Tying the internal iliac artery

Tying the internal iliac artery is the most common emergency arterial ligation. If a patient has severe and continuing uterine bleeding, after delivery for example, you may have to tie her internal iliac arteries on both sides. When her uterus has ruptured, so that its wall hardly feels any more substantial than blood clot, this is one of the few things you can do. It is not an easy procedure. She is likely to be very ill, your anaesthetist may not be able to give her an adequate anaesthetic, her pelvic wall is difficult to get at, and her pelvic retroperitoneum is difficult to work in. If you are expert, doing a hysterectomy may be easier. So start by getting good exposure, and identify the main trunks clearly before you tie them. The collateral circulation is so good, particularly during pregnancy, that tying both iliac arteries is very unlikely to be harmful.

TYING THE INTERNAL ILIAC ARTERY INDICATIONS. (1) Tearing into the lower segment during or base of the broad ligament during a difficult Caesarean section. (2) Severe and persistent PPH when packing fails to control bleeding. (3) Persistent bleeding from an abortion continuing after evacuation. (4) Rupture of the uterus. (5) Trauma to the uterus.

METHOD. If you already have the patient's abdomen open, tying her internal iliac arteries is quickly done. But don't be in too much of a hurry: you must not damage the accompanying vein (see below). Often, you need to tie them when you have not already got the abdomen open. If so make a quick lower median incision.

Hold back her abdominal contents and examine her pelvic brim. You will see her ureter crossing her common iliac artery at the point where it divides into its internal and external iliac branches (A, in Fig. 3-7). Open her peritoneum and lift up her ureter (B). Insert a haemostat under her internal iliac artery (C), and tie it. Do the same thing on the other side.

CAUTION ! (1) Don't tie her internal iliac vein which is closely related to the artery posteriorly. Doing so will increase the venous pressure in her uterus and make bleeding from it worse. (2) Don't damage her internal iliac vein. If you do, bleeding from the tear will be difficult to control and you will have to tie it.

On both sides, if necessary, also tie the anastomotic vessels that connect her ovarian arteries with her uterine arteries. Find them in her broad ligaments under the cornual ends of her tubes.

Fig. 3-8. EXPOSING THE EXTERNAL ILIAC ARTERY. If a wound is so high up in a patient's thigh that you cannot control bleeding by tying his femoral artery below its profunda branch, you may have to tie his external iliac artery. Adapted from ''Farquharson's Textbook of Operative Surgery'. Edited by RF Rintoul. Churchill Livingstone, with kind permission.