When is ligation of the hypogastric (internal iliac) artery indicated in gynecologic surgery?

Indications for Hypogastric Artery Ligation in Gynecologic Surgery

Hypogastric (internal iliac) artery ligation should be reserved as a salvage procedure for life-threatening pelvic hemorrhage when conservative measures have failed, with the understanding that its effectiveness is limited to 50-70% and it is technically demanding. 1

Primary Indications

Severe Obstetric Hemorrhage

• Intractable postpartum hemorrhage that fails to respond to medical management (uterotonics, tranexamic acid) and initial surgical interventions (uterine compression sutures, packing) 1, 2
• Placenta accreta spectrum when hemorrhage persists after attempted conservative management, though cesarean hysterectomy with placenta left in situ remains the gold standard 3
• Uterine atony refractory to medical therapy and uterine packing 4
• Uterine rupture with ongoing hemorrhage 4

Gynecologic Oncology Surgery

• Massive pelvic hemorrhage during radical hysterectomy or debulking surgery when no single bleeding source is identifiable and the patient remains hemodynamically unstable after initial measures 1
• The procedure may be considered when arterial embolization is not immediately available or has failed in hemodynamically stable patients 1

Critical Performance Considerations

Technical Requirements

• The procedure requires an experienced surgeon who can perform it efficiently, as it is technically difficult and time-consuming 1
• Bilateral ligation is typically necessary to achieve adequate hemorrhage control, as unilateral ligation often fails due to extensive collateral circulation 2, 4
• The surgeon must identify the hypogastric artery as it branches from the common iliac artery, avoiding injury to the adjacent iliac vein (which occurs in approximately 3.8% of cases) 4

Expected Outcomes and Limitations

• Success rates range from 50-77% in avoiding hysterectomy, meaning nearly half of patients will still require definitive surgery 1, 2, 4
• The procedure works by reducing pulse pressure rather than completely blocking blood flow, as three collateral circulations develop rapidly after ligation 2
• Failure is most common with placenta accreta (50% failure rate) and uterine lacerations (100% failure rate in one series) 5

When NOT to Perform Hypogastric Artery Ligation

Preferred Alternatives

• Pre-peritoneal pelvic packing should be considered first in hemodynamically unstable patients, as it is faster, safer, and can be equally effective 3, 1
• Arterial embolization is preferred when the patient is hemodynamically stable and interventional radiology is available, as it targets specific bleeding vessels 1
• For placenta accreta spectrum, proceed directly to cesarean hysterectomy rather than attempting conservative measures that delay definitive treatment 3

Contraindications

• When the patient is too unstable to tolerate the time required for the technically demanding dissection 1
• When less invasive options (packing, embolization) have not yet been attempted in a stable patient 1
• In settings where surgical expertise is insufficient, as improper technique increases risk of vascular injury 1

Fertility Preservation Considerations

• Hypogastric artery ligation does not compromise future fertility or pregnancy outcomes, making it appropriate for young women desiring future childbearing 6, 2
• Subsequent pregnancies require monitoring for intrauterine growth restriction, though uterine and fetal circulations typically normalize through collateral development 6, 2
• Normal vaginal delivery is possible after bilateral ligation 6

Practical Algorithm

1. First-line: Medical management (tranexamic acid 1g IV, uterotonics, uterine massage) 1
2. Second-line: Surgical temporizing (uterine compression sutures, pre-peritoneal pelvic packing) 1
3. Third-line: Consider hypogastric artery ligation IF:
   • Hemorrhage persists despite above measures 1
   • Patient remains hemodynamically stable enough for the procedure 1
   • Experienced surgeon available 1
   • Arterial embolization unavailable or failed 1
4. Definitive: Proceed to hysterectomy if ligation fails 4, 5

Common Pitfalls

• Delaying definitive treatment (hysterectomy) in unstable patients while attempting hypogastric artery ligation, which has a 23-50% failure rate 4, 5
• Confusing the hypogastric artery with the uterine artery during Doppler assessment or surgical identification 3, 7
• Unilateral ligation, which is rarely effective due to extensive pelvic collateral circulation 2
• Attempting the procedure without adequate surgical experience, increasing operative time and risk of iliac vein injury 1, 4