For ligation, adequate exposure is obtained by opening the peritoneum over the common iliac artery and dissecting down to the bifurcation of the external and internal iliac arteries (Fig. 41-35). Branches distal to the external iliac arteries are palpated to veriY pulsations at or below the inguinal area. ligation of the internal iliac artery 5 cm distal to the common iliac bifurcation will usually avoid the posterior division branches (Bleich, 2007). The areolar sheath of the artery is incised longitudinally, and a right-angle clamp is carefully passed just beneath the artery from lateral to medial. Care must be taken not to perforate contiguous large veins, especially the internal
FIGURE 41-34 Uterine compression suture or "brace." The B-Lynch suture technique is illustrated from an anterior view of the uterus in Figures A, B, and 0 and a posterior view in Figure C. The numbers denote the sequential path of the suture and are shown in more than one figure. Step 1. Beginning below the incision, the needle pierces the lower uterine segment to enter the uterine cavity. Step 2. The needle exits the cavity above the incision. The suture then loops up and around the fundus to the posterior uterine surface. Step 3. The needle pierces the posterior uterine wall to reenter the uterine cavity. The suture then traverses to the opposite side within the cavity. Step 4. The needle exits the uterine cavity through the posterior uterine wall. From the back of the uterus, the suture loops up and around the fundus to the front of the uterus. Step 5. The needle pierces the myometrium above the incision to reenter the uterine cavity. Step 6. The needle exits below the incision and the sutures at points 1 and 6 are tied below the incision. The hysterotomy incision is then closed in the usual fashion.
iliac vein. Suture-usually nonabsorbable-is passed under the artery with a clamp, and the vessel is then securely ligated.
he most important mechanism of action with internal iliac artery ligation is an 85-percent reduction in pulse pressure in those arteries distal to the ligation (Burchell, 1968). his converts an arterial pressure system into one with pressures approaching those in the venous circulation. his creates vessels more amenable to hemostasis via pressure and clot formation.
Even bilateral internal iliac artery ligation does not appear to interfere with subsequent reproduction. Nizard and colleagues (2003) reported follow-up in 17 women who had bilateral artery ligation. From a total of 21 pregnancies, 13 were normal, three ended with miscarriage, three were terminated, and two were ectopic.
This modality is now used for many causes of intractable hemorrhage when surgical access is diicult. In more than 500 women reported, embolization was 90-percent efective (Gronvall, 2014; Lee, 2012; Poujade, 2012; Zhang, 2015). After his review, Rouse (2013) concluded that embolization can be used to arrest refractory postpartum hemorrhage. Other reports have been less enthusiastic. Fertility is not impaired, and many subsequent successful pregnancies have been reported (Chauleur, 2008; Fiori, 2009; Kolomeyevskaya, 2009). An important caveat or these procedures is that women with hemodynamic instabiliy related to active bleeding should not be removed rom the operating room.
FIGURE 41 -35 Ligation of the right internal iliac artery. Unembalmed cadaveric dissection shows the right-angle clamp passing underneath the anterior division of the internal iliac artery just distal to its posterior division. (Used with permission from Dr. Marlene Corton.)