Double Ligation of Infundibulopelvic Ligament: Not Necessary
Double ligation of the infundibulopelvic (IP) ligament is not required based on current evidence, as simple single ligation techniques have proven equally safe and effective with no increase in complications while offering shorter operative times.
Evidence from Surgical Ligation Studies
The question of double versus single ligation has been extensively studied in the context of surgical ligature techniques, and the evidence consistently supports simple ligation:
Simple ligation is superior to more complex techniques including stump inversion and double ligation methods, showing similar major morbidity and infectious complications while providing shorter operative times, less postoperative ileus, and quicker recovery 1.
A systematic review and meta-analysis of 11 RCTs including 2,634 patients demonstrated that simple ligation had significantly better clinical outcomes compared to more complex closure methods, with no difference in postoperative infections 1.
Modern Surgical Techniques for IP Ligament
Current surgical practice for IP ligament management during oophorectomy and related procedures emphasizes:
Bipolar coagulation followed by scissors division is the standard technique for IP ligament transection, with no reported intraoperative or late complications in case series 2.
Single-step ligation or energy device application is sufficient for hemostasis of the IP ligament, as meticulous surgical technique and knowledge of retroperitoneal anatomy are more important than double ligation 2, 3.
Laparoscopic procedures involving IP ligament manipulation, including ovarian transposition and oophorectomy, routinely use single ligation or energy device sealing without double ligation, with excellent safety profiles 4, 3.
Clinical Rationale Against Double Ligation
The evidence against routine double ligation includes:
No clinical advantage has been demonstrated for double ligation over single ligation in terms of bleeding complications, with simple techniques being more cost-effective and time-efficient 1.
Operative time is significantly reduced with simple ligation techniques, which translates to decreased anesthesia exposure and overall surgical risk 1.
Modern energy devices (bipolar coagulation, ultrasonic devices) provide adequate hemostasis with single application, making double ligation redundant 2, 3.
Important Caveats
Meticulous surgical technique is paramount: The key to preventing bleeding complications is proper identification of vascular structures, adequate visualization, and complete hemostasis verification rather than double ligation 2, 5.
Anatomical knowledge is critical: Understanding the relationship of the IP ligament to the ureter and other pelvic structures is more important than the number of ligations applied 5.
In cases of bulky or edematous tissue, ensure complete vessel sealing with energy devices or verify secure knot placement with single ligation rather than defaulting to double ligation 2.