AN ANATOMIC APPROACH TO PELVIC HEMORRHAGE DURING SACROSPINOUS LIGAMENT FIXATION OF THE VAGINAL VAULT

Objective: To examine the current clinical problem of life-threatening hemorrhage during sacrospinous vaginal vault suspension, define a man agement solution, and validate current anatomic knowledge of the area involved. Methods: Ten cadaveric female pelves were dissected from a p osterior gluteal approach and from an abdominal approach. The vascular ity of the region of the sacrospinous ligament was mapped. Results: Th ere are multiple and varied collateral vascular supplies and anastomos es in the region of the sacrospinous ligament and buttock, including: 1) superior gluteal, 2) inferior gluteal, 3) internal pudendal, 4) ver tebral, 5) middle sacral, 6) lateral sacral, and 7) external iliac via the circumflex femoral artery system. Anastomoses occurred in all pel ves examined. The frequency of each type of anastomosis varied from 20 -100%. Conclusion: Surgical ligation of the internal iliac artery woul d not likely curb massive hemorrhage during sacrospinous ligament fixa tion, except in certain cases of internal pudendal vascular injury. Th e inferior gluteal artery is probably the most commonly injured vessel in sacrospinous ligament suspension because of its location. Inferior gluteal vessel injury should be approached by the use of packing and vascular clips or packing and arterial embolization. These latter appr oaches should be of primary consideration in the control of hemorrhage at the time of sacrospinous ligament fixation. (C) 1998 by The Americ an College of Obstetricians and Gynecologists.