A 45-year-old woman undergoes elective bilateral oophorectomy for ovarian cancer. During the procedure, the surgeon identifies and ligates the structure marked **D** in the diagram. Which of the following vascular and neural structures is at HIGHEST risk of injury if the **D** ligament is not carefully dissected and isolated before ligation?

Explanation

## Why "Ovarian artery, ovarian vein, and ovarian nerve plexus" is right The infundibulopelvic (suspensory) ligament of the ovary is the primary vascular and neural pedicle to the ovary. It carries the ovarian artery (from the abdominal aorta), ovarian vein (which drains to the IVC on the right and left renal vein on the left), and the ovarian nerve plexus. During oophorectomy, this ligament MUST be identified, carefully dissected, and ligated as a distinct step to prevent hemorrhage and ensure complete removal of ovarian vascular supply. This is a fundamental surgical principle in gynecological oncology (Williams Gynecology 4e; Gray's Anatomy 42e Ch 77). ## Why each distractor is wrong - **Uterine artery and uterine nerve plexus**: These structures are carried in the CARDINAL (Mackenrodt's) ligament, not the infundibulopelvic ligament. The cardinal ligament is ligated separately during hysterectomy or oophorectomy and is the primary support of the cervix and upper vagina. - **Ureter as it crosses the pelvic brim beneath the ligament**: While the ureter does pass beneath the infundibulopelvic ligament as it crosses the pelvic brim, the question asks what is CARRIED BY (contained within) the ligament itself. The ureter is a neighboring structure at risk of collateral injury, not a structure within the ligament. The clinical anchor specifies the contents of the ligament, not adjacent anatomy. - **Iliac vessels at the pelvic sidewall**: The iliac vessels are remote from the infundibulopelvic ligament. They are not contained within or directly associated with this ligament and are not at primary risk during its ligation. **High-Yield:** The infundibulopelvic ligament = ovarian artery + ovarian vein + ovarian nerve plexus; must be ligated during oophorectomy. Right ovarian vein → IVC; left ovarian vein → left renal vein (same drainage pattern as testicular vessels in males). [cite: Williams Gynecology 4e; Gray's Anatomy 42e Ch 77]