Special clinical considerations

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 is often 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 lower limb amputation. Also, accidental ligature of one or both ureters would lead to renal function impairment. Accidental incorporation of the anterior division of the sciatic nerve may lead to foot drop (Figure 1b).

Most authors consider internal iliac artery ligation to be a very safe procedure. The available data suggest that this operation does not result in necrosis of vital pelvic structures. The only report to the contrary is by Tajes4 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. However, his report was 50 years ago.

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