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Harnessing the great arteries in p.p.h dr vivekpatkar


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Hypogastric Artery Ligation

Published in: Health & Medicine

Harnessing the great arteries in p.p.h dr vivekpatkar

  1. 1. Dr. Vivek D. Patkar M.D., D.G.O Ex Honorary Professor LTMMC & LTMGH Sion, Mumbai.
  2. 2. Definition of PPH <ul><li>SHOCK: It is the failure of the circulatory system to maintain adequate cellular perfusion resulting in reduction of O 2 and other nutrients to tissues </li></ul><ul><li>PPH: It is defined as a decrease in hematocrit by 10% points from the time of admission to post partum period or when there is need to give blood transfusion secondary to blood loss. </li></ul><ul><li>ACOG </li></ul>
  3. 3. Statistics ( L.T.M.G.H ) from 1999 to 2005 <ul><li>Average Confinements a year: 7500 to 9100 </li></ul><ul><li>Maternal Mortality per year: 52 to 66 </li></ul><ul><li>Maternal Mortality/ 1000 births 6.9 to 10.5 </li></ul><ul><li>Maternal Mortality due to Obst. Haem 11 to 16 </li></ul><ul><li>per year: </li></ul>
  4. 4. Statistics ( L.T.M.G.H ) from 1999 to 2005 <ul><li>Average Confinements a year: 7500 to 9100 </li></ul><ul><li>APH per year: 89 to 142 </li></ul><ul><li>PPH per year: 54 to 80 </li></ul><ul><li>Intractable PPH per year: 17 to 21 </li></ul><ul><li>Obstetric Hysterectomy’s per year: 11 to 16 </li></ul><ul><li>Hypogastric Artery Ligation’s per year: 3 to 6 </li></ul><ul><li>Uterine Artery Ligation’s per year: 12 to 16 </li></ul>
  5. 5. CLASSES OF HAEMORRHAGE <ul><li>Blood volume in pregnancy = 8.5 – 9 % of patients weight </li></ul><ul><li>Class III and Class IV = INTRACTABLE PPH </li></ul><ul><li>William Roberts : Clinics of North America, 1995 </li></ul>Class I Class II Class III Class IV % Blood Loss 15 20 - 25 30 - 35 40 Pulse Normal 100 120 > 140 Systolic BP Normal Normal 70 - 80 < 60 Mean arterial Pressure 80 - 90 80 - 90 50 – 70 < 50
  6. 6. Statistics Sample Years: 2001 & 2002 PPH Causes No. UTERINE : Atony Retained placenta Placenta praevia Abruptio placenta Adherent placenta Rupture Ut and Lacerations Inversion of Uterus 56 28 14 1 NON UTERINE : Lower gen tr. Lacer Br Lig Hematoma Coagulopathy 10 2 5 Total 116 INTRACTABLE PPH Causes No. UTERINE : Atony Retained placenta Placenta praevia Abruptio placenta Adherent placenta Rupture Ut and Lacerations Inversion of Uterus 8 7 5 1 NON UTERINE : Lower gen tr. Lacer Br Lig Hematoma Coagulopathy 2 1 2 Total 26
  7. 7. PRELUDE TO SURGERY <ul><li>It is assumed before going for surgical </li></ul><ul><li>management that patient has been </li></ul><ul><li>stabilized and basic resuscitation is carried out. </li></ul><ul><li>An attempt at the medical management with oxytocin, Methergin, PG, Ca+. </li></ul><ul><li>Bimanual massage . </li></ul><ul><li>Intrauterine douche with intrauterine and vaginal packing for atony. </li></ul><ul><li>DIC to be ruled out. </li></ul><ul><li>Source and cause of bleeding identified with certainty. </li></ul><ul><li>In intractable PPH you have a limited time frame so may have to skip some of the above steps </li></ul>
  8. 8. <ul><li>Management of PPH is synonymous to </li></ul><ul><li>the working of a military operational head </li></ul><ul><li>quarters it requires: </li></ul><ul><ul><li>* Quick reaction time (20 mins) </li></ul></ul><ul><ul><li>* Interactive team (Anesth, Intensivist, Bl bank) </li></ul></ul><ul><ul><li>* Well equipped OT (Controlled envioroment) </li></ul></ul><ul><ul><li>* Dedicated mission and objective depending on local scenario (suturing : vs ligation : hem evac : O.H.) </li></ul></ul><ul><ul><li>* Fall back options ( Uterine Art. & Hypogastric Art.) </li></ul></ul><ul><ul><li>* Collateral damage (bladder and bowel) </li></ul></ul><ul><ul><li>* Attrition rates (tissue trauma / septicaemia) </li></ul></ul><ul><ul><li>* Escape routes (packing / drain) </li></ul></ul>TACTICAL ANALOGUE
  9. 9. <ul><li>Uterine Artery Ligation </li></ul><ul><li>As an alternative to obstetric hyterectomy in atonic PPH </li></ul><ul><li>During pregnancy uterine artery forms about 90% of blood supply to uterus </li></ul><ul><li>It increases twice in size to help trumpeting of the spiral vessels (luxuriant flow) </li></ul><ul><li>The uterine artery turns upwards from the isthmus and enters the uterus and gives out ascending and descending branch </li></ul><ul><li>Occasionally the uterines may split up into </li></ul><ul><li>2 or 3 branches before entering the uterus </li></ul><ul><li>Hence for UAL to be successful </li></ul><ul><li>sometimes more ligatures may be required!! </li></ul>
  10. 10. 71 UAL’s done <ul><li>Waters reported in 1952 bilateral uterine artery ligation as anatomically sound, physiologically rational and surgically possible method to control non traumatic PPH </li></ul><ul><li>Classic Conservative Methods: </li></ul><ul><li>* Oxytocin </li></ul><ul><li>* Methargin </li></ul><ul><li>* Prostaglandins </li></ul><ul><li>* Bimanual Compression </li></ul><ul><li>* Intramyometral Prostaglandins </li></ul><ul><li>* Uterine Packing B-lynch suture </li></ul>
  11. 11. UAL <ul><li>In case of vaginal Deliveries exploration of uterus and inspection of lower genital tract was done to exclude traumatic cause of PPH </li></ul><ul><li>Decision for uterine artery ligation was taken whenever it was prudent to conserve the uterus </li></ul><ul><li>Escape routes were charted and permission for obst hyst was taken </li></ul>
  12. 12. Procedure <ul><li>STEP I: Uterine artery was ligated at the level of upper end of lower uterine segment, where it runs along uterine border. </li></ul><ul><li>Contd </li></ul>
  13. 13. <ul><li>Procedure Contd </li></ul><ul><li>Incase of LSCS it was done just below or at the angle of incision of CS. </li></ul><ul><li>Bladder was dissected down in case of vaginal delivery. </li></ul><ul><li>Contd </li></ul>
  14. 14. <ul><li>Procedure Contd </li></ul><ul><li>For left uterine artery ligation. Uterus was grasped and elevated anteriorly to the right by left hand. </li></ul><ul><li>Contd </li></ul><ul><li>The palm was put over the left uterine border with thumb anteriorly over the lower uterine segment and four fingers posterior to broad ligament protecting the intestines. </li></ul>
  15. 15. <ul><li>Procedure Contd </li></ul><ul><li>A large mayo needle with no 1 CCG: a suture was passed through the myometrium from anterior to posterior and then brought forward through the broad ligament lateral to uterine vessels and the suture was tied. </li></ul><ul><li>The procedure was repeated on other side. </li></ul><ul><li>Contd </li></ul>
  16. 16. <ul><li>Procedure Contd </li></ul><ul><li>After bilateral uterine artery ligation myometrium assumed a pinkish hue secondary to ischaemia. </li></ul><ul><li>The decrease in bleeding was directly assessed from LSCS incision in case of CS and in case of vaginal delivery by observing per vaginal bleeding </li></ul><ul><li>Contd </li></ul>
  17. 17. <ul><li>Procedure Contd </li></ul><ul><li>STEP II: If decrease in bleeding was inadequate, additional lower stitches (cervico vaginal branch) and ascending branch on either side were taken. </li></ul><ul><li>STEP III: If bleeding still continues, bilateral ovarian arteries were ligated in infundibulopelvic ligament. </li></ul>
  18. 18. <ul><li>UAL success rate 85 to 95% </li></ul><ul><li>Simple, less blood loss </li></ul><ul><li>Surgical time less </li></ul><ul><li>Effective with less complications (hematoma and uretric damage) </li></ul><ul><li>No compromisation of future pregnancy and menstruation </li></ul><ul><li>Can be combined with OAL </li></ul>
  19. 19. ANATOMY of HAL <ul><li>God – Omnipotent , </li></ul><ul><li>Omni – knowledgeable, </li></ul><ul><li>Omni – present BUT </li></ul><ul><li>OMNI PROTECTIONIST! </li></ul><ul><li>Covered the great </li></ul><ul><li>Vessels with a shroud (POST.PERITONEUM) </li></ul><ul><li>Beyond Visual Range (ANAT DISECTION HALL & OT) </li></ul><ul><li>What you don’t see , you don’t perceive and hence ignore </li></ul><ul><li>Anat not as nice and orderly ( GRAY, GRANT, CUN) but occasionally mutilated and mayhem </li></ul>
  20. 20. ANATOMY of HA <ul><li>Aorta divides into common iliacs at fourth lumbar </li></ul><ul><li>The CIA divides into EIA and IIA (HA) at sacrum </li></ul><ul><li>EIA goes along psoas to form femoral </li></ul><ul><li>HA drops medio inf into the pelvic fossa </li></ul><ul><li>Bony landmark for bifurcation of CIA is sacral prom </li></ul><ul><li>Left CIA division fractionally higher (sigmoid) </li></ul>
  21. 21. ANATOMY of HA <ul><li>HA is a retro peritoneal structure </li></ul><ul><li>Anterio medially covered by peritoneum and fibrous fascia </li></ul><ul><li>Ureters cross from lateral to medial at bifurcation </li></ul><ul><li>Anterio laterally lie EIA and obturator nerve </li></ul><ul><li>Posterio medially is the Internal iliac vein </li></ul><ul><li>To the right terminal end of ileum and ceacum overlap </li></ul><ul><li>To the left lower Inf border of sigmoid colon </li></ul>
  22. 22. Division of Hypogastric Artery (Gross CM) Post Division Ant Division Parietal Parietal Visceral Ilio lumbar Obturator Obl. Umbelical Lateral sacral Int pudendal Uterine Superior Gluteal Inf Gluteal Vaginal Sup. Vesical Inf. Vesical M. Haemorrhoidal
  23. 23. Collateral Circulation ( Gross) <ul><li>Areas of Anastomosis </li></ul><ul><li>I. Lumbar Art (Aorta) </li></ul><ul><li>Circumflex Iliac (EIA) ↔ Ilio Lumbar </li></ul><ul><li>II. Middle Sacral (Aorta) ↔ Lateral Sacral </li></ul><ul><li>III. Superior Heamorrhoidal ↔ Middle Heamorrhoidal </li></ul><ul><li>(Br of Inf Mesentric) </li></ul><ul><li>Anastomosis is ipsilateral (vertical) and horizontal along midline. In bilateral HAL horizontal coll. Ceases </li></ul>
  24. 24. Haemodynamics <ul><li>Aortography (OLSON) </li></ul><ul><li>Collaterals present but flow from HA </li></ul><ul><li>forwards gradient 50 to 70 </li></ul><ul><li>After HA ligation reverse flow from Lumbar/ Middle Sacral and Sup. Heamorrhoidal </li></ul><ul><li>In HA Major Reduction in pulse pressure helps stabilize the clot formation </li></ul><ul><li>Collaterals have smaller diameter ( 40 to 50%) which inhibits rapid gradient and blood flow, thus avoiding trip hammer effect ( BURCHELL) </li></ul>
  25. 25. Haemodynamics <ul><li>On cessation of TRIP HAMMER effect the pelvic arterial system is converted to a Venus like system. </li></ul><ul><li>* The drop in pulse pressure </li></ul><ul><li>84% --- B/L HAL </li></ul><ul><li>75% --- U/L HAL </li></ul><ul><li>* The Mean arterial pressure ↓ 25% --- B/L HAL </li></ul><ul><li>↓ 22% --- U/L HAL </li></ul><ul><li>THIS HELPS STABLE CLOT FORMATION </li></ul>
  26. 26. <ul><li>CRISIS !!! 36 Cases </li></ul><ul><li>The situation is grim and tense </li></ul><ul><li>The scenario is unnerving </li></ul><ul><li>The patients condition is precarious </li></ul><ul><li>The relatives have a look of disbelief and foreboding </li></ul><ul><li>The OT scene is chaotic </li></ul><ul><li>The residents/ para medical staff are running helter skelter </li></ul><ul><li>YOU are in a dilema </li></ul><ul><li>“ Too Early to say YES to Late to say No” </li></ul>
  27. 27. <ul><li>Indications for HAL </li></ul><ul><li>Atonic PPH </li></ul><ul><li>Traumatic PPH </li></ul><ul><li>Placenta previa and </li></ul><ul><li>adherant placenta </li></ul><ul><li>Broad ligament hematoma </li></ul><ul><li>Rupture Uterus </li></ul><ul><li>Following a Obstetric </li></ul><ul><li>Hyterectomy, UAL </li></ul><ul><li>Deep Vault or Vaginal </li></ul><ul><li>tears or Hematoma </li></ul>
  28. 28. Procedure <ul><li>Large adequate incision </li></ul><ul><li>preferably midline vertical </li></ul><ul><li>( Decreases op time and improves success rate) </li></ul><ul><li>Vis peritoneum opened between RL and IPL </li></ul><ul><li>Identify ureter, EIA, EIV and obturator nerve </li></ul><ul><li>If hematoma, destruction, edema proceed carefully </li></ul><ul><li>Generally dipping HA not seen </li></ul><ul><li>Trace Common Iliac and follow medially into pelvis fossa ( Ureteric crossing a GIVE AWAY) Contd . </li></ul>
  29. 29. Procedure ( Contd) <ul><li>Dissect fascia anterior to HA </li></ul><ul><li>generally 1 to 2 layers </li></ul><ul><li>Tease it vertically </li></ul><ul><li>Visualize HA and lift gently with </li></ul><ul><li>babcock about 1 to 2 cms below bifurcation </li></ul><ul><li>Areolar tissue that connects HA and HV posterio-medially blunt dissected carefully. </li></ul><ul><li>A right angled clamp (MIXTER, </li></ul><ul><li>ADSONS) passed posteriorly </li></ul><ul><li>preferable lateral to medial </li></ul><ul><li>Care not to damage EIV and HV </li></ul><ul><li>. </li></ul>
  30. 30. Procedure ( Contd) <ul><li>Feed a silk or linen (40) </li></ul><ul><li>(non- absorbable) long, single or </li></ul><ul><li>doubled into the tip of the Mixter </li></ul><ul><li>by holding the suture taut on an artery forceps </li></ul><ul><li>Either retake the same suture around or take a second suture below the first </li></ul><ul><li>Lift the suture and check for pulsations in EIA </li></ul><ul><li>Recheck ureter EIA, CI and bleeding from Venus plexus and then tie </li></ul><ul><li>Recheck pulsations in EIA ( Rule out Spasm) </li></ul><ul><li>Do not transect vessel </li></ul>
  31. 31. Complications <ul><li>< 1 to 9 % depending on experience of </li></ul><ul><li>surgeon and condition of pt ( Lecoq, </li></ul><ul><li>Reich, Sagara, Siegel, Tajes) </li></ul><ul><li>EIA Spasm, thrombosis </li></ul><ul><li>Injury to HV, EIV </li></ul><ul><li>Tying wrong structures– ureter, EIA, CI </li></ul><ul><li>Necrosis of buttocks, perineum, bladder mucosa </li></ul><ul><li>Bladder Atony </li></ul><ul><li>Circulatory disturbances of lower extremities </li></ul><ul><li>In BREENS Series of 334 cases hypogastric vein laceration (16) current series (out of 36, 2) </li></ul><ul><li>Contd. </li></ul>
  32. 32. Int. Iliac/Success rate Authors Year Method No of Women Success Rates Evans et al 1985 Internal iliac artery ligation 14 6/14 (42.8%) Fernandez et al 1988 Internal iliac artery ligation 8 8/8 (100%) Chattopadhyay et al 1990 Bilateral Hypogastric artery ligation 29 19/29 ( 65%) Ledee et al 2001 Bilateral Hypogastric artery ligation 48 43/48 (89.5%)
  33. 33. Failures (2% -- 8%) <ul><li>Presence of large aberrant BL VS </li></ul><ul><li>Dislodging of clots after BL Pressure rises </li></ul><ul><li>Concomitant severe venous bleeding </li></ul><ul><li>Necrosis of BL VS causing bleed </li></ul><ul><li>Coagulopathy and DIC intervening </li></ul><ul><li>Irreversible hypovolumic shock (Time Factor) </li></ul><ul><li>We had 3 failures ( not due to procedure) </li></ul><ul><li>* Couvelaries UT due to coagulopathy </li></ul><ul><li>* Vault, paracervical tears due to </li></ul><ul><li>abberant vsl </li></ul><ul><li>* Rupture Uterus due to hypovolumic </li></ul><ul><li>shock </li></ul>
  34. 34. Incase of Failures <ul><li>Ovarian Art Ligation (↓ collateral by 12-15%) </li></ul><ul><li>Gravity suit if available </li></ul><ul><li>Selective arterial transcatheter embolization (by autologous blood clot/ gel foam/ </li></ul><ul><li>oxidized cellulose, CO 2 </li></ul><ul><li>Wire coils / Baloon catheter / IBS </li></ul><ul><li>Monomer </li></ul><ul><li>Look out for coagulopathy </li></ul><ul><li>Return of Mensis in 98% (Gregori, Kindziersk) </li></ul><ul><li>Return of fertility with normal pregnancy ( Given, Gates, Morgan, Mengert) (Noiugr) </li></ul>
  35. 35. <ul><li>Ovarian Artery Ligation </li></ul><ul><li>Direct branch of Aorta. Take off after renals </li></ul><ul><li>Bl.Supply about 2 to 8% in pregnancy </li></ul><ul><li>Window under IPL </li></ul><ul><li>Take selectively 2 to 3 cms from fimbria </li></ul><ul><li>Right side beware of ureter </li></ul><ul><li>Left side beware of sigmoid </li></ul><ul><li>Indications </li></ul><ul><li>* Atonic PPH stepwise devascularization </li></ul><ul><li>* After HAL fails </li></ul><ul><li>* After Obst. Hyst if bleed continues </li></ul>
  36. 36. <ul><li>Before HAL </li></ul><ul><li>You can attempt COMPRESSION OF AORTA by Harris’s compressor or Debakey clamp </li></ul><ul><li>Temporary tamponade decreases pressure by 60 to 70% </li></ul><ul><li>You can attempt COMPRESSING COMMON ILIACS or pinching uterine arteries for tamponade and helping clot formation </li></ul>
  37. 37. <ul><li>HAL </li></ul><ul><li>HAL is an EMERGENCY, LIFE SAVING, SALVAGE Surgery </li></ul><ul><li>“ Go in Quick and come Out Fast” </li></ul><ul><li>Procrastinate and </li></ul><ul><li>* Lose the plot </li></ul><ul><li>* Conqueror to Vanquished </li></ul><ul><li>* Savior to Executioner </li></ul>
  38. 38. THANK YOU In Surgical Impasse and Intractable PPH the best defense is swift offense, viz. HAL - Michael Smith