Uterine Artery Ligation (UAL) is a surgical method used to reduce blood flow into the uterus by tying off the major vessels supplying the organ. This intervention is performed primarily to manage heavy bleeding that does not respond to less invasive treatments. The purpose of UAL is to achieve hemostasis, or the cessation of bleeding, while preserving the uterus and the patient’s fertility when possible. Reducing the blood supply to the uterus is an effective way to manage life-threatening hemorrhage, offering a surgical alternative to a full hysterectomy.
Reasons for Uterine Artery Ligation
The most frequent indication for Uterine Artery Ligation (UAL) is postpartum hemorrhage (PPH). PPH is defined as blood loss exceeding 1,000 milliliters after a cesarean section or more than 500 milliliters after a vaginal delivery, and it is most commonly caused by uterine atony, where the uterus fails to contract after childbirth. UAL is generally considered a step in a stepwise devascularization approach, reserved for cases where initial conservative treatments, such as uterine massage, medications, and uterine compression sutures, have failed to control the bleeding. This procedure serves as a fertility-sparing option to avoid an emergency hysterectomy.
UAL is also used in gynecological settings to manage or prevent significant blood loss. Surgeons may perform UAL prophylactically during complex procedures like a myomectomy, which is the removal of uterine fibroids. Restricting blood flow before or during the removal of fibroids allows the operation to proceed with less blood loss. Other indications include managing hemorrhage from ectopic pregnancies in the cervix or interstitial areas of the fallopian tube, or controlling bleeding during surgery for certain types of gynecological cancers.
Surgical Technique for Ligation
Uterine Artery Ligation is performed through one of two main approaches: a laparotomy (open abdominal surgery) or a minimally invasive laparoscopic procedure. The open approach is often necessary in acute emergencies, such as severe postpartum hemorrhage, which requires rapid access and visualization. For planned procedures like myomectomy, a laparoscopic approach using small incisions is often preferred, as it results in quicker recovery times.
The goal of the surgery is to identify the uterine artery and apply a suture or clip to restrict blood flow. Surgeons locate the artery where it runs alongside the uterus, often near the internal cervical os or where it branches from the internal iliac artery. In the common O’Leary technique, a suture is passed through the myometrium approximately two to three centimeters medial to the lateral edge of the uterus and then tied. Careful positioning of the suture is performed to avoid injury to the ureter, which runs close to the uterine artery.
The intention of UAL is not to completely cut off all blood supply to the uterus, but rather to reduce the intense pulse pressure and volume of blood flow. The uterus has a rich collateral circulation, receiving blood from other vessels, particularly the ovarian arteries. This ensures the organ remains viable even after the uterine arteries are tied off, allowing the uterus to be saved and function normally in the long term.
Post-Procedure Recovery and Long-Term Outcomes
Following Uterine Artery Ligation, the immediate recovery period typically mirrors that of an open abdominal surgery or cesarean section, involving a hospital stay for monitoring and pain management. Patients are closely observed for continued bleeding or signs of infection. The timeline for recovery depends on the severity of the initial medical event that necessitated the UAL.
A concern for patients is the long-term impact of the procedure on reproductive health, specifically fertility and subsequent pregnancies. Studies show that UAL does not significantly compromise a woman’s ability to conceive or lead to secondary infertility. This positive outcome is attributed to the fact that blood flow to the uterus is rapidly re-established over time through collateral vessels, such as the ovarian arteries, and recanalization of the ligated vessels.
In subsequent pregnancies, the rates of miscarriage, preeclampsia, and fetal growth restriction are comparable to those in women who did not undergo the procedure. Menstrual function is also largely preserved, with most patients returning to a normal cycle. The temporary reduction in blood supply does not typically cause long-term damage to the uterine lining or ovaries.