Internal Iliac Artery Ligation in Obstetrics and Gynecology: Surgical Anatomy and Surgical Considerations

Abstract

The internal iliac artery (IIA) is the main arterial vessel of the pelvis. It supplies the pelvic viscera, pelvic walls, perineum, and gluteal region. In cases of severe obstetrical or gynecologic hemorrhage, IIA ligation can be a lifesaving procedure. Regrettably, IIA ligation has not gained widespread popularity, primarily due to limited surgical training and concerns regarding possible complications, including buttock claudication, impotence, and urinary bladder and rectum necroses. Nowadays, selective arterial embolization or temporary balloon occlusion are increasingly utilized alternatives, which can be applied preoperatively or intraoperatively for threatening severe genital or pelvic bleeding. However, IIA ligation retains its relevance, as the previously described procedures are not always available and have limitations. This article provides a step-by-step guide to the IIA ligation procedure and its possible complications. It also includes a detailed description of the anatomy of the IIA and pelvic arterial anastomoses. This review highlights the importance of a thorough understanding of pelvic anatomy as a prerequisite for safe IIA ligation and posits that training in this procedure should be an integral part of obstetrics and gynecology curricula.

Keywords: anastomoses; anatomy; complications; internal iliac artery ligation; obstetrics and gynecology; step-by-step.

Figure 1

Anatomy of the internal iliac artery ((A,B)—embalmed female cadaver; author’s own material). (A,B) show the left side of the pelvis of the same cadaver. The posterior branch of the IIA has a lateral course (superior gluteal artery) in the pelvic sidewall. The middle rectal artery and iliolumbar artery were cut during dissection. EIA—external iliac artery; IIA—internal iliac artery; EIV—external iliac vein; ON—obturator nerve; OIM—obturator internus muscle; SGA—superior gluteal artery; IGA—inferior gluteal artery; UR—ureter; SUV—superficial uterine vein; OA—obturator artery; UMA—umbilical artery; UA—uterine artery; UT—uterus; PMM—psoas major muscle; IIV—internal iliac vein; VA—vaginal artery; CIAB—common iliac artery bifurcation; BL—bladder; R—rectum; CA—caudal; L—left.

Figure 2

Anatomy of the internal iliac artery ((A,B)—embalmed female cadavers; author’s own material). (A,B) show the left and right pelvic sidewall in two different female cadavers. The posterior branch of the internal iliac artery (superior gluteal artery) has a medial course in both figures. (A)—The sacral plexus and its relation to the divisions of the internal iliac artery are clearly highlighted. The superior gluteal artery runs between the lumbosacral trunk and the anterior ramus of the first sacral nerve and leaves the pelvis through the suprapiriform foramen. The inferior gluteal artery is located between the anterior rami of the second and third sacral nerves and leaves the pelvis through the infrapiriform foramen. (B)—The course of the uterine artery ventral to the ureter can be clearly seen. EIA—external iliac artery; IIA—internal iliac artery; EIV—external iliac vein; ON—obturator nerve; SGA—superior gluteal artery; IGA—inferior gluteal artery; UR—ureter; SUV—superficial uterine vein; SVA—superior vesical artery; LSAs—lateral sacral arteries; OA—obturator artery; UMA—umbilical artery; UA—uterine artery; PMM—psoas major muscle; IIV—internal iliac vein; VA—vaginal artery; CIAB—common iliac artery bifurcation; BL—bladder; UT—uterus; R—rectum; LST—lumbosacral trunk; S1, S2, S3—anterior rami of the sacral spinal nerves; Ca—caudal; L—left; Cr—cranial.

Figure 3

Anatomy of the internal iliac artery of (A,B) embalmed female cadavers; author’s own material. (A,B) show the right and left pelvic sidewalls in two different female cadavers. A—Presence of the inferior vesical artery in a female. B—Anomalous shape and course of the internal and external iliac arteries. The internal iliac artery follows a direct caudal course. EIA—external iliac artery; EIV—external iliac vein; IIA—internal iliac artery; FR—femoral ring; IVA—inferior vesical artery; SVAs—superior vesical arteries; IGA—inferior gluteal artery; SGA—superior gluteal artery; UA—uterine artery; OA—obturator artery; PR—promontory; UT—uterus; R—rectum; BL—bladder; R—right; Ca—caudal; L—left.

Figure 4

Some surgical steps during internal iliac artery ligation in case wherein the uterus is presented (open surgery (left side)—author’s own material). (A)—incision of the parietal peritoneum and identification of the ureter (steps 3 and 4). (B)—Identification of the internal iliac artery and entrance point of Latzko’s lateral pararectal space (steps 5 and 6). (C)—Development of lateral pararectal space (step 6). (D)—Ligation of the internal iliac artery. The posterior division is located just caudal to the surgical clamp. The instrument passes from lateral to medial beneath the artery (step 8). EIA—external iliac artery; OV—ovarian vessels; UR—ureter; UT—uterus; BL—posterior leaf of broad ligament; RL—round ligament (cut); AD—left adnexa; IIA—internal iliac artery; LSE—lateral pararectal space entrance; LS—lateral pararectal space; Cr—cranial; L—left.

Figure 5

Some surgical steps during internal iliac artery ligation in case wherein the uterus is presented (open surgery (left side)—author’s own material). (A)—dissection between the IIA and the underlying ipsilateral vein (step 7). (B)—The “ tripod” structure, with the ureter located medially and the external iliac artery positioned laterally. The structure in the middle is the internal iliac artery. EIA—external iliac artery; IIA—internal iliac artery; UR—ureter; UT—uterus; IIV—internal iliac vein; Cr—cranial; R—right.

Figure 6

The second group of anastomoses (embalmed cadavers; author’s own material). (A)—Anastomoses between the middle rectal artery and the superior rectal artery. (B)—Anastomoses between the lateral sacral arteries and the median sacral artery. (C)—Anastomoses between the lumbar artery and the iliolumbar artery. AA—abdominal aorta; CIA—common iliac artery, SRA—superior rectal artery; MRA—middle rectal artery; IIA—internal iliac artery; EIA—external iliac artery; MSA—median sacral artery; LSA—lateral sacral artery; LA—fourth lumbar artery; ILA—iliolumbar artery, Cr—cranial; L—left; R—right.

Figure 7

Arterial and venous corona mortis (fresh cadaver; author’s own material). EIA—external iliac artery; EIV—external iliac vein; PMM—psoas major muscle; OA—a proper obturator artery was injured during dissection. There was no accessory or aberrant obturator artery; ON—obturator nerve; OV—obturator vein; OIM—obturator internus muscle; FR—femoral ring; PS—pubic symphysis; aCORM—arterial corona mortis; vCORM—venous corona mortis; L—left; Ca—caudal.

Figure 8

Horizontal and vertical anastomoses of the IIA (author’s own material). UA—uterine artery; OA—obturator artery; IEA—inferior epigastric artery; LSAs—lateral sacral arteries; MSA—median sacral artery; LA—fourth lumbar artery; ILA—iliolumbar artery; SRA—superior rectal artery; MRA—middle rectal artery; SVA—superior vesical artery; IVA—inferior vesical artery; IRA—inferior rectal artery; OVs—obturator vessels; EIVs—external iliac vessels; IEVs—inferior epigastric vessels; IPA—internal pudendal artery; DCIA—deep circumflex iliac artery; MCFA—medial circumflex femoral artery; LCFA- lateral circumflex femoral artery; SGA—superior gluteal artery; IGA—inferior gluteal artery.