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 management solution, and validate current anatomic knowledge of the area involved.

Methods: Ten cadaveric female pelves were dissected from a posterior gluteal approach and from an abdominal approach. The vascularity of the region of the sacrospinous ligament was mapped.

Results: There are multiple and varied collateral vascular supplies and anastomoses in the region of the sacrospinous ligament and buttock, including: 1) superior gluteal, 2) inferior gluteal, 3) internal pudendal, 4) vertebral, 5) middle sacral, 6) lateral sacral, and 7) external iliac via the circumflex femoral artery system. Anastomoses occurred in all pelves examined. The frequency of each type of anastomosis varied from 20-100%.

Conclusion: Surgical ligation of the internal iliac artery would not likely curb massive hemorrhage during sacrospinous ligament fixation, except in certain cases of internal pudendal vascular injury. The 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 approaches should be of primary consideration in the control of hemorrhage at the time of sacrospinous ligament fixation.