Selective ligation of the hepatic artery for trauma of the liver.

Selective ligation of sundry hepatic arteries in patients with hepatic trauma obviated death from hepatic bleeding in 59 of 60 patients treated with this method of hemostasis. Hepatic insufficiency did not occur in survivors. Reconstitution of intrahepatic arterial flow is rapidly accomplished by collateral arteries. When the source of hemorrhage is perihepatic, that is, hepatic veins and retrohepatic vena cava, hepatic artery ligation is ineffective. Two patients died from this kind of hemorrhage.     

Hypogastric artery ligation for obstetric hemorrhage

Ligation of the hypogastric arteries has been recommended for control of obstetric hemorrhage. However, specific information regarding its effectiveness is lacking. The hospital charts of 19 patients undergoing bilateral hypogastric artery ligation for the control of otherwise intractable obstetric hemorrhage were reviewed. Indications included uterine atony (15), lateral extension of a low-transverse uterine incision (three), and placenta accreta (one). This procedure was effective in controlling bleeding in eight of 19 patients (42%). Hysterectomy was necessary in the remaining 11 patients. In these patients, blood loss, operating time, and intraoperative morbidity was increased when compared with a group of 59 patients undergoing emergency hysterectomy for obstetric hemorrhage without prior ligation of the hypogastric arteries. Surgical approaches to hypogastric artery ligation are discussed.     

Uterine artery ligation for postabortal hemorrhage.

A case is presented that demonstrates that bilateral ligation of the ascending branches of the uterine artery to control uterine hemorrhage is as effective in the first trimester as it is in the last trimester.     

Hypogastric artery ligation for severe hemorrhage in obstetric patients

Ligation of the hypogastric arteries (HAL) was first introduced into surgery by the end of the 19(th) century to control intractable hemorrhage from the uterus of women with advanced cervical cancer. At present, HAL is one in a spectrum of operative methods to control life-threatening postpartum hemorrhage before hysterectomy. Bilateral ligation of the internal iliac artery does not result in complete blockage of but to a significant decrease in blood supply to the female pelvic organs. Soon after ligation three previously existent collateral circulations will develop. Due to the smaller caliber of these arteries, the arterial pulse and pulse pressure are virtually eliminated. The effectiveness of HAL in avoiding hysterectomy for postpartum hemorrhage has been reported in up to 50% of cases. HAL has no adverse effect on subsequent fertility or pregnancy outcome, however, assessment for intrauterine fetal growth restriction is recommended. This safe and effective procedure should be taught during obstetric and gynecologic training.     

Hypogastric artery ligation for intractable pelvic hemorrhage.

OBJECTIVE: To assess the outcomes of bilateral hypogastric (internal iliac) ligation performed to control intractable pelvic hemorrhage and avoid hysterectomy. METHODS: A review of indications and outcomes for 117 cases of bilateral hypogastric artery ligation over 15 years (1990-2004). RESULTS: Apart from a slight lesion to the hypogastric vein, no complications were observed. Hemorrhage was effectively controlled in all 37 obstetric cases. In 13 of these cases, the uterus was preserved even when there was cervical pregnancy, placenta previa, placental abruption, uterine atony, and uterine rupture, and 4 women were delivered of mature infants. Hemorrhage was effectively controlled in 41 of 80 gynecologic cases. Prophylactic reduction of pelvic blood flow was the indication for the procedure in 39 cases, 5 of whom involving Jehovah's Witnesses adverse to blood transfusion. The uterus was preserved in only a few of the 41 controlled cases, but one woman (so far) was delivered of a mature infant. CONCLUSION: Hypogastric artery ligation was found to be indicated if (1) life-threatening pelvic hemorrhage could not be controlled by conservative methods; (2) prophylactic reduction of pelvic blood flow was needed to prevent anticipated hemorrhage; and (3) preservation of reproductive function was desired. The procedure was found to be safe and usually effective and should be taught during obstetric and gynecologic training.     

Internal iliac artery ligation for arresting postpartum haemorrhage

OBJECTIVE: To study the role of internal iliac artery ligation (IIAL) in arresting and preventing postpartum haemorrhage (PPH). DESIGN: Retrospective chart review of women undergoing therapeutic IIAL for PPH or prophylactic IIAL for risk of PPH. SETTING: Tertiary care hospital in Pune, India. SAMPLE: Women admitted to King Edward Memorial (KEM) Hospital, Pune, India, who underwent IIAL to control or prevent PPH. METHODS: Bilateral IIAL was performed in all women. MAIN OUTCOME MEASURES: Need for re-laparotomy or hysterectomy to control haemorrhage, complications of the procedure. RESULTS: Out of 110 women who underwent IIAL, 88 had therapeutic IIAL for PPH from atony (36), genital tract injury (23), placenta praevia (21), placental abruption (4), uterine inversion (3) or coagulopathy (1). Hysterectomy was performed after IIAL failed to arrest haemorrhage in 33 (39.3%) of 84 women (excluding 4 with vaginal lacerations). Hysterectomy was more likely with uterine rupture (79%) than with nontraumatic PPH (up to 27%). Failure to control haemorrhage by IIAL was evident immediately, and bleeding arrested by IIAL did not recur to require later laparotomy in any woman. Out of 22 women at high risk for PPH undergoing prophylactic IIAL at caesarean section, none had subsequent haemorrhage. One woman had an iliac vein injury that was repaired with no further morbidity. There were no ischaemic complications either during inpatient stay or up to 6 weeks. CONCLUSIONS: IIAL is useful in the treatment and prevention of PPH from any cause. Early resort to IIAL effectively prevents hysterectomy in women with atonic PPH. In traumatic PPH, IIAL facilitates hysterectomy or repair as indicated and prevents reactionary haemorrhage.     

Laparoscopic uterine artery ligation for treatment of symptomatic adenomyosis

STUDY OBJECTIVE: To investigate the effect of laparoscopic uterine artery ligation on symptomatic adenomyosis. DESIGN: Prospective pilot study (Canadian Task Force classification II-2). SETTING: Tertiary care major teaching hospital. PATIENTS: Twenty women with symptomatic adenomyosis. INTERVENTION: Laparoscopic ligation of bilateral uterine arteries with hemoclips and electrocoagulation of bilateral uterine ovarian vessels. MEASUREMENTS AND MAIN RESULTS: Patients underwent sonographic measurement of uterine size, and recorded amount of menstruation and dysmenorrhea preoperatively and postoperatively. Six months postoperatively, mean uterine size had decreased by an amount ranging from 0.4% to 74.0%. Two of nine women achieved remission of the mass effect of an enlarged uterus. Thirteen of 16 patients achieved bleeding control and 5 returned to eumenorrhea or hypomenorrhea. Twelve of 16 patients achieved control of dysmenorrhea and 6 were analgesic free. However, nine women experienced nonmenstrual pain after surgery, three of whom underwent hysterectomy later. Treatment was rated as satisfactory by 15% of patients, but 45% were dissatisfied. Seventeen women would have refused to undergo the procedure if they could make the decision again. CONCLUSION: Poor satisfaction in this preliminary study suggests that symptomatic adenomyosis may not be effectively treated by laparoscopic uterine artery ligation.     

Uterine artery ligation for management of uterine fibroids.

OBJECTIVE: To determine the efficacy of uterine artery ligation by the vaginal route for the management of symptomatic uterine fibroids. A pilot study had suggested that the procedure was effective. METHODS: After bilateral uterine artery ligation, ultrasonic measurements of uterine and fibroid volumes were determined at 6 and 12 months in 21 women (age, 31-49 years) with symptomatic fibroids. The severity of symptoms was assessed preoperatively and postoperatively. RESULTS: Mean uterine and fibroid volumes were significantly reduced at 6 and 12 months. A consistent pattern of decreased duration of menstrual blood flow was recorded. All participants who completed follow-up expressed satisfaction with treatment outcome. CONCLUSION: The procedure was found to be a safe, inexpensive, and effective therapeutic option for the treatment of symptomatic uterine fibroids.