Pelvic hemorrhage is an obstetrical or gynecologic (OB/GYN) emergency that clinicians will invariably encounter during their medical career. Effective management of this potentially disastrous situation requires a surgeon who is well versed in pelvic anatomy and has an understanding of the disease entity or clinical scenario that causes hemorrhage, sound surgical decision-making, and operative dexterity, and a capacity to lead an operative team to optimize patient safety. Multiple surgical techniques have been described to aid an OB/GYN facing pelvic hemorrhage. One of the more historical techniques that still upholds its importance in the operative arena is HAL, a highly efficacious technique for addressing uncontrollable pelvic bleeding in the field of obstetrics and gynecology.

Dr. Howard A. Kelly, of the Johns Hopkins Hospital, originally described the procedure in 1893 as a means to control life-threatening intraoperative bleeding on a patient with cervical cancer undergoing a hysterectomy. He began his historical article by stating, “I bring before you this evening an exceedingly interesting case from several standpoints, one of which is novel and I think suggestive.”¹ Dr. Kelly astutely drew attention to the benefits of HAL as follows: “The special points of interest in this case are (1) the prompt benefit derived from transfusion, and (2) the apparent cure of the carcinoma by cutting off its main blood supply.”¹

Dr. Kelly was correct in describing this procedure as novel. Thereafter in the 1960s, Burchell studied the clinical science behind the effectiveness of HAL and found that with ligation of both hypogastric arteries, the arterial pulse pressure distal to the ligation decreased by 85%.² If the procedure is done unilaterally, the pulse pressure decreases by 77% on the same side and 14% on the opposite side. Blood flow decreases by 48% distal from the point of ligation, but it is the large drop in pulse pressure that makes blood vessels more amenable to hemostasis via pressure and clot formation.

Gaining excellent exposure to the pelvic retroperitoneum is the first critical step in performing a successful HAL. To do so, the pelvic sidewall peritoneum should be opened along the psoas tendon, staying lateral to the external iliac vessels and just parallel to the ovarian vessels. Entry into the retroperitoneal space can be accomplished safely in two places on either side of the abdomen: by dividing the round ligament or by overlaying the psoas muscle in the pericolic gutter.

On the patient’s right side, the pericolic gutter is accessed by elevating the cecum and displacing it medially (Fig. 64-1). On the patient’s left side, it is the sigmoid colon that must be elevated and displaced medially (Fig. 64-2). Traction on these portions of the colon tents up the peritoneum, where they attach to the parietal peritoneum, allowing safe entry into the retroperitoneum.

The four structures that must be identified at this time are the common iliac artery, external iliac artery, the internal iliac (hypogastric) artery, and the ureter (Fig. 64-3). The common iliac arteries branch laterally from the abdominal aorta at the level of the fourth lumbar vertebrae. The internal and external iliac arteries split from the common iliac arteries at the lumbosacral articulation. The external iliac artery runs on the lateral aspect of the psoas muscle. The hypogastric artery runs inferiorly toward the greater sciatic foramen and along the medial aspect of the psoas muscle. Near the superior margin of the foramen, it divides into an anterior division and a posterior division.

The posterior division arises within 5 cm of the common iliac artery bifurcation in 95% of the population—a detail critical to the success of HAL.³ The posterior division of the hypogastric artery has three subdivisions or branches: the iliolumbar, lateral sacral, and gluteal (superior and inferior) arteries. The anterior division extends distal to the posterior division and has six major branches: the pudendal, uterine, middle rectal, obturator, vaginal, and umbilical arteries.

After the relevant anatomy is clearly identified, the pararectal space is delicately dissected using blunt instruments or gentle use of the fingers (Fig. 64-4A). The ureter will be on the medial aspect of the peritoneal reflection, where it can be retracted manually or with the aid of a vessel loop. Laterally, the hypogastric vein may be apparent; however, if it is not, deep dissection to isolate it should not be done given the risk of massive hemorrhage if injured.