Step-by-step ligation of the internal iliac artery

Abstract

The internal iliac artery is the main vascular supply of pelvic visceral structures. All pelvic surgeons must know the anatomic landmarks and basic steps of internal iliac artery ligation in order to stop massive pelvic hemorrhage. This cadaveric demonstration and clinical review of the internal iliac artery shows the anatomic landmarks and basic steps of internal iliac artery ligation.

Keywords: hypogastric; bleeding; postpartum; pelvic; Gynecologic.

Conflict of interest statement

Conflict of Interest: No conflict of interest is declared by the authors.

Figures

Figure 1

Anatomy of the internal iliac artery. Basic anatomic structures and branches of the internal iliac artery; Right pelvic side wall, superior view (1. Common iliac artery, 2. External iliac artery, 3. Internal iliac artery (IIA), 4. Superior gluteal artery, 5. Iliolumbar artery, 6. Lateral sacral artery, 7. Uterine artery (red line), 8. Ureter (white line), 9. Umbilical artery (obliterated), 10. Inferior gluteal artery, 11. Internal pudendal artery, 12. Obturator artery, 13. Obturator nerve (yellow line), 14. Lumbosacral trunk (yellow line), 15. S1 Nerve (yellow line), 16. Middle rectal artery, X. Ligation point of IIA)

Figure 2

Entering the retroperitoneum (2a-d). a. The lateral parietal peritoneum over the pelvic side wall (over the psoas major muscle and external iliac artery) between the round ligament (ligamentum teres uteri) (blue line) and infundibulopelvic ligament (ligamentum suspensorium ovarii) (red line) is cut (X). During this step the uterus is pulled towards the counter side (caudally) of the pelvic wall where we plan to enter the retroperitoneum. (A: Uterus, B: Right fallopian tube, C: Right ovary, D: Rectum, E: Bladder), b. The incision is extended cranially to the level of pelvic brim (green line) parallel to the infundibulopelvic ligament, c. superior view, d. lateral view: Posterior leaf of the broad ligament (ligamentum latum uteri), (the peritoneum with the ovarian vessels), is retracted medially so the retroperitoneal area (red circle) is visualized

Figure 3

Identification of the ureter and internal iliac artery (3a-e). a. The ureter runs on the posterior leaf of the broad ligament under the ovarian vessels, medial to the anterior branch of internal iliac artery; therefore, holding the posterior leaf and making a blunt dissection towards sacrum (white arrow) targeting the deeper part of posterior leaf will guide to identify the ureter; b, c. The ureter (F, white line) is identified on the base of the broad ligament, medial to the internal iliac artery (G, red line); d, e. The adipose and lymphatic tissue over the internal iliac artery is dissected with a caudal movement (white arrow) (3d). The ureter (F, white line), internal iliac artery (G, red line), external iliac artery (H), and the common iliac artery (I) will be noticed just over the pelvic brim at the upper part of pararectal space (3e) [borders of pararectal space: posteriorly sacrum, medially ureter and rectum, laterally internal iliac artery and anteriorly uterine artery and cardinal ligament (ligamentum transversum cervicis)]

Figure 4

Ligation of internal iliac artery (4a-e). a. A right-angle clamp is placed under the anterior division of internal iliac artery (white arrow), after the main trunk gives the branches of the posterior division (3.5 cm after the origin of internal iliac artery); b. Care should be taken not to harm the underlying external iliac vein, located on the infero-lateral part of the internal iliac artery. Accordingly, the right-angle clamp should be moved from lateral to medial under the internal iliac artery (white arrow) while holding the end point of clamp upperly; c. After getting on the other side beneath the internal iliac artery, the suture material is grasped (red circle) and pulled backwards in the same direction; d. The ureter, external iliac artery, and other important anatomic landmarks are re-checked and finally the suture is tied carefully (red rectangle); e. Superior view of right pelvic side wall, how to ligate the internal iliac artery, with close anatomic structures