Internal Iliac Artery Ligation: A Stepwise Approach

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Video Description

This video presents a stepwise approach to an internal iliac artery ligation (IIAL) at laparotomy.

Presented By

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Dr. Ari Sanders
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Dr. Jessica Papillon-Smith
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Dr. Julia Kfouri
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Dr. Ally Murji

Affiliations

University of Toronto, Mount Sinai Hospital & Women’s College Hospital

Read More: 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.

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