Internal Iliac and Ovarian Artery Ligation in the Control of Pelvic Haemorrhage

EDITORIAL COMMENT: This paper will interest ail general gynaecologists and obstetricians because all of us know that the occasional patient will be a candidate for bilateral internal iliac artery ligation because of uncontrollable haemorrhage, usually resulting from uterine rupture, or placenta praevia accreta (increta, percreta), the latter often associated with a previous lower segment Caesarean section. In these patients iliac artery ligation is required when hysterectomy has failed to arrest haemorrhage, and when coagulopathy has been excluded or corrected. It is no use the anaesthetist encouraging the surgeon to ligate the internal iliac arteries during a difficult Caesarean hysterectomy when the blood is not clotting, which is often the case when there is a placenta praevia accreta and significant haemorrhage has occurred before the operation began. Internal iliac ligation may also occasionally be indicated as a means to control postpartum haemorrhage when the placenta is delivered and the uterus is intact and well contracted; bilateral ovarian artery ligation may also be helpful in such patients. Over the last 30 years this editor has often heard it said that specialists in training should learn the technique of internal iliac artery ligation. This is neither practical nor proper practice, since to perform the procedure in a patient who does not require it is unethical, and most consultants encounter a patient who needs the operation no more than 4 ‐ 5 times in a professional lifetime; moreover, when the need arises the surgeon is likely to feel unequal to the occasion! Also, as the writer of this review can confirm, the procedure when properly performed may fail to control the haemorrhage; in this situation packing of the pelvis is usually performed with the pack being removed 24 hours later, usually at laparotomy. The obvious solution is to have internal iliac artery ligation performed, when it is indicated, by a gynaecological oncologist or vascular surgeon. Since these colleagues are seldom immediately available without notice, we should all seek their assistance when there is a real possibility that their help will be needed, before the patient presents a clinical emergency. It must not be overlooked that these patients almost always require expert resuscitation, skilled anaesthesia and dedicated postoperative nursing care in an intensive care ward. Summary: Bilateral ligation of the internal iliac artery with or without ligation of the ovarian arteries was carried out in 17 patients who had life‐threatening pelvic haemorrhage; 14 were due to obstetric haemorrhage, 2 followed abdominal hysterectomy and 1 intractable haemorrhage associated with carcinoma of the cervix. The procedure was successful in arresting the haemorrhage in 13 patients but 4 needed hysterectomy in spite of the ligation; 1 patient died from disseminated intravascular coagulation following surgery and 1 had cardiac arrest due to extensive blood loss during surgery and died 12 hours later. A review of the literature, a brief description of the procedure and its indications are discussed.