Management of arterial and venous hemorrhage during sacrospinous ligament fixation: cases and review of the literature

Introduction and hypothesis: Sacrospinous ligament fixation (SSLF) for pelvic organ prolapse repair can incur significant intraoperative hemorrhage. Management of vascular injury is challenging because of limited visualization of the surrounding pararectal space and is not well described in the literature.

Methods: We evaluate cases of intraoperative venous and arterial hemorrhage during SSLF. Based on a review of the literature, we present a systematic approach to the treatment of venous and arterial hemorrhage associated with SSLF.

Results: Vascular injury to the hypogastric and pudendal venous plexi may be controlled using directed compression and topical hemostatic agents. Vascular injury to the inferior gluteal artery, its coccygeal branch, or other arteries, may require embolization.

Conclusion: Life-threatening bleeding is a rare complication of transvaginal SSLF. Knowledge of surrounding pelvic vascular anatomy, treatment options, and communication with ancillary staff is essential for the treatment of sacrospinous ligament hemorrhage.