Internal iliac artery ligation (IIAL) is a technique to control pelvic hemorrhage by ligating the internal iliac arteries. It preserves fertility and can be life-saving when other options risk compromising the patient. IIAL works by reducing blood flow and pressure in the pelvis, allowing clots to form and stop bleeding. The pelvis has extensive collateral circulation, so ligation does not cause ischemia. IIAL is effective for prophylactic or therapeutic control of hemorrhage from the uterus, cervix, or broad ligament. It carries risks if not performed carefully to avoid injuring nearby structures like veins and ureters.

1. INTERNAL ILIAC
LIGATION
DR SNEHA RONGE
MBBS MS OBGY (PUNE)

2. PELVIC BLOOD SUPPLY

3. ► The pelvic organs are supplied by the visceral branches of the internal iliac
(hypogastric) artery and by direct branches from the abdominal aorta .
► It is one of the branches of common iliac artery
► Ureter lies anteriorly and internal iliac vein posteriorly.
► The internal iliac artery generally divides into anterior and posterior divisions
in the area of the greater sciatic foramen

4. Internal iliac artery
► The internal iliac artery, also known as the hypogastric artery, contains
anterior and posterior divisions.
► Its anterior division supplies blood to central pelvic viscera
► The female pelvis has extensive collateral circulation, and the internal iliac
artery shares arterial anastomoses with branches of the aorta, external iliac
artery, and femoral artery.
► For this reason, ligation of the internal iliac's anterior division can be
performed without compromise to pelvic organ viability.

5. Branches of internal iliac artery

6. ► Massive pelvic hemorrhage is a potential complication while undergoing obstetric
and gynecological surgery.
► Pelvic hemorrhage, whether postpartum or related to gynecological surgery, is
associated with a great degree of morbidity and mortality and has to be controlled
immediately without compromising the rest of the pelvic blood supply.
► Internal iliac artery ligation (IIAL) is a safe, rapid and very effective method of
controlling bleeding from genital tract.
► Even in the most catastrophic situations, rapid alternatives to hysterectomy are
needed for women wishing to preserve their reproductive potential and to prevent
high surgical and anesthetic risk in an already compromised patient.
► Besides, it is the only answer in massive broad ligament hematoma, in torn
vessels retracted within the broad ligament, and even in postoperative
hemorrhage after abdominal or vaginal hysterectomy where no definitive bleeding
point is detectable

7. History
► Howard Kelly first pioneered ligation of the internal iliac (hypogastric) artery
in the treatment of intraoperative bleeding from cervical cancer prior to this
technique being applicable to postpartum hemorrhage.
► In the United Kingdom and the United States, the operation was reported
before 1900 and, since then, many surgeons have practiced it and found it
useful.

8. Physiology of internal iliac liagation
► Because of the excellent collateral circulation in the pelvis, vascular
compromise does not occur when one or both internal iliac arteries are
ligated
► The hypogastric artery distal to the point of ligation is never emptied of
blood because the rich anastomotic network starts to function immediately
after ligation
► There is virtual abolition of the arterial pulse pressure. This is associated with
reduced mean blood pressure and rate of blood flow in the collateral system
► As a result, the trip-hammer effect of arterial pulsations is abolished.
► The surgeon must be aware that bilateral ligature of the internal iliac artery
is more effective than the unilateral procedure in that the patient has less
chance of returning to theater for secondary surgery to control hemorrhage

9. Physiology
► Internal iliac ligation causes Reduction in
► Pulse pressure by 85%
► Mean arterial pressure by 25 to 50 %
► Blood flow by 50 %
► Which promotes clot formation
► The ligation converts arterial system into venous system leading to stable clot
formation thus bring hemostasis

10. Indications
►Prophylactic
►Therapeutic
►Elective

11. Prophylactic indications
► post-abortion and postpartum hemorrhage suspected,
► abruption placenta,
► abdominal pregnancy,
► placenta accreta,
► recurrent placenta previa,
► prior hysterectomy when all conservative measures have failed,
► groin dissection and vulvovaginectomy,
► extensive endometriosis,
► Intraligamentous leiomyoma,
► pelvic inflammatory disease.

12. Urgent therapeutic indications
► Bleeding of the broad ligament,
► Uterine rupture,
► Uterine perforation,
► Uterine atony,
► Placenta accreta,
► Ovarian rupture,
► Bleeding of the cervical cancer,
► Conization of cervix,
► Extensive lacerations of cervix,
► Advanced endometrial carcinoma,
► Vaginal sarcoma,
► Vaginal vault bleeding after hysterectomy,
► Bladder perforation
► Jehovahs witness

13. Elective indication
► In elective settings, I.I.A. is either ligated or embolized during the
endovascular repair of aorto-iliac arterial aneurysms .

14. Procedure
► Internal iliac artery ligation
1-- good abdominal relaxation ; SA/GA anesthesia is key of visualization
►
2-- 15to20 degree head low position ; help to drain pelvic veins & decreases
congestion to avoid vein injury which is rare but fearful
►
3-- pack intestine with 2 dry mops. ; only rectum stays in midline & rest will
not trouble ; dry will soak fluid & blood keep area clean
►
4--assistant should able to held & lift a uterus out of incision & tilt it towards
thighs of patient; makes uterosacral & infundibulopelvic ligaments prominent
so we can see in between area of interest.

15. Procedure
► 5- now we are seeing ureter crossing at division of common iliac artery &
running medially
► 6- catch loose fold of peritoneum 4 cm below bifurcation & just lateral to
ureter& make window
► 7- blunt instrument: our index fingers are introduced & peritoneum opened
parallel to vessels
► 8 - loose fibrofatty tissue is separated by gently sweeping of index fingers
paralel to vessels. With 3 strokes showing internal iliac artery from its origin
► 9- 3cm below bifurcation we see laterly external iliac vein & medially internal
iliac artery. Separate both vessels with blunt dissection

16. ► Internal iliac artery ligation is done 3-4 cm below its origin as posterior
division branches within 2cm.
► In upper 2cm internal & external iliac artery & veins & ureter come closer
► 3cm below origin - external iliac vein is 1.5cm antero lateral &
internal iliac vein is 1cm postero medial to internal iliac artery so it becomes
relatively safe site for ligation

17. ► Once the vessel is located, a Mixter right-angle clamp is passed under the
vessel lateral to medial , and two free ties of no. 1 or 0 absorbable suture are
passed beneath and then secured .
► The artery is ligated but not transected (Gilstrap, 2000).
► Care is required in passing instruments beneath the artery because the thin-
walled internal iliac vein is easily lacerated

19. ► Bilateral internal iliac artery ligation (BIIAL) reduces pelvic flow by 49 % and
pulse pressure by 85 % resulting in venous pressures in the arterial circuit,
thus promoting hemostasis .
► Within seconds of ligation, blood enters the collaterals in retrograde fashion.
► The practical effect is that pelvic ischemia does not occur

20. Ligation of internal iliac and
development of collateral circulation
Systemic artery Internal iliac artery
Lumbar (aorta) Iliolumbar
Middle sacral (aorta) Lateral sacral
Sup rectal (inf mesenteric ) Middle rectal
Ovarian (aorta ) Uterine
Inf epigastric (ext iliac) Obturator
Lateral circumflex (femoral) Sup gluteal
Med circumflex Inf gluteal
Deep circumflex
iliac(ext iliac)
Sup gluteal

22. Postoperative care
► Intensive care is necessary because these women may be moribund and have
required huge blood transfusion.
► Large hematomas or collections of serosanguineous fluid can be drained
through separate stab wounds.
► Antibiotics are not indicated after ligation of the arteries.
► Early ambulation is advisable in all cases.
► An indwelling catheter may be necessary to facilitate adequate assessment
of urinary output in women who are at risk of serious morbidity.

23. Studies
► Several studies have described normal postligation fertility in these women,
and an investigation evaluating flow with color Doppler sonography showed
recanalization of ligated arteries within an average of 5 months (Demirci,
2005; Khelifi, 2000; Nizard, 2003).
► Occlusion of the internal iliac artery decreases mean blood flow in branches
distal to ligation by 48 percent, which in many cases slows hemorrhage
sufficiently to allow identification of specific bleeding sites

24. Clinical considerations
► The major pitfall associated with ligation of the hypogastric artery is delay.
► When hemorrhagic shock is irreversible, this operation will not overcome it.
► Inadequate transfusion is another pitfall in the therapy of patients with severe
hemorrhage. Blood loss is often seriously underestimated.
► Failure to remember that the vaginal artery is a separate branch of the
hypogastric artery, rather than a branch of the uterine artery, may lead the
surgeon into the pitfall of an unnecessary and ineffective hysterectomy for control
of bleeding.
► Injury to the external iliac artery from retractors or mistaken ligation of this
vessel can lead to lower limb amputation.
► Accidental ligature of one or both ureters would lead to renal function
impairment.
► Accidental incorporation of the anterior division of the sciatic nerve may lead to
foot drop

25. Potential failures and consequences
► Occasionally, ligation of the hypogastric arteries fails to stem pelvic
hemorrhage.
► The reason for this is not clear, but some suggestions are:
► (1) Massive necrosis after infection with destruction of the vessels;
► (2) The presence of large, aberrant branches feeding blood to the area;
► (3) Dislodgement of clots when blood pressure rises;
► (4) Concomitant severe venous bleeding; however, this is rare;
► (5) Coagulopathy with deranged hematological indices.

26. Other precautions
► Avoiding accidental ligation of the common or external iliac artery
► Avoid damage to ureters
► Avoid damage to other vessles

27. Conclusion
► IIAL is an effective fertility preserving and sometimes the only available life-saving
procedure for combating pelvic hemorrhage.
► The procedure of IIAL can be very safe and simple in practiced hands with no
major intraoperative complications.
► Meticulous understanding of retroperitoneal anatomy is mandatory to prevent
inadvertent injury to the adjoining structures.
► Timely decision making is crucial to improve patient outcome.
► IIAL combats pelvic hemorrhage while maintaining the uterine perfusion.
► Ovarian perfusion may decrease following IIAL although no apparent effect on
ovarian functions was observed.
► In conclusion, all obstetricians and gynecologists must be trained and familiarized
in IIAL to include this tool in their arsenal against pelvic hemorrhage and surgeons
must lower their threshold for its use in emergent situations

28. Thank you