Surgical ligation of the hypogastric artery (internal iliac artery)

The article was professionally consulted by MSc, Dr. Trinh Thi Thanh Huyen - Obstetrician and Gynecologist - Department of Obstetrics and Gynecology - Vinmec Hai Phong International General Hospital

Hypogastric artery ligation reduces the mean pressure and blood flow rate in the pelvic circulatory system, which in turn reduces pelvic bleeding. Hypogastric artery ligation is often indicated to manage blood loss in the obstetric emergency and many other situations.

The iliac artery divides into two main branches, the external iliac artery (which becomes the femoral artery when it crosses the inguinal ligament) and the internal iliac artery (also called the hypogastric artery) when it descends into the pelvis. The hypogastric artery divides into two main branches, anterior and posterior branches.
When ligation of the hypogastric artery will block the blood flow to the hypogastric artery, thereby reducing the blood flow immediately in the pelvic organs (uterus, ovaries, fallopian tubes). During ligation of the hypogastric artery, the systolic pressure decreased by 85% in the uterine artery, the mean pressure decreased by 25%; Arterial pressure will become venous pressure thereby reducing blood pressure to the uterus.
If performed successfully, hypogastric artery ligation can reduce blood flow to the uterus by 48%. The advantage of hypogastric artery ligation surgery is that the vascular system in the female pelvis is very rich, so when ligation of one or two hypogastric arteries, vascular damage will not occur, internal organs will not be damaged. The pelvis will be supplied with blood by other blood vessels, no uterine necrosis will occur.
Hypogastric artery ligation is often indicated in cases of postpartum obstetric blood loss when medical interventions are ineffective or indicated in the following cases:
Bleeding in the pelvic region due to other causes equal previa , trauma or tear of the lower uterine segment. When performing complex surgery prone to pelvic bleeding, it is necessary to reduce the blood flow in the pelvic area during surgery. In some types of cancer surgery, such as trophoblastic cancer, it is necessary to reduce the amount of blood reaching the cancer cells. In emergency during surgery, patients with a lot of blood loss need quick intervention, these indications are often not specified in advance but depend on the progress of the surgery. Surgical ligation of the hypogastric artery should be indicated early, if the patient loses too much blood, it will cause clotting disorders.

Performer: Trained and experienced obstetrician and surgical assistant team. Equipment: Sterilized major surgical instruments; Neslaton catheter, Disteur used to dissect and expose hypogastric artery, ureter; cotton, bandage, surgical gauze, needle, fine thread. Patient: Should be prepared as an obstetric emergency. Before surgery, the patient will be consulted by medical staff about the purpose and possible complications after surgery.

Stage 1: Make a posterior peritoneal incision corresponding to the position of the hypogastric artery. Determine the landmark located at 2-3cm to the right and left of the protrusion. The pulsation position can be determined by using the index finger to probe the right and left main arteries descending to the bifurcation of the external iliac and internal iliac arteries. Once the landmark has been identified, use forceps to pull the peritoneal fold up and cut a hole in the posterior peritoneum at the right spot. Then, with curved scissors, separate the peritoneum and cut the peritoneum about 4 cm downward along the path of the internal iliac artery. During peritonectomy, attention should be paid to the ureter, because the ureter is located just below the peritoneum and crosses the iliac artery, if not careful the manipulation process can cause damage to the ureter. Stage 2: Perform exposure of the ureter and hypogastric artery. Use curved scissors to close the lower peritoneal surface, then open the nose to pull out to separate the subperitoneal layer, pay attention not to cut because it is easy to cut the ureter by mistake. Expose the ureter, then thread or a small rubber tube 1.5-mm in diameter through the lower surface of the ureter, pulling the ureter to the side. Perform the scissor dissection as above to continue dissecting the peri-iliac artery, exposing the main iliac artery gradually down to the bifurcation of the internal and external iliac arteries. Perform gentle separation of the internal iliac artery from the anterior wall of the iliac vein. Stage 3: Conduct ligation of the hypogastric artery. Using an obtuse nasal clip, pass through the inferior surface of the hypogastric artery and anterior to the hypogastric vein from the outside to the inside. When the medial margin of the hypogastric artery is clearly visible, open the clamp to clamp a perlon thread that is pulled through the hypogastric artery. After determining that the thread was properly threaded below the hypogastric artery, ligation of the hypogastric artery was performed, cutting the suture 1 cm from the knot. Stage 4: Suture to restore the peritoneum. Check the inguinal pulse, return the ureter to its original position, and then suture the peritoneal incision with catgut sutures.

Because the hypogastric artery is located in a difficult-to-access position, lies completely behind the peritoneum, adjacent to the ureter and many blood vessels, nerves, large and small lumbosacral muscles,... so the artery is ligated. Lowering is a difficult technique. Complications that may occur during surgery are:
Injury to the adjacent large blood vessels, the internal iliac vein and the external iliac vein. Ureteral injury. Retroperitoneal hematoma. Wrongly ligation of the external iliac artery causes lower extremity ischemia. The success of the surgery depends largely on the skill and experience of the surgeon. Patients after surgery need to be closely monitored, detect complications for timely intervention.