Afterwards, the bladders, ureters and bowel must be inspected to exclude trauma

[35]. Uterine Artery Ligation Uterine artery ligation is one of the easiest and most effective surgical measures to control PPH. It is relatively safe, can be performed easily, and allows for future childbearing. The uterine arteries supply 90% of the blood to the uterus; therefore, ligation drastically decreases blood flow and subsequent blood loss [11]. Despite this percentage, the surgeon should not worry about resultant uterine necrosis, as adequate blood supply is still available [22]. This procedure is performed as follows. First the vesicouterine fold of peritoneum is identified and incised transversely in order to mobilize the bladder inferiorly. Next, the LY2606368 manufacturer uterus is externalized Niraparib cost for full exposure in order to identify an avascular window in the broad ligament. If an avascular area is not readily apparent, the surgeon may use the lateral border of the uterus. A No. 1 chromic INCB028050 concentration catgut or polyglycolic

suture should be used to make a posterior to anterior stitch through the myometrium at a site 2-3 cm medial to the uterine artery. The needle is returned anterior to posterior through the avascular window at a site just below the level of the utero-vesical peritoneal reflection. The two ends are tied securely, completing the ligation. The ureters, bladder and bowel should all be inspected for inadvertent trauma before repeating the procedure on the contralateral

uterine artery [11]. Utero-Ovarian Artery Anastomosis Ligation Ligation of the utero-ovarian artery anastomosis is similar to the uterine artery ligation. An avascular area is identified in the meso-ovarium, just inferior to the utero-ovarian ligament. Using this site as a securing point, a ligature is placed around the utero-ovarian anastomosis. The ovaries should be checked to ensure ovarian blood supply has not been compromised [11]. Please refer to Figure 4 for an anatomic depiction. Figure 4 Significant Uterine Vessels. The uterine artery, the anastomosis of the utero-ovarian artery and the hypogastric artery are all acceptable places to perform an arterial ligation. Internal Iliac Artery Reverse transcriptase (Hypogastric Artery) Ligation Internal Iliac artery ligation is the next step in treatment. Bilateral ligation of the vaginal branch decreases pulse pressure in the distal arteries by 85%, improving. Unfortunately this procedure has a low success rate, estimated at 40%, mostly attributed to the late stage at which the ligation is attempted and that it is frequently complicated by hematoma formation and tissue edema that obscure the anatomy [11]. The steps to perform the internal iliac artery ligation are as follows. An 8-10 cm incision is made in the peritoneum parallel and lateral to the ureter which opens the retroperitoneal space.