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  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Methods
 ::  Results
 ::  Discussion
 ::  References
 ::  Article Tables

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PAPERS
Year : 1993  |  Volume : 39  |  Issue : 4  |  Page : 194-6

Ligation of internal iliac arteries for control of pelvic haemorrhage.


Dept of Gynaecology and Obstetrics, KEM Hospital, Parel, Bombay, Maharashtra.,

Correspondence Address:
Y S Nandanwar
Dept of Gynaecology and Obstetrics, KEM Hospital, Parel, Bombay, Maharashtra.

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PMID: 0007996495

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 :: Abstract 

This is a retrospective review of the internal iliac ligations (IAL) done over a period of 3 years. Both gynaecological and obstetric cases were considered. A total of 46 ligations were performed. The additional treatment required was hysterectomy to control haemorrhage. Intra-and post-operative complications were noted. A comparative review of the effectiveness of IAL in different situations is done and alternative modalities of treatment are considered.


Keywords: Combined Modality Therapy, Comparative Study, Female, Hemorrhage, epidemiology,etiology,surgery,Human, Hysterectomy, Iliac Artery, surgery,Intraoperative Complications, epidemiology,etiology,Ligation, adverse effects,methods,mortality,Morbidity, Pelvis, Postoperative Complications, epidemiology,etiology,Retrospective Studies, Survival Rate, Treatment Failure,


How to cite this article:
Nandanwar Y S, Jhalam L, Mayadeo N, Guttal D R. Ligation of internal iliac arteries for control of pelvic haemorrhage. J Postgrad Med 1993;39:194

How to cite this URL:
Nandanwar Y S, Jhalam L, Mayadeo N, Guttal D R. Ligation of internal iliac arteries for control of pelvic haemorrhage. J Postgrad Med [serial online] 1993 [cited 2014 Dec 18];39:194. Available from: http://www.jpgmonline.com/text.asp?1993/39/4/194/594





  ::   Introduction Top


Pelvic haemorrhage, whether postpartum or related to surgery, is associated with a great degree of morbidity and mortality and has to be controlled immediately without compromising the rest of the pelvic blood supply. Ligation of the internal iliac arteries (IAL) a time tested, easy method, achieves the goal, as seen by extensive radiographic studies[1].

Internal iliac artery ligation can be traced back to 1812 when it was done unilaterlly for a gluteal aneurysm. Baurngartner used bilateral artery ligation for treatment of haemorrhage secondary to carcinoma of the uterus while Howard Kelly[2] of Baltimore in 1894 was the first one to ligate both the internal iliacs along with ovarian arteries for bleeding cervical carcinoma with extensive broad ligament involvement.


  ::   Methods Top


This is a retrospective review of the internal iliac ligations done at University hospital over a 3 year period. Both unilateral and bilateral ligations, performed as a prophylactic and therapeutic measure, were considered. The approach used to reach the internal iliac arteries and the additional treatment required (eg hysterectomy) to control haemorrhage was noted. The intra-operative and post-operative complications, morbidity and mortality were recorded.


  ::   Results Top


A total of 46 internal iliac ligations (IAL) were Deriormed, 44 bilateral and 2 unilateral. The indications are listed in [Table - 1]. All therapeutic and most prophylactic ligations were done through a retro-peritoneal approach along with lymphadenectomy for the treatment of carcinoma cervix. Thirty-one of thirty-eight ligations done for gynaecological indications were associated with radical hysterectomy, a prophylactic measure against cervical carcinoma. The single case of intra-operative unilateral ligation was also a prophylactic ligation, Following hysterectomy for a 24 week size fibroid uterus, dilatation of the ureter on the right side was noted on table due to a constricting sture of the uterine vessel pedicle. A right-sided internal iliac artery ligation was performed, the uterine pedicle suture was deligated and thus the ureter was released. The patient had an uneventful recovery.

Obstetric complications necessitated 8 internal iliac artery ligations. Three obstetric hysterectomies were subtotal hysterectomies, 2 had been performed at private hospitals for placenta previa, the third was for rupture uterus at the University Hospital. This patient needed an unilateral internal iliac ligation for post-operative right vaginal angle bleeding.

The complications encountered during and after surgery were as follows: 1. intra-operative ureteric injury, 2. superficial injury to the internal iliac vein, 3. failure to control haemorrhage in one case of atonic PPH, and 4. one patient died due to post-operative DIC.


  ::   Discussion Top


After ligature, circulation in the parts supplied by the internal iliac artery would be carried on by the anastomosis of i) the uterine and ovarian arteries; ii) the middle and the superior vesical arteries; iii) the iliolumbar with the last lumbar and iv) the lateral sacral with the middle sacral arteries[3]. Burchell[1] has put forward the mechanism responsible for controlling pelvic haemorrhage following ligation of internal iliac artery without compromising blood supply. He observed that blood flowed freely from a severed uterine artery even after bilateral IAL. The ligation of internal iliacs greatly dampened the pulse pressure and transformed the pelvic arterial system into a venous like system with slow and sluggish blood flow. The 'trip hammer effect' of the arterial pulsation was lost. The blood clots, which were formed distal to the ligation, therefore remained in place it also allowed for identification of remaining individual bleeders for ligation, which would otherwise be difficult[4].

Burchell[1] also proved that with bilateral ligation, the drop in pulse pressure was 85% whereas with unilateral ligation it was 77% on the same side and 14% on the opposite side. The mean arterial pressure decreased to 24% with bilateral ligation and with unilateral ligation the decrease was 22% on the same side and 10% on the opposite side. The rate of blood flow dropped to about 48% on the same side after ligation.

Reich and Nechtow[5] have emphasised that the biggest pitfall with IAL was waiting too long to perform it. The traditional surgical approaches towards IAL have been either trans-peritoneal or extra- pe riti one al. On the other hand, ligation of the internal iliac vessels from the gluteal aspect is considered as a resort when every means of controlling haemorrhage from the pelvic approach has been unsuccessful [6]. In addition the extent of haemostasis achieved and collaterals formed remains same as for the selective anterior division ligation[7]. Therefore, main trunk ligation is recommended to decrease operative time.

The failure to control post-partum haemorrhage occurred in 1 of the 4 patients due to uterine atony. The reported incidences of such failure in other series are 25%[8] and 34%[9]. Stephen and Patrician on the other hand have found the procedure effective in atonic PPH and have reported 50% failure rate in placenta accreta and uterine tears. A comparison of our hospital data with other studies is shown in [Table - 2] and [Table - 3]. In our study, we had one ureteric injury, one superficial injury to the internal iliac vein and one mortality. None of our patients had any delayed complications like ischaemic necrosis, parathesias of gluteal region or bladder atony.

Embolisation of the internal iliac artery with foreign and autologous material is a relatively recent alternative to the ligation. It can only be done in central institutes where skilled arteriographic facilities are available and can have problems like peripheral reflux embolisation. It is of great use in bleeding due to malignancy and has the advantage of retaining the temponade effect of the haematoma. Full term pregnancies with no complications like intrauterine growth retardation have been reported after bilateral internal iliac and ovarian artery ligation. O'leary[12] carried out 110 cases of bilateral uterine artery ligation for treatment of postcaesarean haemorrhage and has reported 12 pregnancies in his study. Mengert et al[13] reported 5 term pregnancies in patients who had IAL. Three of these patients had an additional ovarian artery ligation.

According to Smith and Wyatt[14] whenever possible, a prior attempt to control pelvic haemorrhage by arteriographic embolisation should be made because this does not compromise the possibility of successful subsequent surgery. Internal iliac ligation is a valuable surgical procedure and should be the first line of treatment where conservation of the uterus is desired. The complications encountered are few if the procedure is performed carefully and with knowledge of pelvic anatomy. The expertise to perform IAL should therefore be present in the armamentarium of every obstetrician and gynaecologist who may be faced with the need to control pelvic haemorrhage immediately.

 
 :: References Top

1. Burchell RC. Physiology of internal iliac ligation. J Obstet Gynaecol Br Commonwealth 1968; 75:642-651.  Back to cited text no. 1    
2.Kelly H. Ligation of both internal iliac arteries for haemorrhage in hysterectomy for carcinoma uterus. John Hopkins Med J 1894; 5:53-54.  Back to cited text no. 2    
3.Williams LP, Warwick R, Dyson M, Bannister LH. Gray's Text Book of Anatomy, 37th ed. Edinburgh: Churchill Livingstone; 1989, pp 777- 781.  Back to cited text no. 3    
4.Iffy L, Charles D, Humbert LR, Jahir CS. Textbook of Operative Perinatology and Surgical Management of Obstetric Haemorrhage. Invasive Obstetric Techniques, 1st ed. New York: MacMillan Publishing Co; 1984, pp 751-758.  Back to cited text no. 4    
5.Reich WJ. Nechtow MJ. Ligation of internal iliac arteries. A life saving procedure for uncontrollable gynaecological and obstetric haemorrhage. Int Surgery 1961; 36:157-168.  Back to cited text no. 5    
6.Thomas B. Gynaecological Surgery and Urology, 2nd ed. St Louis, USA: CV Mosby Co; 1957, pp 441-446.  Back to cited text no. 6    
7.Nandkishore G, Patikar VD, Niyogi GM, Jhankaria, Vaidya PR. Hypogastric artery ligation and its aftermath. J Obstet Gynaecol India 1991; 41:252-255.  Back to cited text no. 7    
8.Dalvi SA, Penkar SJ, Nagwekar S, Chaubal D. Ligation oi internal iliac artery procedure of choice in obstetric gynaecological haemorrhage. J Obstet Gynaecol India 1988; 38:575-578.  Back to cited text no. 8    
9.Chattopadhyay SK. Surgical control of obstetric haemorrhage internal iliac artery ligation or hysterectomy. Int J Gynaecol Obstet 1990; 32:345-352.  Back to cited text no. 9    
10.Stephen E, Patrician MS. The efficacy of internal iliac artery ligation in obstetric haemorrhage. Surg Gynaecol Obstet 1985; 160:250-253.  Back to cited text no. 10    
11.Saha AM. Scope of internal iliac artery ligation in obstetric and gynaecological emergences. J Obstet Gynaecol India 1989; 39:244-247.  Back to cited text no. 11    
12.O'Leary JA. Pregnancy after bilateral uterine artery ligation. Obstet Gynaecol 1980; 55:112-113.  Back to cited text no. 12    
13.Mengert WJ, Burchell RC, Blumstein RW, Daskal JK. Ligation of internal iliac and ovarian arteries. Obstet Gynaecol 1969; 34:664-666.  Back to cited text no. 13    
14.Smith D, Wyatt J. Embolisation of the hypograstic arteries in the control of massive vaginal haemorrhage. Obstet Gynaecol 1977; 49:317-322.   Back to cited text no. 14    


    Tables

[Table - 1], [Table - 2], [Table - 3]

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