Evaluation of the arterial kink point during flexion of the hip: A dynamic angiographic study in iliac endofibrosis patients.

PURPOSE: The aim of the study was to determine the flexion point's location of the ilio-femoral arterial axis and its angulation. MATERIALS AND METHODS: Thirty-seven dynamic digital subtraction angiographies were analyzed and were included in the current study. Different lengths were measured, based on specific anatomical landmarks: the origin of the external iliac artery, the inguinal ligament and the bifurcation of the femoral artery. These lengths were measured in extension and during flexion of the hip in order to determine the flexion point of the artery. RESULTS: In extension, some physiological angulations of the external iliac artery were measured. During flexion of the hip joint, the distance from the kink point to the bifurcation of the common iliac artery was respectively 82 ± 21 mm (range 48-116) on the right side and 95 ± 20 mm (range 59-132) on the left side. The distance from the kink point to the inguinal ligament was respectively 38 ± 40 mm (range 12-138) on the right side and 26 ± 23 mm (range 8-136) on the left side. The distance from the kink point to the bifurcation of the femoral artery was respectively 45 ± 29 mm (range 15-107) on the right side and 27 ± 12 mm (range 10-66) on the left side. During flexion, the angulation of the flexion point of the ilio-femoral axis was 114 ± 18° (range 81-136°). CONCLUSIONS: The flexion point was located cranially to the inguinal ligament and below the departure of the external iliac artery.

Meralgia paresthetica.

Meralgia paresthetica is a common but probably underrecognized syndrome caused by dysfunction of the lateral femoral cutaneous nerve. The diagnosis is based on the patient's description of sensory disturbance, often painful, on the anterolateral aspect of the thigh, with normal strength and reflexes. Sensory nerve conduction studies and somatosensory evoked potentials may be used to support the diagnosis, but both have technical limitations, with low specificity and sensitivity. Risk factors for meralgia paresthetica include obesity, tight clothing, and diabetes mellitus. Some cases are complications of hip or lumbar spine surgery. Most cases are self-limited, but a small proportion of patients remain with refractory and disabling symptoms. Treatment options include medications for neuropathic pain, neurolysis, neurectomy, and radioablation, but controlled trials to compare efficacy are lacking.

Morphological variability of lateral femoral cutaneous nerve and its potential clinical significance.

BACKGROUND: The lateral femoral cutaneous nerve is derived from the dorsal branches of the L2 and L3 spinal nerves. It travels across the pelvis and heads towards the anterior superior iliac spine. It passes under the lateral part of the inguinal ligament and then divides into two branches, which are responsible for sensory innervation of the anterolateral and lateral skin of the thigh. However, the course of this nerve can vary morphologically. Numerous differences have been observed in its exit from the pelvis and in the number of its main trunks and branches. Additionally, its angle with the inguinal ligament and its placement in relation to other structures (such as the femoral artery, femoral nerve, and the sartorius and iliacus muscles) also vary. All of these variants have potential clinical implications. Therefore, the aim of this review is to present the morphological variability of the lateral cutaneous nerve and to explore how these anatomical differences can introduce clinical concerns. MATERIALS AND METHODS: Presented review of the literature was written based on over 30 studies. Comprehensive literature search was done using PubMed in order to study the morphological variability of lateral femoral cutaneous nerve (LFCN). To be included in this review studies needed to be meet certain criteria: been published before December 2023, present information valuable to this paper (variability of lateral femoral cutaneous nerve/clinical significance). The search included how LFCN vary either among fetuses and adults in the aim of providing more complex information about the variability of this nerve. During the search key words as following were used. No particular references were excluded from the analysis. All relevant studies were included, and citation tracking was used to identify publications. RESULTS: This review presents the description of variability of LFCN and its potential clinical impact. In the review differences in adult and fetuses were considered, morphological variability were divided into 4 groups: the origin of the nerve, the way it leaves the pelvis, the branching pattern, the angle between LFCN and surrounding structures and then, clinical significance were considered basing on available literature.

[Application of superior iliac fascia block of inguinal ligament combined with patient controlled intravenous analgesia in elderly patients after hip arthroplasty].

OBJECTIVE: To compare the effect of patient-controlled intravenous analgesia(PCIA) and superior inguinal ligament iliac fascia block combined with PCIA after hip replacement in the elderly. METHODS: Total of 82 elderly patients were treated with hip arthroplasty from June 2019 to June 2021 and randomly divided into observation group and control group. There were 42 patients in control group, including 18 males and 24 females, aged from 60 to 78 years old with an average of (70.43±3.67) years old, 28 femoral neck fractures and 14 femoral head necrosis, who received PCIA. The study group consisted of 42 cases, including 20 males and 22 females, aged from 61 to 76 years old with an average of (69.68±3.74) years old, 25 femoral neck fractures and 17 femoral head necrosis, who received superior inguinal ligament iliac fascia block combined with PCIA. Pain visual analogue scale (VAS) and Ramesay sedation scores at 2 h, 6 h, 12 h, 24 h and 48 h after operation were evaluated. In addition, the follow-up results of the total consumption of sufentanil and the total number of PCIA compressions at 48 hours after operation, the first time of landing after surgery, the time of hospital stay, the incidence of adverse reactions, the satisfaction with analgesia of two groups were observed. RESULTS: All patients were followed up for 9 to 24 months with an average of(13.85±2.67) months. There was no significant difference in operation time and intraoperative bleeding between two groups (P>0.05). There was no difference in VAS between two groups at 2 hours after operation (P>0.05), and the VAS of the study group at 6 h, 12 h, 24 h and 48 h after operation were lower than those of the control group(P<0.05). The Ramesay sedation scores of the study group at 2 h, 6 h and 12 h after operation were higher than those of the control group(P<0.05), and there were no differences in Ramesay score between two groups at 24 h and 48 h after operation (P>0.05). The consumption of sufentanil in the study group within 48 hours after operation was lower than that in the control group (P<0.05), and PCIA compression times were lower than those in the control group(P<0.05), and the time of first landing was earlier than that in the control group(P<0.05). There was no significant difference in hospital stay, adverse reaction rate, complications between two groups (P>0.05). The satisfaction of analgesia in the study group was higher than that in the control group (P<0.05). CONCLUSION: Superior iliac fascia block of inguinal ligament combined with PCIA has significant analgesic and sedative effects after hip arthroplasty in the elderly. It can reduce the amount of sufentanil used and the total number of PCIA compressions, which is conducive to the early activity of patients out of bed, improve the satisfaction of analgesia.

The radiographic relationship of the femoral head, inguinal ligament, and common femoral artery bifurcation for optimal vascular access.

Objective: Common femoral artery (CFA) access is commonly used for endovascular interventions. Access site complications contribute to significant morbidity and mortality. This study characterizes the radiographic variability in the relationship of the femoral head, the inguinal ligament, and the CFA bifurcation, to identify the zone of optimal CFA access. Methods: Human cadaver dissection of the inguinal ligament and CFA bifurcation was performed. The inguinal ligament and CFA bifurcation were marked with radiopaque pins and plain anteroposterior radiographs were obtained. Radiographic measurements of the femoral head length, the distance of the top of the femoral head to the inguinal ligament, and to the CFA bifurcation were obtained. Results were reported as percentage of femoral head covered by the inguinal ligament or the CFA bifurcation relative to the top of the femoral head. A heatmap was derived to determine a safe access zone between the inguinal ligament and CFA bifurcation. Results: Forty-five groin dissections (male, n = 20; female, n = 25) were performed in 26 cadavers. The mean overlap of the inguinal ligament with the femoral head was 11.2 mm (range, -19.4 to 27.4 mm). There were no age (<85 vs ≥85 years) or sex-related differences. In 82.6% of cadaveric CFA exposures, there was overlap between the inguinal ligament and femoral head (mean, 27.7%; range, -85.7% to 70.1%), with 55.6% having a >25% overlap. In 11.1%, there was an overlap between the lower one-third of the femoral head and the CFA bifurcation. Cumulatively, heatmap analysis depicted a >80% likelihood of avoiding the inguinal ligament and CFA bifurcation below the midpoint of the femoral head. Conclusions: Significant variability exists in the relationship between the inguinal ligament, CFA bifurcation, and the femoral head, suggesting the lack of a consistently safe access zone. The safest access zone in >80% of patients lies below the radiographic midpoint of the femoral head and the inferior aspect of the femoral head.

How I do it: using a hammock mesh in the reconstruction of inguinal ligament during a wide en-bloc resection of a groin mesenchymal tumor.

PURPOSE: In case of soft tissue sarcomas (STS), an en-bloc resection with safe margins is recommended. To ensure safe removal without tumor rupture, STS of the groin area, retroperitoneal or pelvic mesenchymal tumors may require incision or resection of the inguinal ligament. Solid reconstruction is mandatory to prevent early and late postoperative femoral hernias. We present here a new technique of inguinal ligament reconstruction. METHODS: Between September 2020 and September 2022, patients undergoing incision and/or resection of inguinal ligaments during a wide en-bloc resection of STS of the groin area in the Department of General Surgery in Strasbourg were included. All patients had an inguinal ligament reconstruction with biosynthetic slowly resorbable mesh shaped as a hammock, pre- or intraperitoneally, associated or not with loco-regional pedicled muscular flaps. RESULTS: A total of 7 hammock mesh reconstructions were performed. One or several flaps were necessary in 57% of cases (4 patients): either for inguinal ligament reconstruction only (n = 1), for recovering of femoral vessels (n = 1), and for both ligament reconstruction and defect covering (n = 2). The major morbidity rate was 14.3% (n = 1), related to a thigh surgical site infection due to sartorius flap infarction. After a median follow-up of 17.8 months (range 7-31), there was neither early nor late occurrence of post-operative femoral hernia. CONCLUSIONS: This is a new surgical tool for inguinal ligament reconstruction with the implementation of a biosynthetic slowly resorbable mesh shaped as a hammock, which should be compared to other techniques.

Cadaveric Study of Variations in the Course of Lateral Femoral Cutaneous Nerve: Insight to Prevent Injury.

Objective: A recent spurt in incidence of meralgia paresthetica to 0.1-81% due to minimally invasive anterior approach to hip joint has resulted in reinterest in anatomy of lateral femoral cutaneous nerve (LFCN). Familiarity with variations in the course of LFCN will reduce the morbidity associated with orthopedic procedures around the anterior superior iliac spine (ASIS) and inguinal ligament (IL). Methods: Twenty five adult human formalin embalmed cadavers were dissected. Course and relations of nerve to ASIS, IL and sartorius muscle was noted, distance of nerve from ASIS at IL was measured and statistically analyzed. Results: Mean distance of LFCN from ASIS at IL was 1.73±1.15 cm. Differences between two sides and sexes was statistically not significant (p=0.51 and p=0.96 respectively). Inferomedial to ASIS, 94% of LFCNs crossed IL with 92% of them present within 4 cm medial to ASIS. Majority of LFCNs (90%) exited pelvis and entered thigh posterior to IL. Out of these nerves 48% were single trunks on entry into thigh, then bifurcated into anterior and posterior branches. Remaining LFCNs bifurcated proximal to IL or at level of IL. Trifurcations were seen in 6% while a rare case of pentafication was observed. In 66% main trunk/branches were present in intermuscular cleft between sartorius muscle and tensor fascia lata. Conclusions: Care should be exercised by surgeons while dissecting around IL as more than half of nerves are liable to be injured during operative procedures. This would help in better anticipation of problem, acceptance and reducing litigation.

Anatomical study and clinical importance of the inferior epigastric artery / Estudio anatómico e importancia clínica de la arteria epigástrica inferior

SUMMARY: The inferior epigastric artery (IEA) is a major blood vessel that supplies the anterior abdominal wall. The aim of the current study was to provide clinicians, surgeons, and obstetricians with sufficient anatomical data on the inferior epigastric artery, such as its origin and branching pattern. The study included 20 embalmed cadavers, these cadavers were dissected, and the inferior epigastric artery and vena comitans/venae comitantes were identified and traced downwards to the external iliac vessels. The origins, caliber, course and pedicle length of both the artery and the vein(s) were studied. The inferior epigastric artery arose independently from the distal external iliac artery deep to the inguinal ligament in 19 (95 %) cadavers. The artery entered the rectus abdominis muscle at its middle third in 13 (65 %) cases and at its lower third in the remaining specimens. In this study, we found that the artery divided into two branches in 18 (90 %) of the cases; in the remaining two cases, it continued as one trunk. The average pedicle length was 7.2 cm. The mean caliber of the IEA was 3.7 mm. In 18 (90 %) dissections, the venous drainage consisted of a pair of venae comitantes that united to form a common vessel at their draining point on the external iliac vein. The average diameter was 3.9 mm. The current study focuses on the anatomical features of the inferior epigastric artery to increase the success rate of abdominal and pelvic operations in clinical practice.

RESUMEN: La arteria epigástrica inferior (AEI) es un vaso sanguíneo principal que irriga la pared abdominal anterior. El objetivo del presente estudio fue proporcionar a los médicos, cirujanos y obstetras suficientes datos anatómicos sobre la arteria epigástrica inferior, como su origen y patrón de ramificación. El estudio incluyó 20 cadáveres embalsamados, los que se disecaron y se identificó la arteria epigástrica inferior y la vena concomitante y se siguieron hasta los vasos ilíacos externos. Se estudiaron los orígenes, calibre, trayecto y longitud del pedículo tanto de la arteria como de la (s) vena (s). La arteria epigástrica inferior surgió independientemente de la arteria ilíaca externa profunda al ligamento inguinal en 19 (95 %) cadáveres. La arteria ingresó al músculo recto del abdomen en su tercio medio en 13 (65 %) casos y en su tercio inferior en las muestras restantes. En este estudio, encontramos que la arteria se dividió en dos ramas en 18 (90 %) de los casos; en los dos casos restantes, continuó como un tronco. La longitud media del pedículo fue de 7,2 cm. El calibre medio del AEI fue de 3,7 mm. En 18 (90 %) disecciones, el drenaje venoso consistió en un par de venas concomitantes las que formaron un vaso común en su punto de drenaje en la vena ilíaca externa. El diámetro medio fue de 3,9 mm. El estudio actual se centra en las características anatómicas de la arteria epigástrica inferior con el propósito de mejorar la tasa de éxito de las cirugías abdominales y pélvicas en la práctica clínica.

Toward Data-Driven Learning Healthcare Systems in Interventional Radiology: Implementation to Evaluate Venous Stent Patency.

We developed a code and data-driven system (learning healthcare system) for gleaning actionable clinical insight from interventional radiology (IR) data. To this end, we constructed a workflow for the collection, processing and analysis of electronic health record (EHR), imaging, and cancer registry data for a cohort of interventional radiology patients seen in the IR Clinic at our institution over a more than 20-year period. As part of this pipeline, we created a database in REDCap (VITAL) to store raw data, as collected by a team of clinical investigators and the Data Coordinating Center at our university. We developed a single, universal pre-processing codebank for our VITAL data in R; in addition, we also wrote widely extendable and easily modifiable analysis code in R that presents results from summary statistics, statistical tests, visualizations, Kaplan-Meier analyses, and Cox proportional hazard modeling, among other analysis techniques. We present our findings for a test case of supra versus infra-inguinal ligament stenting. The developed pre-processing and analysis pipelines were memory and speed-efficient, with both pipelines running in less than 2 min. Three different supra-inguinal ligament veins had a statistically significant improvement in vein diameters post-stenting versus pre-stenting, while no infra-inguinal ligament veins had a statistically significant improvement (due either to an insufficient sample size or a non-significant p value). However, infra-inguinal ligament stenting was not associated with worse restenosis or patency outcomes in either a univariate (summary-statistics and Kaplan-Meier based) or multivariate (Cox proportional hazard model based) analysis.

Laparoscopic inguinal ligament suspension combined with hysterectomy for the treatment of uterovaginal prolapse.

AIM: To demonstrate the efficacy and safety of a modified technique of laparoscopic inguinal ligament suspension (LILS) with hysterectomy for the treatment of uterovaginal prolapse. METHODS: A total of 57 patients were treated by LILS combined with hysterectomy between Jan 2014 and Feb 2016. The perioperative parameters, such as operative time, estimated blood loss, length of stay and intra- and postoperative complications were recorded. The Pelvic Organ Prolapse questionnaire classification was applied to evaluate the Pelvic Organ Prolapse stage, and Patient Global Impression of Improvement scale was used to determine the patients' satisfaction. Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire were used to evaluate the functional improvement. All data were collected preoperatively and then at 12 months postoperatively. RESULTS: The mean surgical time was 130.4 (82-190) min, the average blood loss was 50.4 (10-300) mL and the mean hospitalization was 5.3 (4-8) days. The rates of intra- and postoperative complications were low. After a minimal of 12 months follow-up, the anatomical success rate was 85.5%, and the subjective satisfaction rate was 92.7%. The functional measures also presented a significant improvement with no recurrence of prolapse. CONCLUSION: LILS combined with hysterectomy was a safe and effective technique and might be considered as an alternative treatment for patients with uterovaginal prolapse.

Age-related changes in inguinal region anatomy from 0 to 19 years of age.

Knowledge of the age-related changes in inguinal region anatomy is essential in pediatric urological and abdominal surgery, yet little is published. This study aimed to determine the position of inguinal region structures and growth of the surrounding pelvis and inguinal ligament in subjects from 0 to 19 years of age. Anonymized contrast-enhanced CT DICOM datasets of 103 patients (63 male: 40 female) aged from 0 to 19 years had left and right sides analyzed by three independent observers. Exclusion criteria were applied. Growth of the pelvis and inguinal ligament were determined using fixed bony reference points. The position of the deep inguinal ring and femoral vasculature were determined as ratio of inguinal ligament length, measured from the anterior superior iliac spine. Growth of the pelvis in vertical and horizontal dimensions and of the inguinal ligament followed a positive polynomial relationship with increasing age, with no observed increase in growth rate during puberty. From 0 to 19 years, the deep inguinal ring moved superolaterally with respect to the inguinal ligament (from 0.74 to 0.60 of the distance along the inguinal ligament) and the femoral artery and vein moved medially (from 0.50 to 0.58, and 0.61 to 0.65 of the distance along the inguinal ligament, respectively). The position of the femoral artery, vein, and deep inguinal ring followed a logarithmic relationship with age. No significant left:right side or male:female differences were observed. From 0 to 19 years of age the femoral vasculature and deep inguinal ring change position as the pelvis grows around them. Clin. Anat. 32:794-802, 2019. © 2019 Wiley Periodicals, Inc.

Revisiting the genital and femoral branches of the genitofemoral nerve: Suggestion for a more accurate terminology.

The genitofemoral nerve is a branch of the lumbar plexus originating from the ventral rami of the first and second lumbar spinal nerves. During routine dissections of this nerve, we have occasionally observed that the genital branch of the genitofemoral nerve gave rise to the femoral branch, and the femoral branch of the genitofemoral nerve gave rise to the genital branch. Therefore, this study aimed to investigate the aforementioned distributions of the genitofemoral nerve in a large number of cadaveric specimens. Twenty-four sides from fourteen fresh-frozen cadavers derived from nine males and five females were used in this study. For proximal branches of the genitofemoral nerve, that is, as they first arise from the genitofemoral nerve, the terms "medial branch" and "lateral branch" were used. For the final distribution, the terms "genital branch" and "femoral branch" were used. On eight sides (33.3%) with nine branches, one or two branch(s) from either the medial or lateral branch became coursed as the femoral or genital branches (five became femoral and four became genital branches). Our study revealed that the distribution of the genitofemoral nerve is more complicated than previously described. The "medial branch" and "lateral branch" that we have used in the present study for describing the proximal branches of the genitofemoral nerve are more practical terms to describe the genitofemoral nerve. Clin. Anat. 32:458-463, 2019. © 2019 Wiley Periodicals, Inc.

Laparoscopic inguinal ligament suspension: a novel procedure to repair uterine prolapse.

INTRODUCTION AND HYPOTHESIS: Traditionally, surgical treatment for uterine prolapse has included hysterectomy. However, more patients now prefer a uterine-preserving operation because of concerns about fertility or sexual dysfunction. In this video, we describe a novel approach to correcting uterine prolapse in an attempt to demonstrate an alternative option for patients. METHODS: A 42-year-old woman with symptomatic stage I-IV uterine prolapse (POP-Q: Aa +2, Ba +2, C + 3, gh 6.5, pb 3, TVL 8.5, Ap 0, Bp 0, D 0) underwent inguinal ligament suspension. The principle steps and techniques to complete the operation are outlined in the video. RESULTS: Prolapse repair was successfully completed without any intraoperative complications. The uterus was restored to its anatomic position. During the 12-month follow-up, neither recurrence nor postoperative complications, such as mesh exposure, de novo incontinence or bowel obstruction, etc., occurred. CONCLUSIONS: Laparoscopic inguinal ligament suspension is a safe and feasible alternative for correcting the uterine prolapse. This surgery could be an attractive choice for patients who prefer a uterine-sparing surgery.

A qualitative literature review exploring the role of the inguinal ligament in the context of inguinal disruption management.

PURPOSE: Groin injury, sportsman's groin and inguinal disruption (ID) refer to a diffuse chronic groin pain syndrome that has significant impact on athletes and is often unresponsive to conservative management. The ID aetiology is poorly understood but may involve weakness of the inguinal ligament attachments or the posterior inguinal canal wall or the tendons of adductor longus and rectus abdominis. We discuss the literature in which the inguinal ligament was directly targeted for ID management in athletic populations. Secondarily, we discuss the anatomical reclassification of the inguinal ligament to a tendon based on the above information. METHODS: This was a qualitative review of the published literature, in English, from January 2007 to February 2017. RESULTS: Five research papers, including 264 patients, were appraised. In patients with ID, tears were identified in the inguinal ligament, and to relieve pain, the surgical treatment of the ligament by tenotomy was shown to be beneficial. Techniques such as radiofrequency denervation involving the inguinal ligament and ilioinguinal nerve were also shown to relieve symptoms in athletes. CONCLUSIONS: This qualitative review has specifically focused on the literature directly targeting the inguinal ligament in ID which is a relatively unexplored management approach. When treated as a tendon, the inguinal ligament appears to be an appropriate ID therapeutic target. Integrated studies and randomised clinical trials will promote a better understanding of the role of the inguinal ligament and its tendinous properties in ID and provide a foundation for evidence-based management of chronic groin pain in athletes.

Two Year Outcome After Chronic Iliac Vein Occlusion Recanalisation Using the Vici Venous Stent®.

OBJECTIVE/BACKGROUND: The aim was to assess two year outcomes with placement of the Vici Venous Stent® in patients with chronic iliofemoral venous occlusions (complete blockage). METHODS: This was a retrospective single centre study comprising patients treated with the Vici Venous Stent for venographically verified iliofemoral venous occlusion and post-thrombotic syndrome (Villalta score ≥ 5 points) at least 12 months after acute deep vein thrombosis. Venography and intravascular ultrasound were used peri-operatively; duplex ultrasound was used to assess stent patency during follow up. RESULTS: Eighty-eight patients (101 limbs) had stent placement between March 2014 and October 2016. Median pre-treatment Villalta score was 14 (range 5-33). Stenting extended across the inguinal ligament in 63 limbs (62%) in order to land in a healthy venous segment. Six patients (7%) required endophlebectomy and fistula creation. Median imaging follow up was 21 months (range 0-41 months). Primary, assisted primary and secondary patency rates at one year were 59%, 78%, and 87%, respectively, and two years 51%, 73%, and 82%, respectively. Forty-three limbs (43%) had re-intervention (lysis, venoplasty, and/or placement of stent) during follow up; median time to re-intervention was 32 days (range 0-520 days). At 24 months, 37 of 53 limbs (70%) with available Villalta assessment showed clinically significant improvement (>30% reduction of baseline score). Villalta scores at the 6, 12, and 24 month clinical follow up were significantly lower than before stenting (p < .001, all time points). In a subset analyses of limbs with stenting terminating above and below the inguinal ligament, secondary cumulative patency rates at 24 months were 90% and 79%, respectively; clinical outcome showed 58% vs. 73% of limbs with clinically significant improvement, respectively. There was no statistically significant difference in patency or clinical outcomes. CONCLUSION: The Vici Venous Stent is associated with a good secondary patency rate and durable and substantial symptomatic resolution in patients with chronic post-thrombotic occlusions, regardless of whether stents extended beneath the inguinal ligament.

The Ideal Size of Mesh for Open Inguinal Hernia Repair: A Morphometric Study in Patients with Inguinal Hernia.

Introduction This study was done to analyze the morphometric features of the inguinal canal with different types of inguinal hernias to determine the appropriate size of mesh required to cover potential sites of recurrence. A morphometric assessment in the particular population is essential to recommend the appropriate mesh size in inguinal hernias to cover all the potential sites of recurrence. Materials and methods This was a prospective observational study, including all consecutive patients undergoing open inguinal hernia repair under local/regional/general anesthesia over a period of three years. Surgeries that were done in emergencies for complicated hernias, laparoscopic repair, and recurrent inguinal hernias were excluded. Intra-operative parameters were studied to predict the appropriate mesh size, which included the position of the superficial and deep inguinal ring (SIR and DIR) with the diameter, the distance of SIR and DIR from the anterior superior iliac spine (ASIS), and the distance from the summit of the muscular arch to the inguinal ligament. The differences in morphometric details between the types of hernias and categorical variables were assessed using the chi-square test. Results The study included a total of 170 patients with a mean age of 50.67 + 17.59 years. An indirect hernia was the most common type in patients less than 60 years. The mean distance from ASIS to SIR was 10.2+ 1.9 cm, and in indirect hernia patients, it was found to be significantly increased (p=0.042). The mean distance from ASIS to DIR was 4.14+1.57 cm, where the indirect hernia patients had a significantly less distance (p=0.029). The mean length of the inguinal canal in a direct hernia was 5.66 + 0.5 cm, whereas, in an indirect inguinal hernia, it was 6.46 + 0.8 cm, which was significant (p=0.029). The mean distance from the midpoint of the inguinal ligament to the summit of the muscular arch was 4.03 cm, and there was no significant difference between the indirect and direct hernia patients. Conclusion After considering the morphometric assessments of the length of the inguinal canal, the mean distance from the midpoint of the inguinal ligament to the summit of the muscular arch, the mean distance from ASIS to DIR, the ideal mesh size for the population would be 9 X 15 cm to cover all the potential sites of recurrence.

Laparoscopic inguinal ligament suspension with uterine preservation for pelvic organ prolapse: A retrospective cohort study.

OBJECTIVE: To introduce an alternative surgical technique of laparoscopic inguinal ligament suspension (LILS) with uterine preservation and evaluate its efficacy and safety for patients with severe pelvic organ prolapse (POP). METHODS: Between June 2014 and December 2015, 35 patients with symptomatic stage III or IV were treated by LILS with uterine preservation. The perioperative parameters including surgical time, blood loss, hospital stay and complications were recorded. The anatomical cure rate was evaluated according to the Pelvic Organ Prolapse Questionnaire (POP-Q) assessment. The anatomical points were analyzed by dynamic Magnetic Resonance Imaging (MRI). Validated questionnaire of the Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Impact Questionnaire (PFIQ-7) and the Pelvic organ prolapse urinary Incontinence Sexual Questionnaire (PISQ-12) were recorded to evaluate the symptom severity, quality of life and sexual activity. RESULTS: The mean surgical time was 163.8 ±â€¯42.3 min (range: 120-280 min), the mean estimated blood loss was 48.6 ±â€¯60.5 ml (range: 10-200 ml), and the mean hospital stay was 5 days (range: 3-7 days). No intra-operative complications were encountered. The anatomical success rate at postoperative 6-month and 12-month was 97.1% and 94.3%, respectively. The postoperative anatomical points on straining showed a significant improvement on dynamic MRI as compared to baselines. The symptom severity, quality of life and sexual activity also presented significant improvement both 6-month and 12-month after surgery. After a minimal 12 months follow-up, no postoperative complications occurred and the recurrence prolapse were low. CONCLUSION: LILS with uterine preservation is a feasible, effective and safe surgical alternative in the treatment of POP for patients who desire to reserve uterus. Longer follow-up data from larger studies are required to confirm the benefits of LILS with uterine preservation as a minimally invasive surgical approach.

Laparoscopic inguinal ligament suspension versus laparoscopic sacrocolpopexy in the treatment of pelvic organ prolapse: study protocol for a randomized controlled trial.

BACKGROUND: Pelvic organ prolapse (POP) is a common health problem. The lifetime risk of undergoing surgery for prolapse is 11%. POP significantly affects the effects on quality of life and activities of daily living. Laparoscopic sacrocolpopexy (LSC) has been viewed as the gold standard treatment for women with POP who desire reconstructive surgery. However, LSC is associated with technical difficulties, resulting in a long learning curve and operative time. Recently, our team introduced a new laparoscopic technique of inguinal ligament suspension (LILS) and had confirmed its safety and efficacy in treating vaginal vault prolapse. As a new surgical technique for POP, a prospective randomized controlled trial comparing the LILS with the standard technique of LSC is necessary. Therefore, we will conduct a trial. METHODS: The trial is a randomized controlled trial. It compares LILS with LSC in women with stage 2 or higher uterine prolapse. The primary outcomes of this study are perioperative parameters, including surgical time, blood loss, intraoperative complications, and hospital stay as well as surgical anatomical results using the pelvic organ prolapse questionnaire (POP-Q) classification at 6 weeks, 6 months, 12 months, and annually till 5 years after surgery. Secondary outcomes are subjective improvement in urogenital symptoms and quality of life, postoperative complications, postoperative recovery, sexual functioning, and cost-effectiveness at each follow-up point. Validated questionnaires will be used and the data will be analyzed according to the intention-to-treat principle. Based on an objective success rate of 90%, a noninferiority margin of 15%, and a dropout of 20%, 107 patients are needed in each arm to prove the hypothesis with a 95% confidence interval. DISCUSSION: The trial is a randomized controlled, multicenter, noninferiority trial that will provide evidence whether the efficacy and safety of LILS is noninferior to LSC in women with symptomatic stage 2 or higher uterine prolapse. TRIAL REGISTRATION: China Trial Register (CTR): ChiCTR-INR-15007408 . Registered on 9 November 2015.

Minimally invasive anterior pelvic internal fixation: An anatomic study comparing Pelvic Bridge to INFIX.

OBJECTIVES: Anterior external fixation for pelvic ring fractures has shown to effectively improve stability and reduce mortality. However, these fixators can be associated with substantial morbidity such as pin tract infection, premature loss of fixation, and decreased quality of life in patients. Recently, two new methods of subcutaneous anterior pelvic internal fixation have been developed; the INFIX and the Pelvic Bridge. These methods have the purported advantages of lower wound complications, less surgical site pain, and improved quality of life. We sought to investigate the measured distances to critical anatomic structures, as well as the qualitative and topographic differences notable during implantation of both devices in the same cadaveric specimen. MATERIALS AND METHODS: The Pelvic Bridge and INFIX were implanted in eleven fresh cadavers. Distances were then measured to: the superficial inguinal ring, round ligament, spermatic cord, lateral femoral cutaneous nerve (LFCN), femoral nerve, femoral artery, and femoral vein. Observations regarding implantation and topography were also recorded. RESULTS: The INFIX had greater measured distances from all structures except for the LFCN, in which its proximity placed this structure at risk. Neither device appears to put other critical structures at risk in the supine position. Significant implantation and topographic differences exist between the devices. The INFIX application lacked "safety margins" concerning the LFCN in 10/11 (90.9%) specimens, while Pelvic Bridge placement lacked "safety margins" with regard to the right superficial ring (1/11, 9%) and the right spermatic cord (1/11, 9%). CONCLUSIONS: Both the Pelvic Bridge and INFIX lie at safe distances from most critical pelvic structures in the supine position, though INFIX application places the LFCN at risk.