A large Mayo needle with #2 chromic catgut is used to enter and exit the uterine cavity at A and B. The suture is looped over the fundus and then reenters the uterine cavity posteriorly at C, which is directly below B. The suture should be pulled very tight at this point. It then enters the posterior wall of the uterine cavity at D, is looped back over the fundus, and anchored by entering the anterior lateral lower uterine segment at E and crossing through the uterine cavity to exit at F. The free ends at A and F are tied down securely to compress the uterus.
Hayman described a modification of the B-Lynch suture that is performed without a hysterotomy. Two to four vertical compression sutures are placed, as needed, but in contrast to the B-Lynch technique, these sutures pass directly from the anterior uterine wall to the posterior uterine wall. A transverse cervicoisthmic suture can also be placed if needed to control bleeding from the lower uterine segment.
Pereira described a technique in which a series of transverse and longitudinal sutures of a delayed absorbable multifilament suture are placed around the uterus via a series of bites into the submucosal myometrium. Two or three rows of these sutures are placed in each direction to completely envelope and compress the uterus, similar to the way one might truss a stuffed roast. When the transverse sutures are brought through the broad ligament, care should be taken to avoid damaging blood vessels, ureters, and fallopian tubes. The longitudinal sutures begin and end at the last transverse suture nearest the cervix, and do not enter the uterine cavity. The myometrium should be manually compressed prior to tying down the sutures to facilitate maximal compression.
Cho described a technique in which a straight number 7 or 8 needle with #1 chromic catgut is used to place sutures in a small rectangular array to compress the anterior and posterior uterine walls against one another at sites of heavy bleeding. The through and through sutures extend from the serosa of the anterior wall to the serosa of the posterior wall. After creating a square, the ends are tied down as tight as possible to compress the myometrium. Two to five squares/rectangles are made, as needed.
Sutures are placed to ligate the ascending uterine artery and the anastomotic branch of the ovarian artery. The procedure should be performed on each side.
This technique is challenging even for an experienced pelvic surgeon, especially when there is a large uterus, a transverse lower abdominal incision, ongoing pelvic hemorrhage, or the patient has a high body mass index. Successful and safe bilateral hypogastric ligation becomes even more difficult when attempted by a surgeon who rarely operates deep in the pelvic retroperitoneal space. For these reasons, uterine compression sutures, uterine artery ligation, and arterial embolization have largely replaced this procedure.