Hypogastric Artery Ligation Technique
- Author: Chee Weng (David) Leong, MBBS; Chief Editor: Vincent Lopez Rowe, MD more...
Ligation of the hypogastric (internal iliac) artery can be performed either via an open approach (intraperitoneal or extraperitoneal) or via an endovascular approach. In an emergency situation, bilateral retroperitoneal approaches to control both the right and the left hypogastric artery are time-consuming; accordingly, this approach is often reserved more for elective settings.
A midline incision is made. Viscera are packed away to the contralateral side of the pelvis. The bifurcation of the iliac artery is identified via two landmarks, the sacral promontory and an imaginary line through both anterosuperior iliac spines.
On the left side, the sigmoid mesocolon is mobilized via an incision over the lateral peritoneum. The peritoneum can be incised longitudinally directly over the iliac bifurcation, and the incision can be extended proximally and distally for a few centimeters. The medial peritoneal flap and medial pelvic contents are retracted medially and the lateral flap retracted laterally. Blunt dissection is then performed around the vessels, opening the areola tissue.
Once the bifurcation is exposed, the hypogastric artery is confirmed as the branch coming off at right angles and coursing medially and inferiorly. The external iliac artery is visually confirmed as traversing laterally and superiorly over the psoas muscles to form the common femoral artery beneath the inguinal ligament. Careful and meticulous dissection is performed to separate the internal iliac artery from the veins.
A right-angle forceps is used to separate the plane between artery and vein and to isolate and control the artery with a Silastic loop. The internal iliac artery is then ligated with ligature clips or suture ties, as required.
A transverse curvilinear skin incision is made over the lower abdomen. The incision is started two fingerbreadths above the midpoint between the umbilicus and pubis and is extended laterally from the edge of the rectus muscle obliquely upward to a point two fingerbreadths above and medial to the anterior superior iliac spine. The external and internal oblique and transverse abdominal muscles are divided in line with this incision.
The extraperitoneal plane is entered and bluntly developed superiorly and inferiorly, and the peritoneal sac is retracted medially to expose the iliac vessels. The hypogastric artery is controlled by careful dissection in the plane between the artery and the vein, and the vessel is controlled and ligated as described above.
A percutaneous approach is made by directing a 19-gauge puncture needle into the common femoral artery in a retrograde fashion and angled at approximately 45-60° cranially. Ultrasonographic guidance facilitates positioning of the puncture.
A wire is passed into the artery through the needle, and an appropriately sized arterial sheath is advanced into the artery via the Seldinger technique, then secured in place.
The index hypogastric artery can be approached from either the ipsilateral or the contralateral side after the aortic bifurcation is crossed. Appropriately shaped catheters are used to advance a hydrophilic guide wire into the hypogastric artery. Once the index hypogastric artery has wire access, the sheath can be advanced into the artery, and either the vessel can be coil-embolized or an Amplatzer plug can be deployed to occlude the vessel.
Kelly H. Ligation of both internal iliac arteries for hemorrhage in hysterectomy for carcinoma uteri. Bull John Hopkins Hosp. 1894. 5:53.
Evans S, McShane P. The efficacy of internal iliac artery ligation in obstetric hemorrhage. Surg Gynecol Obstet. 1985 Mar. 160(3):250-3. [Medline].
Clark SL, Phelan JP, Yeh SY, Bruce SR, Paul RH. Hypogastric artery ligation for obstetric hemorrhage. Obstet Gynecol. 1985 Sep. 66(3):353-6. [Medline].
Mwipatayi BP, Naidoo NG, Dreyer C, Jadwat S, Beningfield SJ. Isolated Internal Iliac Artery False Aneurysm Presenting asUrinary Retention. EJVES Extra. 2004. 8:86-89.
Boynukalin FK, Boyar H, Gormus H, Aral AI, Boyar N. Bilateral hypogastric artery ligation in emergency setting for intractable postpartum hemorrhage: a secondary care center experience. Clin Exp Obstet Gynecol. 2013. 40(1):85-8. [Medline].
Papp Z, Toth-Pal E, Papp C, Sziller I, Gavai M, Silhavy M. Hypogastric artery ligation for intractable pelvic hemorrhage. Int J Gynaecol Obstet. 2006 Jan. 92(1):27-31. [Medline].
Fiori O, Deux JF, Kambale JC, Uzan S, Bougdhene F, Berkane N. Impact of pelvic arterial embolization for intractable postpartum hemorrhage on fertility. Am J Obstet Gynecol. 2009 Apr. 200(4):384.e1-4. [Medline].
Rayt HS, Bown MJ, Lambert KV, Fishwick NG, McCarthy MJ, London NJ. Buttock claudication and erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair. Cardiovasc Intervent Radiol. 2008 Jul-Aug. 31(4):728-34. [Medline].
Bratby MJ, Munneke GM, Belli AM, Loosemore TM, Loftus I, Thompson MM. How safe is bilateral internal iliac artery embolization prior to EVAR?. Cardiovasc Intervent Radiol. 2008 Mar-Apr. 31(2):246-53. [Medline].
Kim MK, Oh BC, Kim HJ, Kim YG, Jeong YB. Complete bladder gangrene caused by bilateral hypogastric artery ligation during laparoscopic radical hysterectomy. J Minim Invasive Gynecol. 2009 Jan-Feb. 16(1):76-7. [Medline].
Sinnathamby CS. Last’s Anatomy. 11. Elsevier Limited; 2006.
Yu PC, Ou HY, Tsang LL, Kung FT, Hsu TY, Cheng YF. Prophylactic intraoperative uterine artery embolization to control hemorrhage in abnormal placentation during late gestation. Fertil Steril. 2009 May. 91(5):1951-5. [Medline].