To describe two different approaches of performing internal iliac artery ligation and their usefulness in different clinical situations.

Internal iliac artery ligation is a very useful method to control pelvic hemorrhage. It can become a necessity at any point of time while performing obstetric or gynecological surgeries, and it is a procedure that needs to be accomplished in a matter of few minutes, before the patient goes into irreversible shock.

Internal iliac artery ligation can be done by approaching the artery by opening the retroperitoneal space, either by dividing the round ligament or by opening the pouch of Douglas. The internal iliac artery is identified by locating the bifurcation of the common iliac artery with the ureter crossing it. The external iliac artery is the lateral branch of the common iliac artery and it runs a straight course to continue as the femoral artery in the lower limb. The ureter is identified by peristalsis, and the internal iliac artery is the short medial branch of the common iliac which runs a short course and immediately divides into an anterior and a posterior division, which in turn divide into a number of branches. The uterine artery is the branch of anterior division of the internal iliac artery. The internal iliac artery is ligated by passing a stout suture material under it with the help of a right-angled forceps, or it can be directly occluded with clips, applied using a clip applicator.

Both the approaches are equally effective and easy to perform. Approaching the internal iliac artery through the round ligament is easier in gynecological surgeries, whereas the pouch of Douglas approach is easier during cesarean section.

Internal iliac artery ligation is almost always performed as an emergency, though the need to perform it can be anticipated in advance and the gynecologist can be prepared for it. It is essential for gynecologists to be conversant with this life and a uterus-saving procedure. There are two approaches of doing this procedure and the choice is entirely on the individual. It may not be possible to approach the pouch of Douglas when there are dense adhesions as in case of a frozen pelvis. And it may be time-consuming to approach the internal iliac artery by dividing the round ligaments when there is postpartum hemorrhage. Therefore, it is useful to know both the approaches, because one might encounter a situation where one may find it difficult to follow the technique one is familiar with.

Podder AR, Jyothi GS. Internal Iliac Artery Ligation: A Retrospective Analysis of Two Different Approaches. J South Asian Feder Obst Gynae 2017;9(3):230-234.