Surgical Management of Intractable Pelvic Hemorrhage
Louis G. Keith, Robert L. Vogelzang and Daniel L. Croteau
Table Of Contents
Louis G. Keith, MD
Robert L. Vogelzang, MD
Daniel L. Croteau, MD
PHYSIOLOGY OF LIGATION
INDICATIONS FOR LIGATION
LIGATION OF THE HYPOGASTRIC ARTERY: SURGICAL TECHNIQUE
ANEURYSMS OF THE HYPOGASTRIC ARTERY
TREATMENT OF PELVIC HEMORRHAGE WITH INTERNAL ILIAC ARTERY EMBOLIZATION EMBOLIZATION
THE NORTHWESTERN EXPERIENCE WITH PELVIC EMBOLIZATION FOR UTERINE BLEEDING UTERINE BLEEDING
The background of ligation of the hypogastric (internal iliac) arteries for control of pelvic hemorrhage is not clear. Medical historians attribute the procedure to different surgeons in diverse specialties. In the United States, the operation was reported before 1900. Since then, diverse articles about this procedure have appeared sporadically; its usefulness has been demonstrated in many areas dealing with the pelvis and its contents.
Ligation of the hypogastric arteries can be a lifesaving procedure for patients with intractable hemorrhage from pelvic viscera. This is especially true in the field of obstetrics and gynecology, in which hemorrhage remains a major cause of mortality. Some physicians may be reluctant to perform hypogastric artery ligation for fear of injury to the pelvic viscera by interruption of the blood supply. With rare exceptions, this reluctance is unwarranted. Short- and long-term effects of hypogastric artery ligation generally are salutary. In contrast, so-called conservative procedures, such as vaginal packing, suturing of the vaginal vault, and supracervical hysterectomies, frequently fail to control hemorrhage. Before hypogastric artery ligation was considered a potential approach to the problem of pelvic hemorrhage, time, blood, and, alas, lives were lost. The technique of hypogastric artery ligation is acquired easily and should be practiced by the obstetrician and gynecologist.
Topographic Anatomy and Surgical Landmarks
The intra-abdominal arrangement of the iliac vascular system can be projected on the abdominal surface. Beginning at a point 1/2 inch below and to the left of the umbilicus, draw a line inferolaterally so as to bisect a line running medially and inferiorly from the anterosuperior iliac spine to the middle of the symphysis pubis. The upper one third of the umbilicospinal line traces the course of the common iliac artery before its bifurcation. The distal two thirds of the same line delineates the external iliac artery; a line dropped medioinferiorly from this junction to the pelvic floor suggests the course of the hypogastric artery. The external bony landmark to the level of the bifurcation of the common iliac artery is the anterosuperior iliac spine. In most instances a line between both anterosuperior iliac spines bisects the points of bifurcation.
Internally, the aorta generally bifurcates into the common iliac arteries at the level of the fourth lumbar vertebra. The common iliac arteries, in turn, divide into the external and internal iliac (hypogastric) arteries. The external iliac artery courses along the psoas muscle laterally and ventrally to the leg, where it becomes the femoral artery. The hypogastric artery drops medioinferiorly along the border of the psoas muscle into the pelvis. An internal bony landmark for the level of the aortic bifurcation is the sacral promontory (lumbosacral articulation).
Once the hypogastric artery reaches the pelvis, it divides into the so-called anterior and posterior divisions. Those in turn divide into many branches, which are designated collectively as the hypogastric axis (Table 1). Figure 1 illustrates the gross anatomy.
The hypogastric arteries have important relationships to neighboring anatomic structures. Knowledge of these relationships facilitates locating the arteries, as well as dissecting and ligating them. These relationships, listed below, are illustrated in Figure 2, Figure 3 and Figure 4.
The collateral circulation of the pelvis has been the subject of discussion for at least a century. Gray's Anatomy (1870 edition) mentioned the many anastomoses. Anastomoses occur in each hemipelvis, horizontally and vertically across the pelvis.1, 2 The vertical system functions to a greater extent than the horizontal, especially after bilateral ligation. Figure 5 is a schematic representation of what might occur after unilateral ligation.
Three major vertical anastomoses exist in each hemipelvis: (1) lumbar-iliolumbar, (2) middle sacral, and (3) superior hemorrhoidal-middle hemorrhoidal. Bilateral ovarian-uterine anastomoses are another important vertical link. Anastomoses also occur between the inferior epigastric and medial circumflex femoral arteries, the circumflex and perforating branches of the deep femoral artery and the inferior gluteal artery, and the superior gluteal artery and the posterior branches of the lateral sacral artery.
The horizontal anastomoses are the branches of the vesical artery from each side and the pubic branches of the obturator artery from each side. Both systems are outlined in Table 2.
Variations in the Pelvic Circulation
The forgoing anatomic descriptions suffice for practical purposes. Dissection of the branches of the hypogastric artery, however, frequently reveals variation in the number of branches, the relative size of the branches, and the length and diameter of the right and left hypogastric arteries.2, 3, 4 Figure 6 illustrates some of the documented variations in the branches of the hypogastric artery. Table 3 lists the collateral circulation of the branches of the hypogastric artery.
The variations are relatively unimportant; however, some specific exceptions must be mentioned:
In the pregnant patient with this fistula, antepartum bleeding or abnormal enlargement of the uterus is probable. Severe, catastrophic hemorrhage has been reported in the postpartum period or after abortion. Percutaneous femoral aortography establishes the diagnosis. Therapy is achieved via surgery5 (Fig. 8 and Fig. 9)
|PHYSIOLOGY OF LIGATION|
At one time, ligation of the hypogastric system was regarded as equivalent to shutting off all blood to the area. Fortunately, this is not true. If it were, it is likely that the procedure would not be harmless. In reality, the hypogastric artery distal to the point of ligation is never emptied of blood.6 The anastomotic system functions immediately after ligation. What does occur is the virtual abolition of the arterial pulse pressure. This is associated with reduced mean blood pressure and rate of blood flow in the collateral system. As a result, the trip-hammer effect of arterial pulsations is abolished. In effect, ligation changes the distal portion of the artery so that the net pressure is equivalent to that in a vein. Clots remain in situ and are not dislodged by arterial pulsation.
|INDICATIONS FOR LIGATION|
Conventional methods of therapy for pelvic hemorrhage, such as packing, suturing, and the use of hemostatic agents frequently are ineffective. Active indications for surgical intervention include the following conditions in which rapid and life-threatening hemorrhage can occur:
Certain operative conditions are associated with hemorrhage. Operative time frequently is consumed in controlling bleeding areas. Early ligation of both hypogastric arteries allows the surgical procedure to progress in a relatively dry field and saves time.
Prophylactic surgical intervention is indicated in the following conditions and procedures:
|LIGATION OF THE HYPOGASTRIC ARTERY: SURGICAL TECHNIQUE|
Either a midline or a transverse abdominal incision may be used. The surgeon should not use an unfamiliar incision. The transverse incision may take more time, especially when patients are obese. Visualization is better from the opposite side of the pelvis. To work on the contralateral side, the surgeon may elect to change sides during the operation.
In most situations, bilateral ligation is preferable to unilateral ligation. Not only is hemostasis more secure, but also any doubt about a possible return to the operating room is removed. Although it is possible to perform the operation by the extraperitoneal approach, the intra-abdominal approach is preferable except in cases of extreme obesity.
Some surgeons advocate complete transection of the hypogastric vessel between two ligatures. This has no practical or physiologic advantage. On the contrary, its practice may lead to injury of the underlying veins. If such an injury should occur in the course of the operation, applying pressure with a gauze sponge or suturing with an atraumatic needle and fine suture material usually suffices to repair the defect. If this should fail, however, the vein itself can be ligated above and below the defect. Incorporation of the previously tied artery into the suture in the vein adds strength and security as well as a splinting effect.
The choice of suture material depends on the preference of the surgeon. Number 1-0 chromic catgut, double-strand 2-0 black silk, and umbilical artery tape all have been used. Wet umbilical tape is particularly advisable for older patients, who are more likely to have arteriosclerosis. Two ties should be placed firmly but gently in continuity approximately 0.5 cm apart and 0.5 to 1 cm below the bifurcation.
The abdomen is opened and the viscera packed away in the usual manner. Identification of the bifurcation of the common iliac artery is made by the two bony landmarks: the sacral promontory and an imaginary line drawn through both anterosuperior iliac spines. A longitudinal incision into the posterior parietal peritoneum is made. If the uterine corpus is present, this incision can be started in the peritoneum on the posterior surface of the round ligament at the junction of the middle and medial thirds. The incision is extended proximally for almost 10 cm. If the uterine corpus is absent, the incision can be started over the external iliac artery and carried proximally to the level of the bifurcation. Another method is to incise into the peritoneum directly over the bifurcation. The incision then is carried distally a few inches. All these incisions have one feature in common: They result in the formation of a medial and lateral peritoneal flap. The ureter is always on the medial flap and may be visualized, reflected, and protected with ease. The ureter normally crosses the common iliac artery from lateral to medial at a point just proximal to the bifurcation.
Once the peritoneum is opened, loose areolar tissue must be wiped away with firm, gentle motions in the direction of the vessels, not across them. Small pieces of dental cotton on long, curved forceps are effective. The fingers also may be used. When the areolar tissue has been removed, the bifurcation comes into view. Correct orientation begins with digital palpation of the bounding pulse. The vein may be visualized posteriorly. The ureter should be located on the medial peritoneal flap. The bifurcation feels like an inverted Y. The branch coming off at right angles is the hypogastric (internal iliac) artery. It courses medially and inferiorly to the palpating finger. The continuing branch is the external iliac artery. It courses laterally and superiorly out over the psoas muscles to the leg, where it becomes the femoral artery.
The surgeon must accurately identify these two branches. There is no room for error. Should the external iliac artery be ligated, the leg that receives its blood supply from this vessel soon will become cold, numb, and pale. Loss of the limb can follow. If the external branch is ligated, the sutures can be cut; however, if the artery has been transected, repair often is difficult.
After identification, the hypogastric artery should be elevated from the vein by Mixter forceps or the forceps designed by Reich and Nechtow2 (Fig. 10). The artery often is firmly adherent to the underlying vein; caution is advised. The point of the instrument should be directed toward the midline and placed at the border of the artery, and the forceps tips should be spread open gently. At the same time, the forceps should be “nudged” medially. When the artery is lifted off the vein, the external branch should be reexamined and reidentified. After confirmation, ligatures should be passed beneath the artery and tied gently but firmly. The artery should not be transected.
The peritoneum should be closed with interrupted 3-0 plain catgut because a continuous suture can kink the ureter. The procedure on the left pelvic wall may be slightly more complicated because it frequently is necessary to mobilize the sigmoid flexure at the “white line” to obtain adequate exposure.
The skin incision in the inguinal area parallels the course of the external oblique muscle. It runs 6 to 8 cm in length in a line 3 to 5 cm medial to the anterosuperior iliac spine. After the fat and subcutaneous tissues are dissected away, a muscle-splitting incision bares the peritoneum. This is gently reflected medially, exposing the posterior surface; the ureter is reflected medially and the vessels laterally. Ligation is performed as previously described. Closure is the same as for a herniorrhaphy (Fig. 11).
Midline Extraperitoneal Approach
A midline extraperitoneal approach to the aorta is advocated by some. One authority extended its use to bilateral ligation of the hypogastric arteries. A midline abdominal incision is made. After the anterior sheath of the rectus muscle is exposed and opened below the level of the umbilicus, dissection caudal to the semilunar line of Douglas is performed, and the peritoneal and preperitoneal fat are separated. The peritoneum and its contents are reflected to the right (or left), thus exposing the retroperitoneal structures7 (Fig. 12).
Concomitant Ovarian Vessel Ligation
If the ovarian vessels are also to be ligated, the tube and ovary are picked up with Babcock's forceps and put on a stretch away from the origin of the infundibulopelvic ligament. The ovarian artery and vein may be palpated as cordlike structures beneath the peritoneum. Numerous varicosities may obscure the area, but selection of a free space in the peritoneum is crucial. The varicosities can be pushed away by the thumb and first finger. Once the clear spot has been found, a suture ligature (chromic catgut on an atraumatic curved noncutting needle) is passed and tied. A second, parallel ligature completes the procedure.
The major pitfall associated with ligation of the hypogastric artery is delay. When hemorrhagic shock is irreversible, this operation will not overcome it. Inadequate transfusion is another pitfall in the therapy of patients with severe hemorrhage. Blood loss often is seriously underestimated.
Failure to remember that the vaginal artery is a separate branch of the hypogastric artery rather than a branch of the uterine artery may lead the surgeon into the pitfall of an unnecessary and ineffective hysterectomy for control of bleeding. Injury to the external iliac artery from retractors or mistaken ligation of this vessel can lead to loss of the entire lower limb.
Special care is not necessary. Large hematomas or collections of serosanguineous fluid can be drained through separate stab wounds. Usually this is unnecessary. Antibiotics are not indicated after ligation of the arteries. Their use is dictated only by the presence of infection. Early ambulation is advisable in all cases. Bladder atony will not develop; an indwelling catheter may be necessary to facilitate adequate assessment of urinary output.
Injury to Vital Structures
Opinions endorsing the safety of the procedure are overwhelming. The available data suggest that this operation does not result in necrosis of vital pelvic structures. One report to the contrary is by Tajes,8 who cited a case of his own in which this operation resulted in necrosis of the buttocks. Tajes also reviewed two previously reported cases: In one case, the bladder mucosa sloughed; in the other, scrotal necrosis ensued.
Maintenance of Reproductive Function
It has not always been possible to follow young patients for whom this operation has been performed. More important, many patients do not understand the exact nature or extent of their operation. A patient may remember only that she was sick and bleeding, that she was operated on, and that she recovered. The following consultation case illustrated this point:
The incidence of postoperative amenorrhea is not known. It is common for menses to resume after the operation. There have been reports of normal pregnancy and delivery occurring after bilateral hypogastric artery ligation, although it is impossible to say how frequently this occurs. It is entirely reasonable to believe that reproductive capacity is not lost after this operation, provided that the patient has a normal uterus. It is important to remember that pituitary necrosis (Sheehan's syndrome discussed elsewhere in these volumes) can affect the ability to reproduce after postpartum hemorrhage, especially if blood replacement has been delayed or inadequate, hemorrhage has been severe, and shock profound. Fortunately, this is not a common occurrence.
Occasionally ligation of the hypogastric arteries fails to stem pelvic hemorrhage. The reason for this is not clear, but some suggestions are (1) massive necrosis after infection with destruction of the vessels; (2) the presence of large, aberrant branches feeding blood to the area; (3) dislodgment of clots when blood pressure rises; and (4) concomitant severe venous bleeding; however, these circumstances are rare.
|ANEURYSMS OF THE HYPOGASTRIC ARTERY|
Aneurysms of the hypogastric artery are uncommon. Symptoms can range from subtle to bizarre. Thus, the detection of aneurysms by physical diagnosis is difficult unless they are specifically sought, and the diagnosis of ruptured aneurysm is rarely made before surgery. Even during exploratory surgery, these deformities may be missed.
Hypogastric artery aneurysms are generally found among older individuals who develop sudden abdominal pain and vascular collapse. Other symptoms may include rectal hemorrhage, bladder-neck obstruction, and pain in the buttocks and thigh. Aneurysms of the hypogastric artery frequently are associated with aneurysms at other locations.
The majority of successful surgical procedures for this condition include some form of arterial reconstruction. Unfortunately, the use of reconstruction operations is associated with a greater risk of ischemia of the colon developing as a result of interruption of the inferior mesenteric arterial blood supply9 (Fig. 13, Fig. 14, Fig. 15 and Fig. 16).
Arterial reconstruction is relatively easy for experienced physicians to perform; however, it becomes more difficult when the ovarian artery and its branches are not visualized, when the presence of excessive subcutaneous fat makes it difficult to locate the femoral artery, and when preexisting arteriosclerosis is present.
The major usefulness of this procedure relates to oncology. Benign lesions generally displace the principal pelvic vessels and produce a gradual reduction in the caliber of their branches, unaccompanied by infiltration of the surrounding tissue. Infiltration of adjacent tissues with accompanying new vessel formation, however, suggests malignancy; malignancy also is suggested by the presence of a rich arteriolar network of irregular distribution, the persistence of the opaque image attributable to the presence of calcium deposits within a tumor, and an early venous discharge of contrast medium as a result of arteriovenous communications.10
|TREATMENT OF PELVIC HEMORRHAGE WITH INTERNAL ILIAC ARTERY EMBOLIZATION EMBOLIZATION|
Advancements in arteriographic techniques have not been fully appreciated or widely used in gynecologic practice. The emergence of arteriography as a well-defined subspecialty of radiology has led to the development and refinement of catheterization techniques that assist in the control of pelvic hemorrhage. Even relatively small arteries, such as the uterine branches of the internal iliac vessels, can be catheterized in the presence of massive retroperitoneal hematomas that distort normal anatomic findings. As a result, therapeutic embolization is effective in arresting massive pelvic hemorrhage caused by trauma (obstetric or otherwise) or cancer. To date, however, the technique has not been widely used to control postpartum hemorrhage.
A number of investigators confirm the efficacy of embolization techniques for control of bleeding related to obstetric and gynecologic problems. Mitty and colleagues reported that nine patients with obstetric hemorrhage from uterine, vaginal, or placental tears were successfully treated with surgical gelatin sponge embolization.11 Greenwood and co-workers described nine patients (eight obstetric, one gynecologic) who also were successfully treated with embolization therapy.12 Other series or single case reports document the use of uterine artery or internal iliac embolization in the management of hemorrhage after abortion, vaginal hemorrhage, abdominal pregnancy, vascular malformations, and trophoblastic disease.13, 14, 15, 16, 17 For the most part, success rates have been high, with little or no procedurally related morbidity and no mortality. Other investigators have reported on the use of internal iliac artery embolization to treat continued hemorrhage after successful hypogastric artery ligation, pointing out the relatively high failure rate of this technique as reported in the surgical literature.18, 19
Internal Iliac Artery Embolization
For the most part, the common femoral artery approach can be used to catheterize and embolize the iliac vessels. The use of modern steerable catheters as well as hydrophilic wires and catheters permits catheterization of the anterior divisions of both internal iliac arteries by a single femoral approach (Fig. 17). Other approaches that may be necessary in particularly problematic circumstances include the bilateral femoral approach, which enables the internal iliac artery to be catheterized on the contralateral side, or the brachial artery approach, which can provide access to both internal iliac arteries and their divisions. The disadvantage of the latter approach, however, is the fairly long catheter course from the arm to the pelvis.
Diagnostic arteriography should be carried out before any embolization procedure. An injection at the aortic bifurcation is ideal for visualization of all pelvic vessels. This overview permits the examiner to identify the overall branching pattern of the pelvic vessels. This is particularly necessary because the arrangement of the internal iliac artery branches varies considerably. After pelvic arteriography, selective internal iliac arteriography is carried out with at least two radiographic views of the vessel. The importance of multiple views of the pelvis cannot be overstated. The complexity and overlap of multiple vessels almost always requires several projections to identify vessels and to clarify their course, position, and distribution.
Although the major angiographic sign of bleeding is extravasation of contrast material, many authors do not report this sign in all patients with pelvic bleeding. Indeed, we and others find visualization of morphologic arterial changes, such as enlargement, tortuosity, or compression of the vessel by hematoma, to be helpful signs, especially if extravasation is not present. Among the 12 patients (including a number of actively bleeding patients) in whom we have performed uterine artery embolization, we have not noted active extravasation of contrast material. Rather, our decision to embolize was based on clinical circumstances and knowledge of pelvic anatomy (see below).
In our estimation, superselective catheterization of vessels is also important for the successful performance of embolization. We have found that the uterine artery can be catheterized (in most cases bilaterally) without too much difficulty.
A number of materials can be used for embolization, including Gianturco coils, surgical gelatin pledgets, polyvinyl alcohol foam particles (200 to 1000 μm), and liquids (e.g., tissue adhesives, alcohol). For management of bleeding, we strongly prefer the use of particulate material. In general, surgical gelatin pledgets cut to appropriate sizes of 1 to 5 mm provide ideal hemostasis and allow the vessel to recanalize within 2 to 3 weeks after the threat of hemorrhage has stopped. For more permanent embolizations, such as in uterine arteriovenous malformations, small particles or liquids have been used, but these should be injected with extreme caution because they can produce undesirable side effects in adjacent branch vessels as well as significant tissue necrosis.
Position of Embolization
In most cases of uterine bleeding, superselective uterine artery embolization is the ideal approach. Superselective catheterization and embolization permits complete occlusion of uterine vessels while preserving other normal pelvic arterial structures. In nonuterine bleeding, such as bleeding from vaginal or pelvic sidewall sources, bilateral embolization of the anterior division of the hypogastric artery with surgical gelatin pledgets is the most effective therapy. Some authors prefer anterior division embolization for all circumstances. Despite the fact that specific prospective comparisons have not been made between superselective embolization and less-selective anterior division embolization, we believe that the superselective approach is superior to less-selective embolization techniques.
Embolization of the appropriate or selected branch should be performed to the point of complete vessel occlusion, with production of vascular stasis in the blind segment as judged by frequent angiographic injections of contrast material.
Complications of pelvic embolization predominantly consist of inadvertent embolization of nontarget vessels. Fortunately, the pelvis is so richly supplied by collateral vessels (see above) that the use of medium-sized (1 to 4 mm) occluding agents will rarely result in ischemia unless the (gluteal) branches of the posterior division are occluded.
Other complications have also been reported, including occasional ischemic sciatic neuropathy from overzealous embolization of pelvic artery branches with very small particles. Moreover, the use of liquids or small particles also can produce rectal ischemia (through hemorrhoidal branches) or, rarely, areas of bladder ischemia. For these reasons, all patients must be observed carefully after embolization procedures. Despite the above caveats, pelvic embolization is very well tolerated if appropriately performed by skilled interventional radiologists.
|THE NORTHWESTERN EXPERIENCE WITH PELVIC EMBOLIZATION FOR UTERINE BLEEDING UTERINE BLEEDING|
Our experience with selective transcatheter embolotherapy for uterine hemorrhage includes 12 patients treated between 1987 and 1995. They ranged in age from 16 to 42 years, and all had failed conservative therapy; most had received transfusions and one patient had von Willebrand's disease. Seven patients had postpartum uterine hemorrhage, and five had uterine vascular malformations. In the postpartum group, two had cervical artery lacerations after dilatation and curettage, one had placenta accreta after a cesarean section, one had placental subinvolution with hemorrhage 2 weeks after cesarean section, one had a uterine artery pseudoaneurysm at a cesarean section suture line, one had active bleeding from the uterine fundus after cesarean section, and one had uterine atony with coagulopathy. Among the patients with uterine vascular malformations, two had congenital arteriovenous malformations, and three had complications of gestational trophoblastic disease (choriocarcinoma, invasive mole, or hydatidiform mole).
Our technique for uterine artery embolization utilized the femoral approach. Bilateral uterine artery embolization was used in 10 patients; unilateral uterine artery embolization was used in 2 patients. All patients were embolized with either surgical gelatin pledgets or polyvinyl alcohol foam particles (300 to 700 μm). Two patients had minor complications: One had a femoral artery false aneurysm treated successfully with ultrasound-guided compression; the other patient had transient fever for 3 days after embolization, which was believed to be related to endometritis. No ischemic complications were observed. Of the 12 patients, 11 were cured of hemorrhage; the remaining patient with uterine atony had recurrent bleeding at 8 days, necessitating a hysterectomy. Of the 11 patients who retained their uterus, 1 patient became pregnant 8 months after embolization. The following six case reports illustrate the significant benefits of pelvic embolization for uterine hemorrhage.