Approach Considerations
Ligation of the internal iliac (hypogastric) artery can be performed either via an open approach (intraperitoneal or extraperitoneal) or via an endovascular approach. Laparoscopic internal iliac artery ligation has also been described. [21, 22]
In an emergency situation, bilateral retroperitoneal approaches to control both the right and the left internal iliac artery are time-consuming; accordingly, this approach is often reserved more for elective settings.
In general, ligation of the hypogastric arteries is preferable to embolization; if the latter is performed, proximal embolization is preferable to distal embolization, in that it decreases the risk of ischemic complications. [23]
Transabdominal/Transperitoneal Approach
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 anterior superior 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 internal iliac 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.
Retroperitoneal Approach
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 internal iliac 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.
Endovascular Approach
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. The use of ultrasonography (US) to guide the approach facilitates the 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 internal iliac 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 artery. Once the index internal iliac artery has wire access, the sheath can be advanced into the artery, and either the vessel can be coil-embolized [24] or an Amplatzer plug can be deployed to occlude the vessel.
Complications
Specific complications of internal iliac artery ligation may include the following:
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Infertility and impotence in men
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Buttock and thigh claudication
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Damage to the ureter
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Ischemic limb from damage to the common or external iliac artery
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Damage to other pelvic vessels
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Damage to pelvic nerves, including the hypogastric plexus
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Spinal ischemia
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Bladder gangrene (rare) [25]
It has been suggested that internal iliac artery ligation may reduce ovarian reserve in the short term. [26]
