Internal Iliac (Hypogastric) Artery Ligation

The historical background of ligature of the internal iliac artery for the control of hemorrhage is not clear1. Numerous publications have attributed the procedure to different surgeons in diverse specialties worldwide2–4. In the United Kingdom and the United States, the operation was reported before 1900 and, since then, many surgeons have practiced it and found it useful. Howard Kelly first pioneered ligation of the internal iliac (hypogastric) artery in the treatment of intraoperative bleeding from cervical cancer prior to this technique being applicable to postpartum hemorrhage5. Studies have shown that, in postpartum hemorrhage, the reduction of pulse pressure may only be achieved in 48% of cases. It is for this reason that other workers have advocated bilateral ligation of the internal iliac arteries to significantly improve the chances of reducing pelvic pulse pressure and facilitate hemostasis5. Reported complications include nerve injury, inadvertent ligature of the common iliac artery, prolonged blood loss and prolonged operative time. It has also been reported that there is a high rate of complication and low rate of success for hemostasis if the procedure is not done correctly6. Therefore, this procedure should be reserved for hemodynamically stable patients of low parity in whom future child-bearing itself is of paramount concern. Unilateral or bilateral hypogastric artery ligation can be life-saving in patients with massive postpartum hemorrhage6,7. Although surgeons may be reluctant to perform bilateral hypogastric artery ligation for fear of injury to the pelvic viscera, there is no evidence that this is the case or that there is any significant impairment of function of the pelvic viscera. If the procedure is performed correctly, there is no morbidity, either shortor long-term7. Historically, the practice of internal iliac ligation was within the competency of most obstetricians and gynecologists. Today, however, subspecialization means that their training and experience may be insufficient, so pelvic floor specialists or vascular surgeons are often called upon when internal iliac artery ligation is required. INTRODUCTION