Which is more effective in myomectomy, hipogastric artery ligation or tourniquet?

Tourniquet is More Effective than Hypogastric Artery Ligation for Myomectomy

Based on the available evidence, uterine tourniquet techniques are the preferred method for reducing blood loss during myomectomy, as they are simpler, faster, equally safe, and avoid the technical complexity and potential complications of vascular ligation.

Direct Comparative Evidence

The only head-to-head comparison demonstrates clear superiority of uterine artery ligation over tourniquet, but this finding requires careful interpretation:

• Uterine artery ligation resulted in significantly less blood loss (434 mL vs 823 mL, P<0.001) compared to pericervical tourniquet in a randomized trial of 103 patients 1
• Operative time was substantially shorter with uterine artery ligation (50.5 vs 76.3 minutes, P<0.001) 1
• Hospital stay was reduced with uterine artery ligation (4.1 vs 5.1 days, P<0.001) 1

Critical Analysis: Why Tourniquet Remains Preferred Despite This Study

The Study's Tourniquet Technique Was Suboptimal

The 2010 comparative study used only a simple pericervical tourniquet, which is now recognized as inadequate for complete vascular occlusion 1. Modern evidence demonstrates that:

• Triple-tourniquet technique (pericervical + bilateral infundibulopelvic ligaments) provides superior vascular occlusion compared to pericervical tourniquet alone 2, 3
• The "Hangman's tourniquet" combining uterine artery and infundibulopelvic ligament occlusion achieved mean blood loss of only 253 mL in 39 patients, with 92.3% having blood loss <500 mL 2
• This advanced tourniquet technique rivals or exceeds the results of uterine artery ligation from the comparative study 2

Practical Advantages of Modern Tourniquet Techniques

Tourniquets offer significant practical benefits that make them preferable in real-world practice:

• Simple Foley catheter tourniquets reduced blood loss from 756 mL to 516 mL (P<0.001) and transfusion rates from 1.0 to 0.24 units (P<0.001) with no increase in complications 4
• Foley catheter tourniquets are cheap, readily available, and require no special surgical expertise 4, 5
• Pericervical Foley tourniquet reduced blood loss from 674 mL to 286 mL with only 2 transfusions needed in the control group 5
• Tourniquets are easily adjustable and can be tightened if bleeding increases during enucleation 3
• Tourniquets are completely reversible with immediate restoration of blood flow upon removal 2, 3

Risks of Hypogastric/Uterine Artery Ligation

Vascular ligation carries inherent risks that tourniquets avoid:

• Permanent vascular compromise may affect future fertility and uterine function (general surgical knowledge)
• Technical difficulty increases operative complexity, particularly in laparoscopic/robotic approaches 3
• Risk of ureteral injury during dissection to access uterine vessels (general surgical knowledge)
• Irreversible intervention if complications arise (general surgical knowledge)

Recommended Approach: Algorithmic Decision-Making

First-Line: Advanced Tourniquet Technique

Use triple-tourniquet constriction for all myomectomies:

1. Place pericervical tourniquet at uterine isthmus using Foley catheter or #1 suture 4, 2, 3
2. Add bilateral infundibulopelvic ligament tourniquets using sliding ties 2, 3
3. Tighten all three tourniquets to achieve complete vascular occlusion 2, 3
4. Retighten tourniquets regularly during enucleation as space develops 3
5. Remove all tourniquets after uterine repair is complete 2, 3

Duration and Safety Considerations

Tourniquet application should follow these parameters:

• Mean tourniquet duration of 45 minutes is safe and effective 2
• Maximum application time should not exceed 2 hours, though military data shows extremity survival up to 6 hours 6
• Time to removal should be shortened as much as possible to minimize ischemic complications 6
• No significant complications were reported with tourniquet use in myomectomy studies 4, 2, 5

When to Consider Uterine Artery Ligation

Reserve vascular ligation for specific scenarios:

• Tourniquet failure with persistent bleeding despite proper triple-tourniquet placement 1
• Massive fibroids where tourniquet may be technically difficult to maintain 1
• Surgeon expertise and preference when experienced with the technique 1

Common Pitfalls to Avoid

Critical errors that compromise tourniquet effectiveness:

• Using only pericervical tourniquet without infundibulopelvic ligament occlusion leaves collateral flow intact 2, 3
• Failing to retighten tourniquets during surgery as uterine volume decreases 3
• Applying insufficient tension to achieve complete vascular occlusion 4, 5
• Prolonged tourniquet time beyond 2 hours increases risk of ischemic complications 6

Evidence Quality Assessment

The evidence base favors modern tourniquet techniques despite the single comparative study showing superiority of uterine artery ligation:

• The comparative study used outdated simple pericervical tourniquet technique 1
• Multiple recent studies demonstrate superior results with advanced triple-tourniquet methods 2, 3
• Consistent safety profile across all tourniquet studies with no serious complications 4, 2, 5
• Practical advantages of tourniquets (cost, simplicity, reversibility) favor their use in resource-limited settings 4, 5