provides lateral support to the cervix and upper vagina, resisting uterine descent.
The ureter passes beneath the uterine artery within the upper cardinal ligament about 1-2 cm lateral to the cervix, so clamping this tissue at hysterectomy without identifying the ureter is a leading cause of ureteric injury. In radical (Wertheim) hysterectomy for cervical cancer the parametrium, including the cardinal ligaments, is resected for clear margins after the ureters are dissected free. The cardinal and uterosacral ligaments (level I support) are used to resuspend the vaginal vault in prolapse surgery.
Ureter at risk as it crosses under the cardinal ligament during hysterectomy. Systematic lateral dissection before clamping prevents ureteral injury.
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