Video Description
This video presents a stepwise approach to an internal iliac artery ligation (IIAL) at laparotomy.
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University of Toronto, Mount Sinai Hospital & Women’s College Hospital
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Summary:
- Internal Iliac Artery Ligation (IIAL) is a type of surgery used to slow blood flow to the pelvis. It can help your surgeon prevent or treat life-threatening bleeding in the uterus and pelvic organs if other options don’t work.
- Doctors use IIAL for life-threatening bleeding after childbirth, during surgery, or from an injury. It works by lowering the amount of blood flow to the pelvis without cutting off circulation or putting the pelvic organs at risk.
- To perform an IIAL, your surgeon will make a small incision (cut) in your belly near the internal iliac artery, then close it off with sutures or clips to stop the flow of blood. The exact method can vary depending on the cause and location of the bleed.
- IIAL is safe but does carry small risks for circulation problems, blood clots, and nerve damage. Most people stay in the hospital for a few days and gradually return to normal activities over a few weeks.
Internal Iliac Artery Ligation (IIAL) is a surgical procedure that reduces blood flow to the pelvis by tying off or clipping the internal iliac artery. It’s normally considered a last-resort option for severe pelvic bleeding that doesn’t respond to other treatments.
To address a pelvic bleed, doctors usually try non-invasive treatments like coagulating medications and uterine massage first, or medications that cause uterine contraction. Internal Iliac Artery Ligation (IIAL) can help slow or stop the bleed if these interventions aren’t effective.
In this guide, you’ll learn why IIAL is performed, how it slows pelvic bleeding, what the procedure involves, and what to expect during recovery.
Why Would Someone Need IIAL?
Severe pelvic bleeding is rare, but it can be very difficult to control when it occurs. While it sometimes involves the uterus, the bleeding can originate from any of the veins, arteries, or blood vessels located in the pelvic cavity (lower abdomen).
Doctors typically recommend IIAL for life-threatening bleeds that fail to respond to other non-invasive treatments. It may also be recommended as a preventative measure if you’re at risk of heavy bleeding during surgery or a cesarean section.
The most common indications include:
- Postpartum hemorrhage. Some people experience excessive bleeding after a vaginal delivery or cesarean section. IIAL can help slow the bleeding or even save your life without jeopardizing your ability to have children in the future. Explore our other videos on surgically managing a hemorrhage here.
- Heavy bleeding during surgery. Some procedures, like full or partial hysterectomy (removal of the uterus) and fibroid removal, can cause you to lose a lot of blood. IIAL can help reduce blood loss during and immediately after surgery.
- Injuries or accidents involving the pelvis. A fall, car accident, or pelvic fracture can damage the blood vessels in your pelvis, causing life-threatening bleeding. IIAL helps slow it down so doctors have time to correct the problem.
It’s important to note that severe pelvic bleeding isn’t the same as the bleeding you experience during your monthly period, even if you have very heavy flow. Pelvic bleeds that are serious enough to make IIAL necessary are almost always a medical emergency and generally occur either during surgery or childbirth.
Can Severe Pelvic Bleeds Happen Spontaneously?
In general, severe pelvic bleeds almost never occur spontaneously in healthy patients. Factor V Leiden, hemophilia, and other blood disorders that affect the way your blood clots can increase your risk for a bleed, but aren’t the direct cause in most cases.
Taking blood thinners, like heparin or warfarin, can increase your risk for spontaneous bleeds in the pelvis and other areas of the body. Let your provider know if you’re taking any medication before you have surgery, give birth, or become pregnant.
How Does Internal Iliac Artery Ligation Work?
During an IIAL, your surgeon carefully ties off or clips the internal iliac artery to slow the flow of blood into your pelvis. This gives your body a chance to heal and lowers your need for blood transfusions without putting your pelvic organs at risk.
Here’s a step-by-step overview of how the IIAL works:
- Step One: You’ll be taken to the operating room, where an anesthesiologist will give you medication to make you fall asleep. (Note that frequently, this procedure is performed along with another surgery, like cesarean section or hysterectomy).
- Step Two: The surgeon will perform surgery in the lower abdomen to access the pelvic area. This may be accomplished by laparoscopy, robotics, or open surgery with a larger incision.
- Step Three: The surgeon will carefully move each layer of tissue aside until they can visualize the internal iliac artery. They’ll inspect the area for any potential obstacles, like scar tissue and adhesions related to earlier procedures.
- Step Four: The surgeon will carefully tie off the artery using suture material (surgical thread) or vascular clips. This helps the body form natural clots to stop the bleeding.
- Step Five: Next, the surgeon will ensure that blood can still reach the pelvic organs through other pathways in the pelvis. If bleeding stabilizes, they close the incision.
It’s important to note that IIAL does not cut off blood completely—it just slows it down. In most cases, other vessels, veins, and arteries take over and provide adequate blood flow to the tissues without contributing to the bleed itself.
Which Method is Best for IIAL?
The way your surgeon approaches IIAL can vary depending on what caused your pelvic bleeding in the first place. If you begin to experience a hemorrhage during surgery, like a hysterectomy, c-section, or fibroid removal, your surgeon will access the iliac artery through your existing incision (where possible).
If IIAL is used to address a bleed that isn’t related to surgery, your surgeon will typically make a small cut in your lower abdomen near the iliac artery. You’ll be asleep for the procedure in either case, or have a regional pain block (epidural), so you won’t feel any pain.
There are two main ways to perform an IIAL:
- Traditional suture ligation. This is the most common approach to IIAL. After carefully moving the artery away from nearby structures, your surgeon will tie a ligature (length of surgical thread) around the artery tightly. This prevents blood from flowing into the pelvis through the internal iliac artery closest to the bleed.
- Vascular clipping. This technique often requires less dissection, which can make it safer and easier for some patients. Your surgeon will place a small metal clip directly on the artery to block blood flow. Clips can be removed at the end of your surgery or left in place permanently to reduce blood flow.
Both of these methods are effective at reducing blood loss and can help save your life if you experience an uncontrolled pelvic bleed. If your surgeon plans to use IIAL preventatively, they’ll let you know before you have surgery—this is a great time to ask questions.
What Are the Benefits of IIAL?
IIAL is very safe when completed by an experienced surgeon. In fact, it’s one of the fastest and most effective options for stopping a life-threatening pelvic bleed that doesn’t respond to medication alone.
The main benefits of IIAL include:
- Faster control of a bleed during a true medical emergency, like a postpartum hemorrhage or arterial damage from an accident.
- Less chance for reduced pelvic organ function or damage to local tissues. Redirecting blood flow through other vessels helps preserve circulation, but still slows the bleed.
- A lower risk of needing more serious interventions, like a total hysterectomy. This can be advantageous if you aren’t done having children or may want more in the future.
- A lower risk for bleeds before or during high-risk surgical procedures, like fibroid removal or hysterectomy.
Regardless of why you need IIAL, the goal of the procedure is always the same: to safely tie off the iliac artery and reduce blood flow to the area without jeopardizing your pelvic organs.
What Are the Risks of IIAL?
Like any surgery, IIAL isn’t entirely without risk. Complications like these can affect your recovery and may make it necessary for you to have a second procedure.1
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- Circulatory problems in the pelvis. A reduction in blood flow throughout the pelvis can negatively affect tissues in the area, causing pain. This is relatively rare in healthy patients, as the body will typically redirect blood flow from other nearby vessels.
- Blood clots or Deep Vein Thrombosis (DVT). Surgery of any kind can raise your risk for blood clots. Rarely, these can travel to other areas of the body, like the arms, legs, or lungs. Gentle movement and exercise (when safe) can help lower this risk.
- Injuries to the ureter. The ureter—a small tube that carries urine from the kidney to the bladder—runs directly alongside the internal iliac artery. Nicking, cutting, or clipping the ureter is a rare but potential complication during IIAL.
- Muscle pain in the buttocks. Reduced blood flow after a surgery like IIAL can deprive the muscles in your legs and buttocks of oxygen. While rare, this typically manifests as chronic pain that worsens with exercise.
- Sexual Dysfunction. Damage to pelvic tissues from the IIAL, childbirth, or surgery can interfere with your ability to feel sexual pleasure or have an orgasm. This outcome is extremely rare in uncomplicated bleeds that don’t involve other procedures/injuries.
- Poor bladder tone. Some patients struggle to feel when their bladder is full or experience mild to moderate bladder leakage after an IIAL.
- Nerve injuries. Injuries to pelvic nerves can occur during deeper dissections in the pelvis, although this is very rare.
- Incisional infections. Rarely, the incision your doctor makes to access the internal iliac artery can become infected.
It’s important to be aware of risks like these before you have a procedure, but keep in mind that most patients never experience outcomes like these.
What to Expect After IIAL
What your recovery period will look like after an IIAL will vary depending on why you had the procedure and your overall wellness. In most cases, you can expect to stay in the hospital for between one and three days—this is the best way to ensure you’re in the right place to get help if you experience another bleed.
You may also experience:
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- Mild pain and swelling. This is expected and usually subsides within a few days to a week of your surgery. Your care team can help you address any pain while you’re in the hospital or give you tips for handling it at home after you leave.
- Mild uterine bleeding. You may still experience light to heavy bleeding from the uterus and/or vagina, especially if your IIAL was related to postpartum hemorrhaging. If you soak through a pad or tampon in less than 2 hours, let your doctor know.
- Fatigue. Rapid blood loss from a pelvic bleed can leave your body short on nutrients that help circulate red blood cells. You may feel tired or run-down for a week or two. Staying hydrated and taking iron tablets may help—ask your doctor if you aren’t sure.
- A gradual return to activity. Walking and other forms of gentle exercise can help you recover, but don’t push yourself too hard right away. Most people resume light activities, including seated work, within a few weeks.
- Regular monitoring. Your doctor will closely monitor your healing process in the weeks and months after your surgery.
If you have any concerns after surgery, such as severe pain, fever, or unusual swelling, contact your doctor right away. For more serious symptoms, like a very high fever, confusion, convulsions, or sudden renewed bleeding, call an ambulance or go to the nearest ER.
Internal Iliac Artery Ligation Could Save Your Life!
Internal Iliac Artery Ligation is a proven and effective method for treating severe pelvic bleeds that don’t respond well to other interventions. Understanding how your doctor might use IIAL to save your life in an emergency or lower your risk for a life-threatening bleed can help you make more informed decisions about your care.
CanSAGE is committed to empowering patients and their providers through education. To learn more about your gynecologic and reproductive health, or read about the experiences of patients just like you, explore our patient videos and guides.
Video Transcript: Internal Iliac Artery Ligation: A Stepwise Approach
This video presents a stepwise approach to the ligation of the internal iliac arteries.
The first reported case of internal iliac artery ligation, or IIAL, dates back over 200 years when it was used to treat a gluteal aneurysm.
In 1894, Dr. Howard Kelly first reported using this technique in gynecology to control hemorrhage at hysterectomy for cervical cancer.
Since then, indications for IIAL expanded as it became recognized as a life-saving intervention during obstetrical hemorrhage and a prophylactic intervention for cases where severe bleeding was anticipated.
The mechanism of action behind this procedure is based on hemodynamic studies performed by Dr. Burchell. IIAL significantly reduces pelvic blood flow and arterial pulse pressure, promoting coagulation and hemostasis. However, pelvic blood supply is not compromised due to extensive anastomoses and collateral circulation.
The objective of this video is to highlight 5 key steps in performing an internal iliac artery ligation: accessing the retroperitoneum, dissection of the pararectal space, identifying the anatomy, isolating the internal iliac artery, and ligating the vessel with either sutures or vascular clips.
In the following diagram, the female reproductive organs are illustrated. Feeding these structures is a complex network of major blood vessels.
The common iliac arteries branch off the aorta and divide into the internal and external iliac arteries. The ureter, seen in yellow, crosses the bifurcation of the iliac arteries at the level of the pelvic brim.
Approximately 3 cm from the bifurcation, the internal iliac artery divides into an anterior and posterior branch.
There is significant anatomic variation in this vascular network, but often, the obturator and umbilical arteries are the first two vessels to branch off the anterior division of the internal iliac artery.
Following this, the uterine and vaginal arteries can be identified. The ureter runs beneath the uterine artery.
The superior & inferior vesical, inferior gluteal, middle rectal and internal pudendal arteries make up the remaining branches of the anterior division of the internal iliac artery.
The steps to performing an IIAL will now be reviewed.
Step 1: Access the Retroperitoneum
There are many ways to access the retroperitoneum in the pelvis.
Here, it is accessed by dividing the round ligament.
This allows the leaves of the broad ligament to open, revealing the retroperitoneal space.
Next, the broad ligament is opened in a cephalad direction, lateral and parallel to the infundibulopelvic ligament, allowing even greater access to the retroperitoneal space.
Take a moment to appreciate the anatomic landmarks identified here.
Step 2: Dissect the Pararectal Space
Dissection of this avascular potential space is carried out in a craniocaudal direction, parallel to the course of the great vessels. The dissection in this space must occur medial to the psoas muscle.
The use of a narrow deaver with cephalad traction is critical to optimize visualization and identify the borders of this space.
The pararectal space is bordered by the sacrum posteriorly, the internal iliac artery laterally, the cardinal ligament anteriorly, and the ureter medially.
Step 3: Identify the Anatomy
After dissecting the pararectal space, it is necessary to identify key anatomic structures.
Here, you see the internal and external iliac arteries.
The external iliac vein courses are deep to the external iliac artery, just adjacent to the internal iliac artery. The ureter runs along the medial leaf of the broad ligament within the pararectal space. It can be seen vermiculating here.
While the ureter, which is seen vermiculating here, runs along on the medial leaf of the broad ligament.
Step 4: Isolate the Internal Iliac Artery
After identifying relevant landmarks, the internal iliac artery is isolated by dissecting away the surrounding connective tissue. We use a lauer to help accomplish this.
Note the proximity of the adjacent external iliac artery and vein. Care must be taken to avoid injury to these structures during the dissection.
Step 5a: Vessel Ligation Using the Traditional Suture Ligation Technique
During this technique, it is necessary to completely mobilize a portion of the internal iliac artery away from adjacent structures to safely pass a ligature around it.
Once again, a lauer helps accomplish this.
Repeatedly identifying the anatomy is helpful in maintaining orientation and avoiding complications during this step.
Here some of the vessels from the anterior division of the internal iliac artery can be visualized.
The lauer is used to mobilize the internal iliac artery away from its underlying vein.
Utmost care is required when dissecting underneath the internal iliac artery to avoid damage to the internal iliac vein. (insert somewhere around 4:50)
The ureter can be observed vermiculating safely away from the operative field.
The vessel is then grasped and elevated with Russian forceps while a lauer frees the vessel from the underlying structures. This is performed in a lateral to medial fashion to avoid injury to the adjacent external iliac vein.
A non-absorbable suture is then passed around the artery and tied 3 cm from the bifurcation of the common iliac artery. This is to ensure the posterior division of the internal iliac artery is not compromised during the process. A second free tie can be placed distal to the initial ligature to help avoid recanalization. In this case, the obliterated umbilical artery is spared due to anatomical variation in this vascular network.
Step 5b: Vessel Ligation Using a Contemporary Clipping Technique
This represents a safe alternative to the suture ligation technique.
This technique involves the placement of two large vascular clips 3 cm distal to the bifurcation of the common iliac artery. Complete isolation of the vessel is not required during this technique.
This helps to avoid the extensive dissection involved with suture ligation, potentially decreasing the risk of injury to adjacent vessels.
In this video, we have provided an anatomical overview of the extensive vascular network within the pelvis to understand the mechanism of action and key steps in ligating the internal iliac arteries. These steps are performed on both sides of the pelvis to maximize the benefit of this procedure.