How to ligate the superior gluteal artery at the greater sciatic foramen?

Technique for Superior Gluteal Artery Ligation at the Greater Sciatic Foramen

The most effective approach for ligating the superior gluteal artery at the greater sciatic foramen is through the suprapiriform canal, which requires careful identification of anatomical landmarks and extension of the surgical incision with detachment of the gluteus maximus origin to gain proper exposure. 1, 2

Anatomical Considerations

• The superior gluteal artery exits the pelvis through the suprapiriform canal, which is:

  • 4-4.5 cm long and 0.6-1.0 cm wide
  • Formed by the upper margin of the greater sciatic notch
  • Covered with thin fascia, fasciae of gluteal and piriform muscles, and parietal layer of pelvic fascia 1

• Critical anatomical relationships:

  • Superior gluteal vessels are contiguous with periosteum of the bony notch in all specimens
  • Superior gluteal nerve branches exit caudal or caudal-superficial to the vessels
  • The caudal-most superior gluteal nerve branch lies directly adjacent to the bony notch's periosteum in 65% of cases 3

Surgical Technique

1. Patient Positioning and Incision:

   • Position patient in prone or lateral decubitus position
   • Make a curved incision over the posterior iliac crest, extending it as needed for adequate exposure

2. Exposure of the Greater Sciatic Notch:

   • Detach the origin of the gluteus maximus muscle from the ilium
   • Use the bony origin of gluteus maximus as a landmark to avoid accidentally entering the sciatic notch 4
   • Carefully reflect the gluteus maximus laterally to expose the suprapiriform canal

3. Identification of Neurovascular Structures:

   • Identify the superior gluteal vessels as they emerge from the suprapiriform canal
   • Note: You will encounter a major superior gluteal nerve branch (deep inferior) before encountering the vessels 3
   • Avoid cautery near the nerve branches to prevent iatrogenic injury

4. Vessel Control and Ligation:

   • Laterally retract the gluteus maximus along with the tethered superior gluteal vessels
   • Visualize the injured or target vessels at their exit point from the suprapiriform canal
   • Apply vascular clips or suture ligatures to achieve hemostasis 2

Important Considerations and Pitfalls

• Anatomical Variations: The superior gluteal artery comprises a single vessel in 78% of specimens, dividing into superior and inferior branches 1-3.5 cm along the lateral ilium 3

• Nerve Protection: Multiple superior gluteal nerve branches are present in the greater sciatic notch - protect these to avoid postoperative weakness of hip abductors 3

• Alternative Approaches: If the posterior approach is difficult due to anatomical constraints:

  • Consider a transgluteal approach medial to the sciatic nerves and below the piriformis muscle 5
  • For severe hemorrhage cases, internal iliac artery occlusion by embolization may be necessary 4

• Common Pitfall: Attempting to control bleeding with blind clamping or cautery in the sciatic notch can lead to further vascular injury or nerve damage

This technique provides direct access to the superior gluteal artery at its exit from the greater sciatic foramen, allowing for precise ligation while minimizing blood loss and avoiding damage to surrounding neurovascular structures.