Anatomic structure of the internal iliac artery and its educative dissection for peripartum and pelvic hemorrhage

Abstract

The abdominal aorta is divided into two parts (right and left) at the level of the fourth-fifth lumbar vertebra and called the common iliac artery. Anterior to the sacroiliac joint, common iliac arteries are divided into external and internal iliac arteries. The external iliac artery supplies the lower limb, and the internal iliac artery is the major vascular supply of the pelvis. Internal iliac artery is divided into anterior and posterior trunk. The anterior trunk supplies the pelvis, visceral organs, and the posterior trunk supplies pelvic parietal structures. The broad ligament envelopes the uterus anteriorly and posteriorly with its sheets and continues as the pelvic peritoneum at the lateral side of the pelvic wall. After cutting the pelvic peritoneum, the retroperitoneal area is visualized and the internal iliac artery with other great vessels of the abdomen can be noted.

Basic clinical retroperitoneal anatomy for pelvic surgeons

“…During pelvic lymphadenectomy to dissect the obturator lymph nodes, the surgeon needs to open the paravesical space first then dissect the lateral part on the pelvic side wall. Over the obturator fossa, there are numerous anomalous and collateral vessels, which need tiny and careful dissection to prevent hemorrhage due to injury (8) . Paravesical space contains obliterated umbilical artery and it is in close relation with obturator neurovascular bundle and external iliac vessels with the lymphatic and fatty tissue (9) .…”

Anatomic variations of the Uterine Artery. Review of the literature and their clinical significance

“…The uterine artery traditionally arises from the internal iliac artery, anteriorly (7) . Partly the uterine artery passes, medially, through the base of the broad ligament of uterus before bifurcating at the isthmus level (8) .…”

“…The absence of uterine arteries has also been observed (26,27) with large ovarian vessels being present taking up the uterus blood supply. Obimbo et al (16) 2010 Cadaveric 53 106 89.7% (95) --- 7 Naguib et al (20) 2008 CT Angiography 49 95 93% (89)…”

“…Gomez-Jorge et al (21) 2003 Arteriograms (UFE) 257 38% of 514 43% -6% - 10 Roberts et al (17) 1966 Cadaveric 167 44 56.2% (27) ---11 Lipshutz (13) 1918 Cadaveric 93 67 89.5% (60) --- (14) 64.3% (144) ----2 Kozlov et al (15) 1.6%* 27% and 1.8%* -3% and 1.4%* 2% 1.6%* 3 Arfi et al (18) -62.4% (54)* ---2.3% (2) 4 Albulescu et al (19) 24% ---- 5 Chantalat et al (23) Obimbo et al (16) 10.3% (11) ---- 7 Naguib et al (20) -…”

Step by step ligation of internal iliac artery

“…It arises from the common iliac artery and runs infero-medially in the pelvis. An enormous number of small vessels, collateral circulation and variations exist in pelvic vasculature (1,2) The role of internal iliac artery ligation to control intractable pelvic hemorrhage had been described by Howard Kelly for the first time in 1893 for a cervical carcinoma case (3). Actually, ligation of internal iliac artery could also be a life-saving procedure during peripartum bleeding (4,5).…”