Robotic-Assisted Resection of a Benign Schwannoma of the Obturator Nerve: A Rare Case.

BACKGROUND Neurilemmomas are rare tumors derived from the Schwann cells that comprise the peripheral nerve sheaths. They have a slow growth and rarely display malignancy. Early diagnosis is rare, and the treatment consists by surgical resection. Although robotic-assisted surgery is commonly used for treating retroperitoneal diseases, there are few reports of resection of retroperitoneal and pelvic schwannoma through robotic-assisted surgery. In the present study, we reported a case of complete excision of a benign retroperitoneal schwannoma of the obturator nerve by robotic-assisted surgery. CASE REPORT A 51-year-old woman was referred by her gynecologist for left pelvic discomfort of a 3-month duration. The physical examination was normal, but a computerized tomography scan of the abdomen and pelvis showed an expansive pelvic lesion in the topography of the left iliac vessels, a hypodense contrast enhancement measuring 4.6×3.4 cm. Magnetic resonance imaging showed an extraperitoneal lesion located medially and inferiorly to the left external iliac vessels, with a size of 4.9×3.7 cm, and of probable neural etiology. Surgical resection of the tumor was recommended because of the diagnostic hypothesis of obturator nerve schwannoma. CONCLUSIONS This case showed that retroperitoneal neurilemmomas are difficult to diagnose owing to a lack of specific symptoms, and the best treatment is complete tumor resection. The use of robotic techniques gives greater dexterity to the surgeon, since it provides high-definition 3-dimensional vision, which can make the removal of retroperitoneal tumors susceptible to minimally invasive resection in a safe and effective way.

Bloqueo ecoguiado del nervio obturador al nivel de la rama púbica superior: estudio en cadáver embalsamado en Thiel utilizando látex / Sonographic obturator nerve block at level of superior pubic ramus: A Thiel based cadaveric investigation with latex

Introducción: El bloqueo del nervio obturador proximal tiene una eficacia similar al bloqueo del nervio obturador distal. Los estudios en cadáveres previos que inyectaban azul de metileno y realizaban seguidamente la disección reflejaron que la solución se dispersa a las divisiones anterior y posterior del nervio obturador, en el punto de salida del canal obturador. La absorción de azul de metileno por parte de la fascia y los músculos oscurece la delineación exacta de los nervios teñidos. Nosotros conjeturamos que la inyección de látex al nivel de las ramas púbicas superiores en el plano entre los músculos pectíneo y obturador externo mediante guía ecográfica a tiempo real, seguida de disección demorada en un cadáver embalsamado en Thiel, sería la técnica óptima de investigación en cadáveres. Métodos: Obtuvimos 3 cuerpos donados a la ciencia (BDTS) conforme a las normas estrictas del programa de donación del Departamento de Anatomía Macroscópica y Clínica de la Universidad de Medicina de Graz, y a la normativa sobre enterramientos de Estiria. Los BDTS fueron embalsamados utilizando el método de Thiel, que aporta condiciones muy realistas para las investigaciones con anestesia regional. En 2 cadáveres, las inyecciones de látex se realizaron de forma ecoguiada, y en el tercero se realizaron secciones transversales. Resultados: Nuestras disecciones abiertas de los cadáveres embalsamados en Thiel (C1 y C2) reflejaron que la inyección única de látex en el plano interfascial entre los músculos pectíneo y obturador externo al nivel de la rama púbica superior originó una dispersión adecuada a lo largo del tronco del nervio obturador y sus ramas, en todas las muestras. Conclusiones: La inyección ecoguiada de látex dentro del plano al nivel de las ramas púbicas superiores entre los músculos pectíneo y obturador externo cubre las ramas anterior y posterior y el tronco del nervio obturador.(AU)

Introduction: A proximal obturator nerve block has a similar block efficacy as the distal obturator nerve block. Previous cadaveric investigation injecting methylene blue dye solution and an immediate dissection proved the solution engulfing the anterior and posterior divisions of the obturator nerve as they emerge from the obturator canal. Uptake of methylene blue dye by the fascia and muscles obscures the exact delineation of the stained nerves. We hypothesized that injection of latex at the level of superior pubic rami in the plane between pectineus and obturator externus under real time ultrasound and a delayed dissection in a Thiel-based cadaver would be the optimal cadaveric investigational technique. Methods: Three investigated bodies donated to science (BDTS) fall under the strict rules of the donation program of the Department of Macroscopic and Clinical Anatomy of the Medical University of Graz and the Styrian burial law. The BDTS were embalmed with Thieĺs method which provides very lifelike conditions for investigations with regional anaesthesia backgrounds. In two cadavers (a total of specimens), latex injections were performed under ultrasound, while in the third cadaver cross-sections were executed. Results: Our Thiel based cadaveric open dissection (C1 and C2) demonstrated that a single injection of latex in the inter-fascial plane between the pectineus muscle and the obturator externus muscle at the level of superior pubic ramus led to adequate spread along trunk of the obturator nerve and its branches in all specimens. Conclusions: An in-plane ultrasound-guided latex injections at the level of superior pubic rami, between the pectineus and the obturator externus muscles soaks the anterior ramus, posterior ramus, and the obturator nerve trunk.(AU)

Incidental damage of obturator nerve during laparoscopic pelvic lymphadenectomy in endometrial cancer - Demonstration of a successful repairing procedure.

OBJECTIVE: In order to highlight the importance of intraoperative complications and their management, we demonstrate a video of an iatrogenic left obturator nerve lesion during a pelvic lymphadenectomy for endometrial cancer staging. The repair was promptly performed using an intracorporeal laparoscopic suture for an end-to-end tension-free nerve anastomosis. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: A 70-year-old woman with a stage IB grade I endometrial adenocarcinoma was submitted to a surgical laparoscopic staging with total hysterectomy(TH), bilateral adnexectomy(BA), and bilateral pelvic and lomboaortic lymphadenectomy. After an uneventful retroperitoneal lomboaortic lymphadenectomy, the left paravesical space was dissected until the obturator fossae and a left pelvic lymphadenectomy followed, during which the left obturator nerve was accidentally transected with LigaSure™. INTERVENTIONS: A careful inspection revealed an almost complete transection (80%) of the nerve, with both proximal and distal cut ends identifiable and no fraying of the edges. The thickness of the non-sectioned nervous portion was less than 3 mm, but a tension-free reattachment of both edges seemed manageable. The edges were oriented towards each other and a single stitch suture was placed using a 5-0 prolene, providing an epineural end-to-end coaptation. To reinforce the suture, a Fibrin sealant Tissucol® was applied. The contralateral pelvic lymphadenectomy was then performed, followed by TH and BA. The pieces were removed through the vagina using an endobag. The patient was discharged on the second postoperative day. During the follow-up, there were no signs of diminished adductor function, and neither there was any other detectable residual neuropathy or neurologic deficit involving the left thigh. CONCLUSION: It is crucial to identify intraoperative complications and to develop abilities to manage them. This video proves that it is possible to repair a transected obturator nerve using laparoscopy, when performed by an experienced onco-gynecologist, with extremely good functional results.

Obturator Nerve Injury in Robotic Pelvic Surgery: Scenarios and Management Strategies.

BACKGROUND: Obturator nerve injury (ONI) is an uncommon complication of pelvic surgery, usually reported in 0.2-5.7% of cases undergoing surgical treatment of urological and gynecological malignancies involving pelvic lymph node dissection (PLND). OBJECTIVE: To describe how an ONI may occur during robotic pelvic surgery and the corresponding management strategies. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively analyzed video content on intraoperative ONI provided by robotic surgeons from high-volume centers. SURGICAL PROCEDURE: ONI was identified during PLND and managed according to the type of nerve injury. RESULTS AND LIMITATIONS: The management approach varies with the type of injury. Crush injury frequently occurs at an advanced stage of PLND. For a crush injury to the obturator nerve caused by a clip, management only requires its safe removal. Three situations can occur if the nerve is transected: (1) transection with feasible approximation and tension-free nerve anastomosis; (2) transection with challenging approximation requiring certain strategies for proper nerve anastomosis; and (3) transection with a hidden proximal nerve ending that may initially appear intact, but is clearly injured when revealed by further dissection. Each case has different management strategies with a common aim of prompt repair of the anatomic disruption to restore proper nerve conduction. CONCLUSIONS: ONI is a preventable complication that requires proper identification of the anatomy and high-risk areas when performing pelvic lymph node dissection. Prompt intraoperative recognition and repair using the management strategies described offer patients the best chance of recovery without sequelae. PATIENT SUMMARY: We describe the different ways in which the obturator nerve in the pelvic area can be damaged during urological or gynecological surgeries. This is a preventable complication and we describe how it can be avoided and different management options, depending on the type of nerve injury.

Outcome of transurethral resection of bladder tumour under spinal anaesthesia combined with obturator nerve block in Sri Lanka.

PURPOSE: Transurethral resection of bladder tumour (TURBT) is done under general anaesthesia (GA) with muscle relaxation to prevent obturator jerk and bladder perforation. TURBT under spinal anaesthesia (SA) with obturator nerve block (ONB) may prevent the obturator jerk while eliminating the disadvantages of GA. OBJECTIVES: To assess the outcome of TURBT under SA and ONB. METHODS: Patients undergoing TURBT for lateral wall tumours from 01.11.2017 to 30.10.2020 were prospectively studied. Anterior branch of obturator nerve with plain Bupivacaine was blocked with the guidance of an ultrasound scan and a nerve stimulator. Significant obturator jerk which necessitated conversion to GA was defined as failed ONB. RESULTS: Out of 72 patients with mean age of 66.7 years underwent ONB, 61 (84.7%) were men. Fifty two (72.2%) had unilateral and 20 (27.8%) had bilateral blocks. Sixty one (84.7%) patients had no obturator jerk whereas 5 (7%) had a mild jerk which did not preclude safe resection. Six patients (8.3%) had a failed ONB requiring conversion to GA. None had a bladder perforation requiring laparotomy, developed neurovascular injury or anaesthetic toxicity and only one patient required intensive care monitoring. CONCLUSION: SA with anterior branch of ONB is an effective and safe alternative to GA with muscle relaxation for TURBT although a randomized trial is necessary to determine the true efficacy and safety over the other.

Comparison of different methods of obturator nerve block in transurethral resection of bladder tumors: A systematic review and network meta-analysis.

BACKGROUND: Bladder cancer is the most common malignancy of the urinary system, and accounts for 3% of newly diagnosed tumors. Transurethral resection of bladder tumor plays a key role in treating bladder cancer, among which one of the most serious complications is bladder perforation caused by obturator nerve reflex. Obturator nerve reflex can be prevented by inducing obturator nerve block after lumbar anesthesia. However, No study so far has compared the inhibitory effect of different obturator nerve block approaches on intraoperative obturator nerve reflex and bladder perforation. METHOD: In this study, we conducted a network meta-analysis (NMA) of studies comparing the efficacy of different obturator nerve block approaches performed after lumbar anesthesia in operation. RESULT: The distal obturator nerve block guided by peripheral nerve stimulator is the best approach for preventing obturator reflex. The proximal obturator nerve block guided by ultrasound is the best approach for preventing bladder perforation. CONCLUSION: Spinal anesthesia combined with the distal obturator nerve block guided by peripheral nerve stimulator is the most optimal approach to prevent the obturator nerve reflex. But the doctor should choose the appropriate anesthesia method according to the patient's general condition, tumor location, and doctor's proficiency in puncture techniques.

Acetabular Paralabral Cyst Causing Obturator Nerve Compression in the Setting of Femoroacetabular Impingement Syndrome: A Case Report.

CASE: Large acetabular paralabral cysts can cause compression of the surrounding neurovascular structures leading to sensory and motor deficits. We present a 68-year-old man with obturator nerve denervation from a paralabral cyst secondary to a labral tear associated with femoroacetabular impingement syndrome. Resolution of symptoms and return to full activities were achieved at 3 months and maintained beyond 1 year through open cyst excision, obturator neurolysis, arthroscopic femoral osteoplasty, and labral repair in the same surgical setting. The patient had a successful clinical outcome, with pain and dysfunction resolution. CONCLUSION: Large paralabral cysts may cause obturator nerve compression, which can be successfully treated with open nerve decompression and arthroscopic treatment of labral pathology.

Systematic Review and Meta-Analysis of Inguinal Versus Classic Obturator Nerve Block.

Obturator nerve block (ONB) has been widely applied in transurethral resection of bladder tumor and knee surgery to prevent serious complications such as bladder perforation or to improve the quality of anesthesia during knee surgery. The classic/pubic and inguinal ONB methods are the two primary approaches used. The classic and inguinal ONB methods are two techniques for anesthetizing the obturator nerve, and each method may result in different respective outcomes. We aimed to compare the efficacy of the classic and inguinal methods. We presumed the inguinal approach to be an overall superior technique because it was recently invented and has been reported to provide numerous benefits. This study included randomized controlled trials comparing classic and inguinal approaches to ONB. Two independent investigators extracted study-level data for a random-effects meta-analysis of the comparison between the classic approach and inguinal approaches. We identified five studies comprising 312 patients. The pooled results revealed a higher success rate (risk ratio, 1.15; 95% confidence interval [CI], 1.04-1.27), fewer puncture attempts (mean difference, -0.84; 95% CI, -1.55 to -0.12), and shorter procedure time (mean difference, -28.87; 95% CI, -47.19 to -10.54) for patients given inguinal ONB. The inguinal approach is, overall, the superior method for performing the ONB procedure. The inguinal method resulted in a higher success rate, fewer puncture attempts, and shorter procedure time.

Comparison of three obturator nerve block techniques for injectate spread into the obturator canal: a randomized controlled trial.

PURPOSE: The obturator nerve branches into the obturator canal; therefore, local anesthetic spread into the obturator canal predicts the success of the obturator nerve block (ONB). We compared three ONB techniques for the spread of local anesthetic mixed with contrast medium into the obturator canal. METHODS: We performed the ONB using the classical pubic approach (PA), inguinal approach (IA), or ultrasound-guided methodologic approach (UMA) in 143 patients undergoing transurethral resection of bladder tumors. The obturator nerve course and branching patterns of the UMA group were examined using ultrasound imaging. After injecting a local anesthetic mixed with a contrast medium, we evaluated its spread into the obturator canal using fluoroscopic imaging. P < 0.05 indicated statistical significance. RESULTS: Success rate of obturator canal enhancement was the greatest in the UMA group (84%; P < 0.001); the PA (42.6%; 20/47 patients) and IA (47.8%; 22/46 patients) groups did not differ significantly (P = 1.000). Both branches of the obturator nerve passed above the superior margin of the external obturator muscle (EOM), and the obturator canal was enhanced in 13 of 50 (26%) patients in the UMA group. The posterior branch of the obturator nerve passed between the superior and main fasciculi of the EOM in 37 of 50 patients (74%) in the UMA group; the obturator canal was enhanced in 29 of these 37 patients (78%). CONCLUSION: Local anesthetic spread into the obturator canal using the UMA was superior to that using the PA and IA. Both branches of the obturator nerve could be blocked using the UMA.

Laparoscopic repair of segmental obturator nerve injury defect using an artificial nerve conduit: A case report.

Obturator nerve injury is an uncommon complication frequently associated with pelvic gynecologic or urologic cancer surgery. It can lead to disability or adversely affect quality of life. Large segmental defects are particularly difficult to manage as the limited mobility of the nerve prevents tension-free direct end-to-end anastomosis. A 36-year-old woman with cervical cancer underwent sentinel lymph node biopsy, laparoscopic radical hysterectomy, and bilateral adnexectomy. During the procedure, the sentinel lymph node (right obturator node) adherent to the obturator nerve was resected together with the nerve segment leaving a 3 cm defect. Immediate laparoscopic obturator nerve repair was performed using an artificial nerve conduit leading to successful recovery. We report this unique case due to rarity of large segmental obturator nerve defects and present laparoscopic nerve repair with artificial nerve conduits as a useful treatment alternative of these important injuries, without nerve donor site morbidity.

Long Thoracic Nerve Transfer for Children With Brachial Plexus Injuries.

INTRODUCTION: The transfer of intraplexal and extraplexal nerves for restoration of function in children with traumatic and birth brachial plexus palsies has become well accepted. Little has been written about using the long thoracic nerve (LTN) as a donor in reanimation of the upper extremity. The authors present a case series of nerve transfers using the LTN as a donor in brachial plexus injury. METHODS: A retrospective chart review was performed over a 10-year period at a single institution. The primary outcome measure was the active movement scale. RESULTS: Fourteen patients were included in the study: 10 birth injury patients and 4 blunt trauma patients. Average follow-up time was 21.3 and 10.75 months, respectively. The best outcomes were seen when the LTN was used for reinnervation of the obturator nerve in free functioning muscle transfers. The next most successful recipients were the musculocutaneous and axillary nerves. Outcomes were poor in transfers to the posterior interosseous fascicles of the radial nerve and the radial nerve branches to the triceps. DISCUSSION: The LTN may be a potential nerve donor for musculocutaneous or axillary nerve reinnervation in patients with brachial plexus injuries when other donors are not available during a primary plexus reconstruction. However, the best use may be for delayed neurotization of a free functioning muscle transfer after the initial plexus reconstruction has failed and no other donors are available. LEVEL OF EVIDENCE: Level IV-therapeutic study.

A systematic review and meta-analysis of the hip capsule innervation and its clinical implications.

Detailed understanding of the innervation of the hip capsule (HC) helps inform surgeons' and anaesthetists' clinical practice. Post-interventional pain following radiofrequency nerve ablation (RFA) and dislocation following total hip arthroplasty (THA) remain poorly understood, highlighting the need for more knowledge on the topic. This systematic review and meta-analysis focuses on gross anatomical studies investigating HC innervation. The main outcomes were defined as the prevalence, course, density and distribution of the nerves innervating the HC and changes according to demographic variables. HC innervation is highly variable; its primary nerve supply seems to be from the nerve to quadratus femoris and obturator nerve. Many articular branches originated from muscular branches of the lumbosacral plexus. It remains unclear whether demographic or anthropometric variables may help predict potential differences in HC innervation. Consequently, primary targets for RFA should be the anterior inferomedial aspect of the HC. For THA performed on non-risk patients, the posterior approach with capsular repair appears to be most appropriate with the lowest risk of articular nerve damage. Care should also be taken to avoid damaging vessels and muscles of the hip joint. Further investigation is required to form a coherent map of HC innervation, utilizing combined gross and histological investigation.

Transanterior obturator nerve gateway: a novel approach to achieving intracorporeal distal rectal transection for ultralow rectal cancer.

BACKGROUND: Intracorporeal rectal transection at the anorectal junction for ultralow rectal cancer is technically difficult due to pelvic width and limited roticulation, which might require a transanal transection or an oblique transection with multiple firings. These procedures were reported to be associated with the increased risk of morbidity. To address these problems, we presented a novel technique Transanterior Obturator Nerve Gateway (TANG) to transect rectum for ultralow rectal cancer and evaluated its safety and feasibility in this study. METHODS: A total of 210 consecutive patients who underwent laparoscopic coloanal anastomosis with or without partial intersphincteric resection (CAA/pISR) for rectal cancers between January 2017 and January 2020 were included. Eighty of these patients were analyzed using propensity score matching (PSM). The perioperative characteristics, TANG-related variables, and genitourinary and anal function outcomes were analyzed. RESULTS: Among these enrolled patients, 170 patients underwent traditional transection, and 40 underwent TANG transection; the patients were matched to include 40 patients in each group by PSM. After PSM, there were no significant differences in the operating time (p = 0.351) or bleeding volume (p = 0.474) between the two groups. However, the TANG group had fewer cases of conversion to transanal transection (0 vs. 13, p < 0.001). Moreover, the patients in TANG group had a more desirable transection with longer distal resection margin (1.7 vs. 1.1 cm, p < 0.001), shorter stapling line (6.6 vs. 10.3 cm, p < 0.001) and fewer stapler firings (p < 0.001). The overall postoperative complication rates and genitourinary and anal function outcomes were not significantly different between the two groups. CONCLUSIONS: The TANG approach appears to be a safe, feasible and effective approach for intracorporeal ultralow rectal transection with more distal resection, more vertical transection and fewer stapler firings.

[Analysis of the results of laser destruction of the articular branch of the obturator nerve in elderly and senile patients with degenerative coxarthrosis.]

The aim of the study was to analyze the results of the use of laser destruction of the articular branch of the obturator nerve in elderly and senile patients with degenerative coxarthrosis. The results of treatment of 34 patients over 65 years of age with symptomatic degenerative diseases of the hip joint (HJD) and somatic contraindications for total hip arthroplasty have been prospectively studied. In the study group, in the period from 2017 to 2019, laser destruction of the articular branch of the obturator nerve (970 nm, frequency 9 Hz and power 3 W in a total dose of 100 J) was carried out. The average follow-up was 12 months. To assess the effectiveness of surgical treatment, the dynamics of the pain syndrome in the hip joint was analyzed according to the visual analogue scale, the quality of life according to the SF-36 questionnaire, the functional state of the hip joint according to the W.H.Harris scale and the presence perioperative surgical complications. As a result, it was found that the use of laser destruction of the articular branch of the obturator nerve in degenerative coxarthrosis in elderly and senile patients (if total hip arthroplasty was not possible) made it possible to significantly reduce the level of preoperative pain syndrome, restore the quality of life and improve the functional state of patients with low risks of surgical complications.

Contralateral obturator nerve transfer for femoral nerve restoration: a case report.

BACKGROUND: Femoral nerve injury may occur in severe traffic accident injuries with pelvic fracture. Sural nerve grafts or ipsilateral obturator nerve transfer may be used to restore femoral nerve function. We report a new procedure transferring the contralateral obturator nerve to restore femoral nerve function. CASE DESCRIPTION: A 30 year-old male suffering complete lumbar plexus rapture received a contralateral obturator nerve transfer in our hospital. At 2 years follow up he had gained Medical Research Council Grade 3 muscle strength in his 23th months follow-up, with normal gait, Lower Extremity Functional Scale score of 58.75% and Femoral Nerve Motor Function Scale score 61%. CONCLUSION: The contralateral obturator nerve transfer is a reliable alternative if the nerve graft or ipsilateral obturator nerve cannot be performed.

Peritoneal Retraction Pocket Defects and Their Important Relationship with Pelvic Pain and Endometriosis.

OBJECTIVE: The objective of this video is to demonstrate different clinical presentations of peritoneal defects (peritoneal retraction pockets) and their anatomic relationships with the pelvic innervation, justifying the occurrence of some neurologic symptoms in association with these diseases. DESIGN: Surgical demonstration of complete excision of different types of peritoneal retraction pockets and a comparison with a laparoscopic retroperitoneal cadaveric dissection of the pelvic innervation. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: A pelvic peritoneal pocket is a retraction defect in the surface of the peritoneum of variable size and shapes [1]. The origin of defects in the pelvic peritoneum is still unknown [2]. It has been postulated that it is the result of peritoneal irritation or invasion by endometriosis, with resultant scarring and retraction of the peritoneum [3,4]. It has also been suggested that a retraction pocket may be a cause of endometriosis, where the disease presumably settles in a previously altered peritoneal surface [5]. These defects are shown in many studies to be associated with pelvic pain, dyspareunia, and secondary dysmenorrhea [1-4]. Some studies have shown that the excision of these peritoneal defect improves pain symptoms and quality of life [5]. It is important to recognize peritoneal pockets as a potential manifestation of endometriosis because in some cases, the only evidence of endometriosis may be the presence of these peritoneal defects [6]. In this video, we demonstrate different types of peritoneal pockets and their close relationship with pelvic anatomic structures. Case 1 is a 29-year-old woman, gravida 0, with severe dysmenorrhea and catamenial bowel symptoms (bowel distension and diarrhea/constipation) that were unresponsive to medical treatment. Imaging studies were reported as normal, and a laparoscopy showed a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the lateral border of the rectum. Case 2 is a cadaveric dissection of a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the pelvic sidewall. After dissection of the obturator fossa, we can observe that the pocket is close to the sacrospinous ligament, pudendal nerve, and some sacral roots. Case 3 is a 31-year-old woman, gravida 1, para 1, with severe dysmenorrhea that was unresponsive to medical treatment and catamenial bowel symptoms (catamenial bowel distention and diarrhea). Imaging studies were reported as normal and a laparoscopy showed left uterosacral peritoneal pocket infiltrating the pararectal fossa in close proximity to the rectal wall. Case 4 is a cadaveric dissection of the ovarian fossa and the obturator fossa showing the proximity between these structures. Case 5 is a 35-year-old woman, gravida 0, with severe dysmenorrhea that was unresponsive to medical treatment, referring difficulty, and pain when walking only during menstruation. A neurologic physical examination revealed weakness in thigh adduction, and the magnetic resonance imaging showed no signs of endometriosis. During laparoscopy, we found a peritoneal pocket infiltrating the ovarian fossa, with involvement in the area between the umbilical ligament and the uterine artery. This type of pocket can easily reach the obturator nerve. Because the obturator nerve and its branches supply the muscle and skin of the medial thigh [7,8], patients may present with thigh adduction weakness or difficulty ambulating [9,10]. Case 6 is a cadaveric dissection of the sacrospinous ligament and the pudendal nerve from a medial approach, between the umbilical artery and the iliac vessels. Case 7 is a 34-year-old woman, gravida 1, para 1, with severe dysmenorrhea and catamenial bowel symptoms as well as deep dyspareunia. The transvaginal ultrasound showed focal adenomyosis and a 2-cm nodule, 9-cm apart from the anal verge, affecting 30% of the bowel circumference. In the laparoscopy, we found a posterior cul-de-sac retraction pocket associated with a large deep endometriosis nodule affecting the vagina and the rectum. In all cases, endometriosis was confirmed by histopathology, and in a 6-month follow-up, all patients showed improvement of bowel, pain, and neurologic symptoms. CONCLUSION: Peritoneal pockets can have different clinical presentations. Depending on the topography and deepness of infiltration, they can be the cause of some neurologic symptoms associated with endometriosis pain. With this video, we try to encourage surgeons to totally excise these lesions and raise awareness about the adjacent key anatomic structures that can be affected.

A case report of primary multiple obturator nerve schwannomas.

Primary multiple obturator nerve schwannomas originate from Schwann cells and are extremely rare. Patients with schwannomas are asymptomatic and a retroperitoneal schwannoma is often misdiagnosed as an adnexal mass. In the present study, we describe a 58-year-old woman in whom a right adnexal mass accompanied by endometrial polyp was found incidentally through transvaginal ultrasound. The mass was diagnosed as multiple obturator nerve schwannomas after laparoscopy. Immunohistochemical assay confirmed the schwannomas to be positive for SOX10. To our knowledge, this is the first report to demonstrate a case of multiple schwannomas originating from the obturator nerve and treated by laparoscopic resection.

Minimally Invasive Therapies for Osteoarthritic Hip Pain: a Comprehensive Review.

PURPOSE OF REVIEW: Osteoarthritis (OA) is a highly prevalent cause of chronic hip pain, affecting 27% of adults aged over 45 years and 42% of adults aged over 75 years. Though OA has traditionally been described as a disorder of "wear-and-tear," recent studies have expanded on this understanding to include a possible inflammatory etiology as well, damage to articular cartilage produces debris in the joint that is phagocytosed by synovial cells which leads to inflammation. RECENT FINDINGS: Patients with OA of the hip frequently have decreased quality of life due to pain and limited mobility though additional comorbidities of diabetes, cardiovascular disease, poor sleep quality, and obesity have been correlated. Initial treatment with conservative medical management can provide effective symptomatic relief. Physical therapy and exercise are important components of a multimodal approach to osteoarthritic hip pain. Patients with persistent pain may benefit from minimally invasive therapeutic approaches prior to consideration of undergoing total hip arthroplasty. The objective of this review is to provide an update of current minimally invasive therapies for the treatment of pain stemming from hip osteoarthritis; these include intra-articular injection of medication, regenerative therapies, and radiofrequency ablation.

Different Surgical Reconstructions for Femoral Nerve Injury: A Clinical Study on 9 Cases.

BACKGROUND: Femoral nerve palsy can cause loss in quadriceps function and knee extension disability, which may lead to severe lower extremity impairment. The obturator nerve trunk transfer in the pelvic, the obturator nerve mortal branches transfer out of the pelvic, along with nerve graft, was introduced years ago to restore femoral nerve function. However, the outcomes of these procedures have never been compared. The aims of this study were to give our experiences in surgical reconstruction for femoral nerve injury and to compare the outcomes of different approaches. METHODS: Nine patients with complete femoral nerve injury have been enrolled in this study between March 2012 and July 2016. All patients were followed up for at least 2 years after surgical intervention for sural nerve graft (n = 3), obturator trunk transfer in the pelvic (n = 2), or obturator nerve mortal branches transfer out of the pelvic (n = 4). RESULTS: All patients gained satisfactory quadriceps Medical Research Council grade (M3-M4+) after more than 2 years of follow-up. The sural nerve graft led to the earliest recovery on average, followed by obturator nerve mortal branches transfer in the thigh level and then obturator nerve trunk transfer in the pelvic. The functional outcomes, demonstrated by Lower Extremity Functional Scale and Femoral Nerve Motor Function Scale scores, also showed that the sural nerve graft was the best on average, followed by obturator nerve trunk transfer in the pelvic and then obturator nerve mortal branches transfer in the thigh level. CONCLUSIONS: Our results indicate that all these 3 procedures are safe and reliable ways to reconstruct femoral nerve function and can be applied to patients with different kinds of injuries. The sural nerve graft should be considered in the first place and the obturator nerve transfer at different level (trunk transfer in the pelvic or mortal branches transfer out of the pelvic) can be performed as the alternative.

Anatomic Study of the Bifurcation of the Obturator Nerve: Application to More Precise Surgical/Procedural Localization.

BACKGROUND: This anatomic study aimed to more precisely locate the bifurcation of the obturator nerve in relationship to the obturator foramen. Such information might improve outcomes in neurotization or other procedures necessitating exposure of the obturator nerve and could increase success rates for obturator nerve blockade. METHODS: Fourteen sides from fresh-frozen cadaveric specimens were used in this study. Dissection of the obturator nerve was performed, and its bifurcation into anterior and posterior branches was documented and classified. Measurements of these branches were also performed. Bifurcations of the obturator nerve were classified as type I when proximal to the obturator foramen, type II when inside the obturator foramen, and type III when distal to the obturator foramen. RESULTS: Type I, type II, and type III obturator nerve bifurcations were observed in 14.3%, 64.3%, and 21.4% of sides, respectively. In type I nerves, the mean distance from the bifurcation of the obturator nerve to the obturator foramen was 15.8 mm, and in type II nerves the mean was 14.0 mm. The mean diameter of the main trunk, anterior branch, and posterior branch was 3.74 mm, 2.64 mm, and 2.28 mm, respectively. CONCLUSIONS: Bifurcation of the obturator nerve can occur proximally, distally, or inside the obturator foramen. Therefore using imaging modalities such as ultrasound is strongly recommended for identifying the main trunk or anterior and posterior branches of the obturator nerve before surgery or other procedures aimed at this nerve due to such anatomic variations.