Is internal iliac (hipogastric) artery ligation still effective for controlling severe pelvic hemorrhage after hysterectomy surgery?

Hypogastric Artery Ligation After Hysterectomy: Limited but Potentially Life-Saving

Hypogastric (internal iliac) artery ligation can still be effective for controlling severe pelvic hemorrhage even after hysterectomy has been performed, though it represents a salvage procedure with variable success rates. The procedure works by reducing pulsatile arterial pressure through collateral circulation, allowing thrombosis at bleeding sites 1.

Effectiveness After Hysterectomy

Success Rates and Evidence

• When performed as a salvage procedure after failed hysterectomy, internal iliac artery ligation has demonstrated the ability to control persistent hemorrhage in select cases 2, 3, 4

• The overall effectiveness of hypogastric artery ligation is 50-70% when used for hemorrhage control, which is notably lower than angiographic embolization 1

• In obstetric cases where internal iliac artery ligation was performed after hysterectomy for persistent bleeding, the procedure successfully controlled hemorrhage in 9 patients without requiring relaparotomy 4

Key Limitations Post-Hysterectomy

• The procedure is technically difficult and time-consuming, though experienced surgeons can perform it more easily 1

• After hysterectomy, bleeding may originate from collateral vessels (inferior epigastric artery branches, ovarian arteries) that bypass the ligated internal iliac arteries 2, 3

• The extensive collateral pelvic vasculature means that ligation alone may not control all bleeding sources, particularly when the uterus has already been removed 3

Preferred Modern Approach: Angiographic Embolization

Arterial embolization should be strongly considered as the primary intervention for post-hysterectomy hemorrhage in hemodynamically stable patients 1.

Why Embolization is Superior

• Embolization is particularly useful when no single bleeding source is identifiable and can target collateral vessels that develop after surgical ligation 1, 2

• Successful embolization has been documented even after both hysterectomy and bilateral internal iliac artery ligation, by accessing collateral vessels such as branches of the inferior epigastric or ovarian arteries 2, 3

• The procedure avoids additional surgical morbidity and can be performed with the patient under local anesthesia 2

Clinical Algorithm for Post-Hysterectomy Hemorrhage

Immediate Measures

1. Maintain normothermia (>36°C) and avoid acidosis during ongoing hemorrhage management 1
2. Administer tranexamic acid 1g IV over 10 minutes immediately 1
3. Consider pelvic packing for stabilization if the patient remains hemodynamically stable 1

Definitive Hemorrhage Control Decision Tree

For hemodynamically stable patients:

• First-line: Angiographic embolization should be attempted before considering additional surgery 1, 2
• Embolization can target collateral vessels that bypass previously ligated arteries 2, 3

For hemodynamically unstable patients:

• If angiography is unavailable or cannot be performed within 60 minutes, surgical intervention including internal iliac artery ligation may be necessary 5
• Pre-peritoneal pelvic packing should be considered as an adjunct 5

If hemorrhage persists after hysterectomy and initial surgical measures:

• Internal iliac artery ligation can be attempted as a salvage procedure 4
• However, angiographic embolization should be strongly considered even after surgical ligation, as it can still be successful by accessing collateral circulation 3

Critical Pitfalls to Avoid

• Do not assume that internal iliac artery ligation will control all pelvic bleeding after hysterectomy, as collateral vessels (ovarian, inferior epigastric branches) can maintain hemorrhage 2, 3

• Do not delay angiographic embolization in stable patients in favor of additional surgery, as embolization has higher success rates and lower morbidity 1

• Ensure adequate surgical expertise before attempting internal iliac artery ligation, as the procedure is technically demanding and carries risk of venous injury 1, 6

• Monitor for complications requiring re-exploration, as intraperitoneal hemorrhage occurred in 6 of 45 patients (13%) following hysterectomy in one series 7