Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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142 Surgery and Healing in the Developing World
Internal Iliac Artery Ligation
The placental implantation site may derive a significant portion of its blood
supply from cervical and vaginal branches of the internal iliac artery, and thus bleeding
from the placental site may not abate with uterine artery ligation. To ligate an
internal iliac artery, you need to establish good exposure. Locate the pulsating common
iliac artery, and open the overlying peritoneum. Dissect down to the bifurcation,
and carefully incise the sheath of tissue covering the internal iliac artery. Pass a
suture beneath the artery and tie. Confirm that pulsations in the external iliac continue
and take great care not to lacerate an adjacent great vein. Successful ligation
will reduce pulse pressure to the implantation site but not eliminate it. Bilateral
ligation may be required.
B-Lynch Suture
If bleeding following a low tranverse Cesarean is due to an atonic uterus that has
not responded to uterotonics (or you are without recourse to these), an alternative
or adjunct to ligating the uterine, internal iliac, or ovarian arteries may be placement
of a suture designed to compress the uterus as described by B-Lynch, Coker, Lawal
et al in 1997.
Exteriorize the uterus and ask your assistant to perform bimanual compression.
If this is effective in reducing the hemorrhage, you can anticipate a good result with
placement of the suture. The technique has been described by B-Lynch essentially as
follows. Load a 70-80 mm round bodied needle with a long suture of #2 chromic or
plain gut. (Others have described success using 0 vicryl suture.) Drive the needle
into the lower uterine segment approximately 3 cm below and slightly medial to the
angle of your uterine incision. Reload your driver and now seek a point in the uterine
cavity that is about 3 cm above the uterine incision and 4 cm from the lateral
edge of the uterus. Loop your long suture over the fundus and down towards the
cul-de-sac. Locate a point 4 cm from the lateral edge of the uterus and immediately
below your uterine incision and drive the needle through the posterior lower segment
to reenter the uterine cavity. Draw the suture snug while your assistant provides
compression. Now locate a point on the posterior uterine wall that is located
symmetrically on the opposite side, visible beneath your transverse incision and 4
cm medial to the edge of the uterus. Drive your needle through to emerge from the
posterior surface of the uterus. Again pause for compression of the uterus and to
draw the suture snug. Now loop the suture over the fundus and bring it down to a
point 3 cm above and slightly medial to the angle of your uterine incision. Drive the
needle through the myometrium to emerge again in the uterine cavity. Reload your
needle driver and bring the needle through from within the uterine cavity at a point
3 cm below the incision and again 4 cm from the lateral edge of the uterus. Continue
to compress the uterus and draw your suture snug. Tie the two ends securely
and close the uterine incision in the usual fashion.
Cesarean with Hysterectomy
Hysterectomy following a Cesarean is essentially the same technique as standard
total hysterectomy (consult a gynecologic surgery text) with the following special
considerations.
1. Although the uterus is to be removed, the uterine incision must still be
closed for the sake of hemostasis.
2. Anticipate a large amount of edema and thinning of the lower segment,
especially if the patient had been allowed to labor prior to her Cesarean.