Bilateral Internal iliac artery ligation in emergency pelvic surgery (hypogastric artery)

The 0bjective of this lecture

1/ life saving procedure 2/To be familial with difficult pelvic surgery 3/To know the perfect anatomy of this region 4/To know the indication of bilateral internal iliac artery ligation 5/To know the outcome after this type of procedure 6/ To decrease the injury to other structures during this procedure

Internal iliac artery ligation Pioneered by HOWARD KELLY(Howard Atwood Kelly was an American gynecologist, one of the "Big Four" founding professors at the Johns Hopkins Hospital in Baltimore, Maryland ) for treatment of intraoperative bleeding from cervical cancer prior to its application in post partum h.

Howard Atwood Kelly 

Kelly's sign — If the ureter is teased with an artery forceps, it will contract like a snake or worm. Kelly speculum — A rectal speculum, tubular in shape and fitted with an obturator. Kelly forceps – Large haemostatic forceps; arguably among the most common and best known surgical instruments. Kelly's stitch — Surgery for the bladder neck to correct stress incontinence of urine.

gluteal (superior ) arteries pudendal artery  iliolumbar artery branches of the posterior  lateral sacral artery  gluteal (superior ) arteries    pudendal artery  inferior vesical (uterine in females)a  middle rectal artery vaginal artery anterior division. obturator artery  umbilical artery INFERIOR gluteal

I V A or in female vaginal a inf gluteal CI I EPIG EI II I LA D CIRCUMF ILIAC FA L S A U A S G A S V A O A I V A or in female vaginal a inf gluteal defferant a in m uterin a in f internal middle rectal pudendal a A terminal b

Internal pudendal a terminal branch of I I A Inferior rectal deep a of the penis Perineal a deep a of the clitoris Post sacrotal a dorsal a of penis or Post labial a dorsal a of clitoris

Indication It is essential for surgeons to be aware of the indications for and the technique of iila 1/Intractable post partum h( due to uterine atony rather than due to obstetric trauma. However, some report successful use of BIL in patients with ruptured uterus and placenta accreta) 2/Pelvic bleeding due to trauma 3/Post prostatectomy bleeding

4/Damage control in selective group of pt with massive retroperitonial hemorragr after pelvic fracure 5/In the elective setting the artery is either ligated Or embolized during endovascular repair of aotoiliac arterial aneurysms 6/in the event of supra levator haematoma not responding to conservative management, the recommended treatment is internal iliac ligation, not hysterectomy

A transperitoneal approach. Surgical technique A transperitoneal approach. A knowledge of pelvic anatomy was essential prior to the procedure. The common iliac artery bifurcates into external and internal iliac arteries at the pelvic brim. The ureter crosses the common iliac artery at this level and descends into the pelvis, parallel to the internal iliac artery. A 6–8 cm incision was made in the posterolateral peritoneum in line with the ureter. The peritoneal flap was then retracted medially, with the ureter still attached. The internal iliac artery was identified and exposed by separating pelvic areolar tissue carefully for a length of 2–3 cm.

The exposure was mainly attempted at POINT to avoid ligation of the posterior branch, which supplies the gluteal muscles and buttocks. Once the site of ligation was selected, a right- angled clamp was used to place sutures around the artery. It was important to work within the adventitia of the artery to avoid damage to the veins in the vicinity. The ligature placed under the artery was then tied without cutting the vessel.

The qustion Better to do bil + hysterectomy in post partum h or just bil and conserve uterus 2. is there is procedure before decide for bil that give us the same result in post partum h 3. If did bil & conserve the uterus the uterus can achieve preg. B-Lynch procedure

Apart from conserving future fertility, BIL has other advantages over the more commonly performed emergency hysterectomy for life- threatening obstetric haemorrhage. BIL is associated with less post-operative morbidity compared with emergency hysterectomy and requires less operating time for those experienced with the technique. . Emergency total hysterectomy can be associated with trauma to the bladder, which needs to be reflected down to incorporate the indistinct post-delivery cervix. Bladder damage, haematomas, post-operative adhesions and vault prolapse can be avoided by choosing BIL instead of hysterectomy. Long-term observation of patients after BIL has not shown any increase in distant side-effects

B-Lynch procedure (brace suture) (Christopher B-Lynch Consultant Obstetrics and Gynaecological Surgery) is a form of compression suture used in gynecology. It is used to mechanically compress an atonic uterus in the face of severe postpartum hemorrhage. The technique was first described in 1997. may be particularly useful because of its simplicity of application, life saving potential, relative safety, and its capacity for preserving the uterus and thus fertility. Satisfactory haemostasis can be assessed immediately after application

Out come buttock claudication sexual dysfunction spinal ischaemia Peripheral nerve ischaemia

Ligation of the internal iliac (hypogastric) arteries has been used to control serious obstetric and pelvic bleeding. It is generally well tolerated in the young obstetric or gynaecological patient, presumably because of an extensive collateral blood supply. Acute lumbosacral plexopathies have been described, however, in older patients with vascular disease when the internal iliac arteries are interrupted. but there is CASE report on a teenage patient with similar peripheral nerve ischaemia after bilateral internal iliac artery ligation for postpartum haemorrhage

THEY report on effectiveness and future fertility in 12 women who had internal iliac ligation to control severe obstetric haemorrhage: in 10 out of the 12 women, BIL was successful. Of the two women who subsequently needed emergency hysterectomy, one woman died of disseminated intravascular coagulation. Of the eight women we were able to follow-up to assess reproductive performance, two did not desire future fertility. Three had subsequent pregnancies (50%), of whom two proceeded to term.

In conclusion BIL is a safe, effective procedure for treating life-threatening obstetric haemorrhage with preservation of future fertility. It should be the operation of choice to control severe bleeding in young women of low parity. There is an urgent need to train and familiarize the younger generation of obstetricians to perform BIL.