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KEY QUESTIONS
What are the indications for hypogastric artery ligation (HAL)?
How effective is HAL in controlling a pelvic hemorrhage?
What are the key operative steps in performing HAL?
What are the advantages and disadvantages of HAL?
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CASE 64-1
A 31-y.o. G1P1 with a history of abnormal uterine bleeding secondary to known 7-cm and 6-cm subserosal leiomyomas is admitted for an abdominal myomectomy. She is typed and crossed for 4 units of packed RBCs, with a starting hemoglobin of 12.2 g/dL. Prior to surgery, the patient reinforces her desire for future childbearing.
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Pelvic hemorrhage is an obstetrical or gynecologic (OB/GYN) emergency that clinicians will invariably encounter during their medical career. Effective management of this potentially disastrous situation requires a surgeon who is well versed in pelvic anatomy and has an understanding of the disease entity or clinical scenario that causes hemorrhage, sound surgical decision-making, and operative dexterity, and a capacity to lead an operative team to optimize patient safety. Multiple surgical techniques have been described to aid an OB/GYN facing pelvic hemorrhage. One of the more historical techniques that still upholds its importance in the operative arena is HAL, a highly efficacious technique for addressing uncontrollable pelvic bleeding in the field of obstetrics and gynecology.
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Dr. Howard A. Kelly, of the Johns Hopkins Hospital, originally described the procedure in 1893 as a means to control life-threatening intraoperative bleeding on a patient with cervical cancer undergoing a hysterectomy. He began his historical article by stating, “I bring before you this evening an exceedingly interesting case from several standpoints, one of which is novel and I think suggestive.”1 Dr. Kelly astutely drew attention to the benefits of HAL as follows: “The special points of interest in this case are (1) the prompt benefit derived from transfusion, and (2) the apparent cure of the carcinoma by cutting off its main blood supply.”1
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Dr. Kelly was correct in describing this procedure as novel. Thereafter in the 1960s, Burchell studied the clinical science behind the effectiveness of HAL and found that with ligation of both hypogastric arteries, the arterial pulse pressure distal to the ligation decreased by 85%.2 If the procedure is done unilaterally, the pulse pressure decreases by 77% on the same side and 14% on the opposite side. Blood flow decreases by 48% distal from the point of ligation, but it is the large drop in pulse pressure that makes blood vessels more amenable to hemostasis via pressure and clot formation.
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Gaining excellent exposure to the pelvic retroperitoneum is the first critical step in performing a successful HAL. To do so, the pelvic sidewall peritoneum should be opened along the psoas tendon, staying lateral to the external iliac vessels and just parallel to the ovarian vessels. Entry into the retroperitoneal space can be accomplished safely in two places on either ...