Location of the Deep Epigastric Vessels in the Resting and Insufflated Abdomen.

STUDY OBJECTIVE: To determine whether the location of the superior and inferior epigastric vessels (deep epigastric vessels) change with abdominal insufflation. DESIGN: Descriptive study (Canadian Task Force classification III). SETTING: Tertiary care academic institution. PATIENTS: Patients undergoing gynecologic laparoscopic surgery were recruited. A total of 35 subjects were enrolled. INTERVENTIONS: Subjects underwent color Doppler ultrasound assessment of deep epigastric vessel location preoperatively and intraoperatively following abdominal insufflation. The deep epigastric vessels were identified at 5 points along the abdomen (pubic symphysis, anterior superior iliac spine [ASIS], umbilicus, xiphoid, and midpoint from umbilicus to xiphoid), with the distance from vessels to midline measured. Paired t tests and split-plot analysis of variance were used as appropriate. MEASUREMENTS AND MAIN RESULTS: The mean patient age was 45.6 ± 16.5 years, and mean BMI was 29.8 ± 7.2. A significant difference between vessel location in the resting abdomen and insufflated abdomen was noted bilaterally at the ASIS, umbilicus, and midpoint from the umbilicus to the xiphoid. At each of these points, the deep epigastric vessels were found more laterally after insufflation on average, ranging from 0.6 ± 0.9 cm (p < .001) more laterally at the midpoint between the umbilicus and xiphoid to 1.1 ± 0.8 cm (p < .001) more laterally at the umbilicus. The most lateral location of the deep vessels after insufflation was seen at the ASIS (10.6 cm) and the umbilicus (10.9 cm). In a subanalysis of subjects grouped by body mass index (obese vs nonobese), deep epigastric vessels were more lateral in the insufflated abdomen of obese subjects compared with that of nonobese subjects at the ASIS, umbilicus, and midpoint from umbilicus to xiphoid (p < .05 for each point bilaterally). CONCLUSION: The deep epigastric vessels shift laterally with abdominal insufflation, and may be found as far as 10.9 cm from the midline; this is more lateral than previously described and is clinically significant. Obesity is associated with a more lateral location of the deep epigastric vessels.

Continuous versus interrupted technique of ventricular septal defect (VSD) closure in total correction for tetrology of Fallot pertaining to residal VSD.

OBJECTIVE: To analyze the outcome of continuous versus interrupted closure technique of ventricular septal defect (VSD) closure in Tetrology of Fallot with reference to postoperative residual VSD after total correction. METHODS: A randomised control study was conducted between January 2008 to December 2008 at The Department of Cardiac Surgery, National Institute of Cardiovascular Diseases (NICVD), Karachi. The results of total correction (T.C) of VSD in patients with Tetralogy of Fallot, with emphasis on the suturing technique and eventually on the occurrence of residual ventricular septal defect(VSD) were analyzed. Transventricular as well as transatrial route was used to approach VSD. In thirty patients VSD was closed with 5/0 proline continuous double ended suture while in remaining 30 (50%) patients VSD was closed with interrupted 5/0 prolene double ended sutures. Postoperative echocardiography was done in all patients as a routine on second postoperative day, to document residual VSD. RESULTS: The study included 60 (100%) patients with T.O.F. There were 20 (33.3%) females and 40 (66.6%) males with ages ranging between 04 to 18 years (mean 13.025 +/- 2.123 years). Postoperative echocardiography showed residual VSD in 05 (8.3%) patients at posteroinferior rim of VSD. Of these 05 cases, in four VSD had been closed with continuous 5/0 proline double ended sutures, and one had VSD closed with interrupted 5/0 double ended sutures. CONCLUSION: Residual VSD is common with continuous suturing technique as compared to interrupted suturing technique. This is perhaps because of poor myocardium quality and higher RV pressures in our patients presenting at a late age. Small (less than 05 milimeter) residual VSD can be treated conservatively in haemodynamically stable patients.

The racial distribution of female pelvic floor disorders in an equal access health care system.

PURPOSE: We examined ethnic differences in female pelvic disorders in an equal access health care system. MATERIALS AND METHODS: An electronic medical record review was performed for patients with pelvic floor disorders at a military female pelvic medicine and reconstructive surgery division for a 1-year period. Primary diagnosis codes and patient reported race were reviewed. RESULTS: Mean +/- SD cohort age was 55 +/- 16.3 years. A total of 720 patients were identified, of whom 68.8% were white and 18.6% were black. Pelvic organ prolapse was the primary diagnosis in 34.2% of the women, while 19.7% had stress urinary incontinence and 10.8% had urge urinary incontinence. There was no difference in the prevalence of prolapse between black and white women. However, of patients with incontinence there was a statistically significant difference with urge incontinence in more black women (51.2%) and stress incontinence in more white women (66.2%) (chi-square p <0.05). CONCLUSIONS: There is a similar ethnic distribution of pelvic organ prolapse in an equal access health care system. Of women with incontinence there was a higher prevalence of urge urinary incontinence in black women and a higher prevalence of stress urinary incontinence in white women.

Anatomic comparison of two transobturator tape procedures.

OBJECTIVE: Both outside-in and inside-out methods are available for transobturator tape placement. Our objective was to compare these methods regarding proximity of the tape to the obturator canal and ischiopubic ramus. METHODS: Using seven fresh frozen cadavers, transobturator tapes were placed using the inside-out (TVT-Obturator System, Gynecare, Ethicon Inc, Somerville, NJ) and outside-in (Monarc, American Medical Systems, Minnetonka, MN) methods bilaterally in each cadaver. We dissected to the level of the obturator membrane and measured the distance from the closest aspect of the obturator canal and ischiopubic ramus to each tape. RESULTS: Transobturator tapes placed by using the inside-out technique were significantly closer to the obturator canal than with the outside-in method (mean distances: 1.3+/-0.44 cm compared with 2.3+/-0.41 cm, respectively, P<.001); the greater proximity of the inside-out method was noted in all dissections. Tapes placed with the inside-out method were also farther from the ischiopubic ramus than those placed with the outside-in approach (mean distances: 0.39+/-0.44 cm compared with 0.04+/-0.13 cm, respectively, P=.008). When distances between the tapes relative to the obturator canal were further analyzed according to left or right side, the difference between methods was maintained. Additionally, the distances were consistently farther from the obturator canal on the left side than on the right side regardless of transobturator tape approach. CONCLUSION: The outside-in technique results in the mesh being placed farther from the obturator canal and closer to the ischiopubic ramus, theoretically reducing the risk of neurovascular injury. LEVEL OF EVIDENCE: II.

Relationship of the uterosacral ligament to the sacral plexus and to the pudendal nerve.

We describe the anatomy of the uterosacral ligament with respect to the sacral plexus. In six adult female embalmed cadavers, we identified the uterosacral ligament and its lateral nerve relations. Using the ischial spine as the starting point and measuring along the axis of the uterosacral ligament, we noted that the S1 trunk of the sacral plexus passes under the ligament 3.9 cm [95% confidence interval (CI), 2.1-5.8 cm] superior to the ischial spine. The S2 trunk passes under the ligament at 2.6 cm (95% CI; 1.5, 3.6 cm), the S3 trunk passes under the ligament at 1.5 cm (95% CI; 0.7, 2.4 cm), and the S4 trunk passes under the ligament at 0.9 cm (95% CI; 0.3, 1.5 cm) superior to the ischial spine. The pudendal nerve forms lateral to the uterosacral ligament. Our data demonstrate that the S1-S4 trunks of the sacral plexus, not the pudendal nerve, are vulnerable to injury during uterosacral ligament suspension.

Colpocleisis: a review.

OBJECTIVE: To summarize published data about colpocleisis and to highlight areas about which data are lacking. DATA SOURCES: We conducted a literature search on Medline using Ovid and PubMed, from 1966 to January 2004, using search terms "colpocleisis", "colpectomy", "vaginectomy", "pelvic organ prolapse (POP) and surgery", and "vaginal vault prolapse and surgery" and included articles with English-language abstracts. We examined reference lists of published articles to identify other articles not found on the electronic search. METHODS OF STUDY SELECTION: We examined all studies identified in our search that provided any outcome data on colpocleisis. Because of the heterogeneity of outcome measures and follow-up intervals in case series, we did not apply meta-analytic techniques to the data. RESULTS: Colpocleisis for POP is apparently successful in nearly 100% of patients in recent series. The rate of reoperation for stress incontinence or POP after colpocleisis is unknown. Concomitant elective hysterectomy is associated with increased blood loss and length of hospital stay, without known improvement in outcomes. Few studies systematically assess pelvic symptoms. The role of preoperative urodynamic testing to direct optimal management of urinary incontinence and retention remains to be established in this setting. CONCLUSIONS: Colpocleisis is an effective procedure for treatment of advanced POP in patients who no longer desire preservation of coital function. Complications are relatively common in this group of elderly patients. Prospective trials are needed to understand the impact of colpocleisis on functional outcomes and patient satisfaction.

Anatomic relationship between the vaginal apex and the bony architecture of the pelvis: a magnetic resonance imaging evaluation.

OBJECTIVE: This study was undertaken to define anatomic relationships between the vaginal apex and the ischial spines and sacrum for nulliparous women with normal support. STUDY DESIGN: We retrospectively evaluated the magnetic resonance images of 11 consecutive women who underwent pelvic imaging at Johns Hopkins. Coordinates were recorded for the posterior fornix, sacrum, ischial spines, and cervical vaginal junctions. We calculated vector distances with means, SDs, and 95% CIs. Intraclass correlation coefficients tested interobserver reliability and the Wilcoxon signed rank test compared right- and left-sided measurements. RESULTS: Mean age was 30.4 +/- 9.1 years. The cervical vaginal junction was 1.6 +/- 0.5 cm superior, 1.1 +/- 0.5 cm anterior, and 4.7 +/- 0.4 cm medial to the ipsilateral ischial spine. The posterior fornix was 1.0 +/- 1.0 cm anterior and 5.3 +/- 0.8 cm inferior to the second sacral vertebra. There was excellent interobserver reliability (interclass correlation coefficients = 0.997, P < .001) and no detectable difference between sides. CONCLUSION: Consistent relationships exist between the vaginal apex and ischial spines and sacrum, which may be useful in reconstructive pelvic surgery.

Sexual function among women with urinary incontinence and pelvic organ prolapse.

OBJECTIVE: The objective of this research was to determine whether sexual complaints, such as dyspareunia, are associated with pelvic floor disorders. STUDY DESIGN: We used data collected for the Maryland Women's Health Study. Among adult women scheduled for hysterectomy, we used multiple logistic regression analysis to identify characteristics associated with 4 sexual complaints: decreased libido, vaginal dryness, dyspareunia, and anorgasmia. RESULTS: Among 1299 participants, 495 (38.1%) had evidence of pelvic floor disorders. Sexual complaints were significantly more common among women with pelvic floor disorders (53.2% vs 40.4%, P < .01). In the multiple regression model, urinary incontinence was significantly associated with low libido (odds ratio [OR] 1.96), vaginal dryness (OR 2.11), and dyspareunia (OR 2.04), independent of age, educational attainment, and race. In contrast, pelvic organ prolapse was not associated with any sexual complaint. CONCLUSION: In a cohort of women planning hysterectomy, women with urinary incontinence were significantly more likely to report sexual complaints.

Architectural differences in the bony pelvis of women with and without pelvic floor disorders.

OBJECTIVE: To investigate the hypothesis that the architecture of the bony pelvis differs between women with and without pelvic floor disorders. METHODS: We designed a case-control study of women who had undergone magnetic resonance imaging (MRI) of the pelvis at our institution. Records were reviewed to identify women with and without pelvic floor disorders (urinary or anal incontinence, other symptoms of urinary tract dysfunction, or pelvic organ prolapse). Pelvimetry techniques were standardized. Relevant measures included transverse diameter of the inlet, angle of the pubic arch, intertuberous diameter, interspinous diameter, sacrococcygeal length, depth of sacral curvature, anteroposterior conjugate, obstetrical conjugate, and anteroposterior outlet. Multiple logistic regression analysis was used to identify women with pelvic floor disorders as a function of their pelvic dimensions, controlling for potentially confounding variables. RESULTS: Subjects included 59 women with pelvic floor disorders and 39 women without pelvic floor disorders. Women with pelvic floor disorders had a wider transverse inlet, wider intertuberous diameter, wider interspinous diameter, greater sacrococcygeal length, deeper sacral curvature, and narrower anteroposterior outlet. When controlling for the confounding effects of age, race, and parity, we found that a wider transverse inlet (odds ratio 3.425) and a shorter obstetrical conjugate (odds ratio 0.233) were significantly associated with pelvic floor disorders. CONCLUSION: A wide transverse inlet and narrow obstetrical conjugate are associated with pelvic floor disorders. We speculate that these features of bony pelvic architecture may predispose the patient to neuromuscular and connective tissue injuries, leading to the development of pelvic floor disorders.