Figure 1 illustrates the anatomy in the posterior pelvis. At the top is the external iliac vein with the internal iliac vein (hypogastric vein) coming off cephalad to the sacrospinous ligament. The ischial spine is seen with the attached sacrospinous ligament traveling to the sacrum. The sigmoid colon is located on the left. The surgeon has placed sutures in the top of the prolapsed vagina and the pulley stitch as well as the secure stitch to the sacrospinous ligament approximately 4 cm (2 finger widths) from the ischial spine to avoid the pudendal artery nerve and vein. The vaginal vault has been closed after the hysterectomy has been performed; the pedicles from the hysterectomy are shown tied. The so-called web, the lateral extent of the cardinal ligament, is shown in the brackets between the pararectal space and the rectovaginal space. This web contains a dense complex of veins that are branches of the internal iliac (hypogastric) vein.

Hemorrhage can occur by blunt dissection through opening the posterior vaginal wall. The dissection enters the rectovaginal space. This can occur when the surgeon carries the dissection too far anteriorly rather than extending the finger dissector posteriorly toward the sacrum and palpating the ischial spine. When the dissection is carried into the web and the branches of the internal iliac (hypogastric) vein have been lacerated, copious hemorrhage will occur through the vagina. Individual identification with clamping and tying of individual venous branches of the hypogastric vein is rarely possible.

The solution to this problem is the placing of packs immediately into the pararectal space against the bleeding branches of the veins. When hemorrhage is under control the packs can be rolled slightly laterally and inferiorly. With a long Allis clamp the branches of these veins can be picked up individually. It is extremely difficult to tie off each branch separately. Therefore, a fine synthetic absorbable suture is used to suture-ligate the plexus. After each lacerated venous plexus has been sutured, the pack is further rolled inferiorly and laterally until all branches of the hypogastric vein have been grasped with the long thoracic Allis clamp and each one of the branches is sutured with fine synthetic absorbable suture. This procedure carries some risk to the ureter. At this point, the anesthesiologist should administer 1 ampule of indigo carmine dye intravenously. A water cystoscope should be inserted transurethrally into the bladder. The ureteral orifice on the affected side should be observed for the production of blue urine through the ureteral orifice. If after 10 minutes of observation no urine is seen, a ureteral catheter should be inserted up the ureter on the affected side. If the hemorrhage is controlled and the ureter has been sutured, the surgeon faces two possibilities: (1) to individually unligate the sutured veins until the ureter can be identified and a ureteral stent passed up to the kidney, or (2) to proceed above, open the abdomen, and dissect out the ureter, removing the offending sutures. The veins can be religated under direct observation after opening the paravesical and pararectal spaces.