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Enumerate the indications of ligation of internal illiac artery in obs and gyn

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indications internal iliac artery ligation obstetrics gynecology

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https://pmc.ncbi.nlm.nih.gov/articles/PMC10801552

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Indications for Ligation of the Internal Iliac (Hypogastric) Artery in Obstetrics and Gynecology

The internal iliac artery (IIA), also called the hypogastric artery, is the principal blood supply to the pelvic viscera. Its ligation reduces pulse pressure in the pelvis (abolishing the "trip-hammer effect" of pulsatile flow, as described by Burchell), thereby converting the pelvic arterial system to one resembling a venous capillary network and allowing effective hemostasis by clot formation. It is indicated in two broad categories: obstetric and gynecologic, and within each, indications can be prophylactic or therapeutic.

A. Obstetric Indications

1. Postpartum Hemorrhage (PPH) - the most common indication
  • Refractory uterine atony unresponsive to uterotonics (oxytocin, methylergonovine, carboprost, misoprostol) and bimanual compression
  • PPH where uterine artery ligation (O'Leary sutures) and uterine compression sutures (B-Lynch, Hayman) have failed
2. Abnormal Placentation (Morbidly Adherent Placenta)
  • Placenta accreta, increta, or percreta with intractable bleeding
  • Prophylactic ligation prior to hysterectomy in known placenta accreta spectrum when hemorrhage is anticipated
3. Placenta Previa
  • Hemorrhage uncontrollable by other measures, particularly when associated with accreta
4. Placental Abruption (Abruptio Placentae)
  • Abruptio placenta with uterine atony causing intractable hemorrhage
5. Uterine Rupture
  • Hemorrhage from uterine rupture not controlled by repair
6. Post-cesarean / Post-hysterectomy Hemorrhage
  • Bleeding after cesarean delivery when conservative measures fail
  • Hemorrhage following cesarean hysterectomy - hysterectomy alone may not be sufficient
7. Abdominal/Ectopic Pregnancy
  • Abdominal pregnancy with pelvic implantation of the placenta, where the placenta cannot be safely removed
8. Post-abortal Hemorrhage
  • Uncontrollable bleeding following surgical or medical termination of pregnancy
9. Cervical Pregnancy or Cervical Laceration
  • Uncontrolled hemorrhage from extensive cervical lacerations or low implantation site bleeding
10. Intraoperative Prophylaxis (Prior to High-Risk Procedures)
  • Prophylactic ligation or balloon catheter placement prior to planned cesarean hysterectomy in high-risk cases (e.g., placenta percreta)

B. Gynecologic Indications

1. Advanced Pelvic Malignancy
  • Uncontrollable hemorrhage from advanced carcinoma of the cervix, uterus, vagina, or vulva (historically the very first indication described by Howard Kelly in 1894)
  • Prophylactic ligation during oncogynecologic surgery with expected profuse bleeding (e.g., radical hysterectomy, pelvic exenteration)
2. Post-hysterectomy Hemorrhage
  • Hemorrhage after total or subtotal hysterectomy when the bleeding source cannot be localized to a specific vessel
  • Retroperitoneal hematoma with hemodynamic instability post-hysterectomy
3. Traumatic/Iatrogenic Pelvic Hemorrhage
  • Massive pelvic hemorrhage due to iatrogenic injury (e.g., trocar insertion during laparoscopy) or external trauma (gunshot wounds, pelvic fractures)
  • Pelvic retroperitoneal hematoma secondary to trauma
4. Coagulopathy-Related Hemorrhage
  • Massive pelvic hemorrhage or retroperitoneal hematoma due to primary or secondary coagulation disorders (e.g., DIC), even with no single identifiable bleeding vessel
5. Patients Refusing Blood Transfusion
  • Actual or anticipated hemorrhage in patients who refuse blood products (e.g., Jehovah's Witnesses), used prophylactically before pelvic surgery

Mechanism (Why It Works)

Burchell's classic experiments demonstrated that bilateral IIA ligation reduces arterial blood pressure in pelvic vessels by ~85%, converting the system to one with venous-level flow. This does not cause ischemic necrosis because of the extensive pelvic collateral network (ovarian arteries, lumbar arteries, inferior mesenteric, femoral, and internal pudendal anastomoses). Women have subsequently delivered normal infants after bilateral IIA ligation, confirming its long-term safety.

Key Practical Points

  • Bilateral ligation is more effective than unilateral; unilateral ligation has limited indications (e.g., isolated unilateral hematoma or unilateral cancer)
  • IIA ligation is a second-line surgical measure, used when conservative measures (uterotonics, compression sutures, uterine artery ligation, tamponade balloons) fail
  • It does not preclude future interventional radiology (arterial embolization) in unligated cases, but bilateral ligation effectively eliminates the possibility of future angioembolization - a major downside
  • The procedure should be performed distal to the origin of the posterior division of the IIA to preserve gluteal blood supply
  • Perioperative complications include inadvertent ureteric injury, iliac vein injury, and transient bladder dysfunction
Sources:
  • Berek & Novak's Gynecology (Berek & Novak), p. 161 - surgical principles, hypogastric artery ligation for massive pelvic hemorrhage
  • Creasy & Resnik's Maternal-Fetal Medicine, pp. 947-948 - indications and technique in PPH management
  • Sabiston Textbook of Surgery, 21e - surgical ligation as hemorrhage control; limitations in PAS
  • Schwartz's Principles of Surgery, 11e - obstetric hemorrhage management and O'Leary/hypogastric ligation
  • Kostov et al., 2023 (PMC10801552) - comprehensive review of IIA ligation indications in OB/GYN
  • GLOWM Chapter on Internal Iliac Artery Ligation - prophylactic vs. therapeutic classification
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