Anastomosis entre vasos ilíacos y obturadores en la región retropúbica: estudio en cadáveres / Anastomosis among iliac vessels and obturators in the retropubic region: study in cadavers

Introducción: En las cirugías de la región retropúbica, la sección o ruptura de la anastomosis puede causar graves hemorragias de difícil control. Nuestro objetivo fue verificar la presencia o no de anastomosis arterial o venosa entre los vasos ilíacos y obturadores en la región retropúbica. Materiales y Métodos: Treinta cadáveres (14 hombres/16 mujeres; 60% de raza blanca y 40%, no blanca). Después de la disección, se verificó si había anastomosis y su distancia de la sínfisis púbica. Resultados: El 13,3% no tenía comunicación y el 86,6% tenía algún tipo de anastomosis (p <0,01), la anastomosis venosa fue la más frecuente (p <0,05). La distancia promedio entre la anastomosis y la sínfisis púbica fue de 5,7 cm. Al comparar el sexo, la anastomosis y el lado, el 57% de los hombres presentaba anastomosis en ambos lados, y el 81% y 88% de las mujeres la tenían en el lado derecho e izquierdo, respectivamente (p <0,05). Cuando se comparó la presencia de anastomosis con el lado, el 70% estaba en el derecho y el 73%, en el izquierdo (p >0,05). El 72% de los blancos y el 67% de raza no blanca tenían anastomosis (p >0,05). Conclusiones: La presencia de anastomosis es más frecuente que la ausencia y no existe diferencia significativa en cuanto al lado. Está localizada, en promedio, a 5,7 cm de la sínfisis púbica y la venosa es significativamente más frecuente. Es significativamente más frecuente en las mujeres. No hay diferencia estadística en cuanto a la presencia de anastomosis entre la raza blanca y no blanca. Nivel de Evidencia: IV

Introduction: During surgical interventions, section or rupture of the anastomosis may cause severe difficult-to-control bleeding. The aim of this study was to verify the presence or absence of arterial or venous anastomosis among iliac and obturator vessels in the retropubic region. Methods: Thirty cadavers (14 men/16 women; 60% white and 40% non-white). After dissection, the presence of anastomosis and its distance from the pubic symphysis were verified. Results: The 13.3% presented no communication and 86.6% presented some type of anastomosis (p<0.01). Venous anastomosis was more frequent (p<0.05). The mean distance from anastomosis to pubic symphysis was 5.7 cm. Regarding sex and side, 57% of male specimens presented anastomosis on both sides, while 81% and 88% of women had on the right and left side, respectively (p<0.05). Seventy percent of specimens had anastomosis on the right side and 73% on the left (p>0.05). Anastomosis was observed in 72% of whites and 67% of non-whites. Conclusions: Presence of anastomosis is more frequent than its absence, and there is no significant difference regarding side. It is located at 5.7 cm from the pubic symphysis and venous anastomosis is significantly more frequent. Anastomosis is significantly more frequent in females. There is no statistically significant difference between white and non-white races. Level of Evidence: IV

The prevalence and morphology of the corona mortis (Crown of death): A meta-analysis with implications in abdominal wall and pelvic surgery.

PURPOSE: Corona mortis is a highly variable vascular connection between the obturator and external iliac or inferior epigastric arteries or veins located behind the superior pubic ramus in the retropubic space (space of Retzius). Due to the significant variation in this collateral circulation, detailed anatomical knowledge of the corona mortis is vital to enhance the prevention of possible iatrogenic errors in hernia repair and other pubic surgical procedures. The aim of our meta-analysis was to provide comprehensive data on the prevalence, anatomical characteristics, and ethnic variations of the corona mortis vessel. METHODS: An extensive search was conducted through the major electronic databases to identify eligible articles. Data extracted included investigative method, prevalence of the corona mortis vessels among hemi-pelvises (overall, arterial only, venous only, and combined), distance from the corona mortis to pubic symphysis, and assessment of gender, side, laterality, and ethnicity subgroups. RESULTS: A total of 21 studies (n=2184 hemi-pelvises) were included in the meta-analysis. The overall prevalence of the corona mortis in hemi-pelvises is high (49.3%). A venous corona mortis is more prevalent than an arterial corona mortis (41.7% vs. 17.0%). The corona mortis is more common in Asia (59.3%) than in Europe (42.8%) and North America (44.3%). CONCLUSIONS: As a corona mortis is present in an about half of all hemi-pelvises, it is important to consider the possibilities of its presence when undertaking surgical procedures and plan accordingly to avoid injuries. All surgeons operating in the retropubic region should have a thorough understanding of the anatomical characteristics and surgical implications of a corona mortis.

A South Indian cadaveric study on obturator neurovascular bundle with a special emphasis on high prevalence of 'venous corona mortis'.

Surgical procedures in the pelvic region are very challenging because of the complex anatomy of this region. "Corona mortis" is a term used to describe retro-pubic anastomosis between the obturator and external iliac vessels. It is considered as a key structure as significant haemorrhage may occur if the vessels are cut accidentally during pelvic surgeries. Earlier studies have documented a high frequency of venous anastomosis compared to its arterial counterpart. The objective of our study was to document the prevalence of venous corona mortis in South Indian human adult cadaveric pelvises. We conducted this study on 73 cadaveric pelvic halves. Out of the 73 hemi pelvises, 36 were normal without any variations of the obturator vessels while 37 hemi pelvises (51%) showed the presence of abnormal obturator vessels which proves to be a very high incidence in terms of variations. Out of the 37 hemi pelvises, 25 (68%) showed the presence of 2 obturator veins, out of which 1 was normal and the other was an abnormal obturator vein. 8 hemi pelvises (22%) had only abnormal obturator vein. Most of the abnormal obturator veins drained into the external iliac vein, while two veins drained into inferior epigastric veins. Venous corona mortis is said to be frequently encountered during surgery and is considered to be as important as arterial corona mortis in its clinical implications. Individual evaluation of this risky anatomical structure should be done prior to any surgical interventions.

Delayed presentation of hypovolemic shock after a simple pubic ramus fracture.

Although trauma-induced simple pubic ramus fracture is common in the emergency department (ED), it can result in life-threatening hemorrhagic shock. We describe a 58-year-old woman with closed minimally displaced simple pubic ramus fracture. Hemodynamic instability became apparent 2 hours later. She was successfully treated with transarterial embolization and discharged uneventfully 10 days later. Literature review showed involvement of the superior pubic ramus in all reported cases probably because of hemorrhage from "corona mortis" with delay in shock presentation mostly within 6 hours, suggesting at least an equivalent observation period for these patients, particularly those at high risk for hemorrhage.

Massive haemorrhage due to minimally displaced pubic ramus fracture.

Fractures of the pubic ramus are commonly seen in the emergency room, but they are thought to be minor injuries. Occasionally, these fractures might be associated with massive haemorrhage. Here we report a case of bilateral obturator artery damage due to minimal displaced pubic ramus fracture.

A new composite flap: rectus abdominis muscle flap harvested with pubic bone segment--anatomic considerations.

The aim of this study was to incorporate a segment of pubic bone to rectus abdominis muscle (RAM). Eight RAM flaps from four fresh cadavers were used. During surgical dissection, utmost care was paid to enclose the areolar tissue between the main deep inferior epigastric (DIE) vessels and the pubic bone. A bone segment, 1.5 x 5 cm in dimension with an intact periosteum, was included with the RAM. Surgical dissections revealed two major vascular branches. The first branch arising from the DIE artery (DIEA) at a distance of 5.2 +/- 1.4 cm from the origin gave rise to two consistent subbranches. The second major branch originated from the DIEA at a distance of 8.4 +/- 1.8 cm from the origin. The first branch gave off two subbranches. The second subbranch coursed anteromedially and nourished the periosteum of the pubic bone. Microangiography showed a similar branching pattern of the vessels that create two significant networks. The X-rays confirmed a rich vascular network around the periosteum of the pubic bone. This wealthy nourishment of the pubic periosteum comes mainly from the perpendicular descending branches. In conclusion, a vascularized part of pubic bone can be incorporated to the RAM flap by preserving the delicate vascular network between the DIE vessels and the pubic periosteum.

[Arterial injury associated with tension-free vaginal tape procedure successfully treated by radiological embolization: a case report].

A 75-year-old woman underwent a tension-free vaginal tape (TVT) procedure for urinary stress incontinence. The patient complained of lower abdominal pain, a feeling of lower abdominal distension and nausea three hours after the operation. In addition, systolic blood pressure decreased gradually to 80 mmHg. Enhanced computed tomography revealed a retropubic hematoma sized up to 16 cm X 12 cm X 11 cm and bleeding from a vessel running through the posterosuperior aspect of the pubic bone. Successively, arteriography was performed. The arteriogram also confirmed arterial injury, which was successfully treated by selective embolization using a gelatin sponge and pushable coils. Postoperative course was uneventful requiring neither blood transfusion nor surgical removal of the hematoma.

The Union between gracilis and sartorius muscles in leontopithecus: morphofunctional analysis

RESUMEN: El Tití León Dorado, (Leontopithecus rosalia) es un primate (especie de los Tamarinos y Titíes) de la foresta atlántica brasileña en serio riesgo de extinción. Poco se conoce acerca de su anatomía, específicamente de las uniones musculares. Debido a ello, con el objetivo de comprender la locomoción de éste y otros primates, estudiamos la morfología y morfometría de los músculos grácil y sartorio y la relación entre ellos, en 3 especies de Leontopithecus rosalia. Se examinaron 18 animales adultos, de ambos sexos, sin anormalidades físicas en la región estudiada. El material pertenece a la colección del Centro de Primatología de Rio de Janeiro, Brasil. Los miembros posteriores fueron disecados hasta el nivel de los músculos grácil y sartorio, donde se efectuó la morfometría, obteniéndose, entre los músculos mencionados un área para su análisis histológico. Describimos la morfología de los músculos grácil y sartorio. Se obtuvieron valores promedio de la morfometría muscular y se estudió histológicamente la unión entre esos músculos. El análisis morfológico y morfométrico permite sugerir parámetros descriptivos de esos músculos. El análisis histológico permite concluir que las fibras del músculo grácil y del músculo sartorio no están fusionadas sino que se mantienen juntas a través de tejido conjuntivo, así, se insertan en el lado medial de la tibia. Funcionalmente, creemos que los músculos grácil y sartorio contribuyen a una activa contención de la articulación de la rodilla y sobre la biomecánica de los miembros posteriores de esos primates, conocidos como corredores.

Pelvic angiography for recurrent traumatic pelvic arterial hemorrhage.

BACKGROUND: Angiography is the gold standard for the diagnosis and treatment of pelvic arterial hemorrhage associated with pelvic fractures. In most cases, a single angiogram with embolization is adequate to control pelvic arterial hemorrhage. However, a small subset of patients, require repeat pelvic angiogram to evaluate and treat recurrent hemorrhage. This study seeks to define this population and determine clinical predictors of recurrent hemorrhage. METHODS: We conducted a retrospective case control study comparing patients with traumatic pelvic fracture undergoing repeated pelvic angiogram versus a single angiogram between the years 1995 and 2000. Stepwise logistic regression was used to identify the independent predictors of recurrent hemorrhage. RESULTS: In the years studied, 556 patients underwent a pelvic angiogram to evaluate for pelvic arterial hemorrhage associated with pelvic fractures. Among these, 42 (7.5%) patients underwent a second angiogram for suspected recurrent hemorrhage. In comparison to the initial angiogram, the source of bleeding on the repeat angiogram occurred at a new bleeding site in 68%, at a previously embolized site in 18%, and both in 14%. Significant risk factors for recurrent pelvic arterial hemorrhage included hypotension or transfusion of >2 U of blood per hour before the initial angiogram, pubic symphysis widening, and more than two injured arteries requiring embolization (p < 0.05). Of these, more than two injured arteries requiring embolization (odds ratio, 16.0; 95% confidence interval, 2.9-88) and transfusion of >2 U of blood per hour (odds ratio, 6.9; 95% confidence interval,1.9-25) were independent predictors of recurrent hemorrhage. CONCLUSION: Angiographic control of traumatic pelvic arterial hemorrhage is highly successful. However, recurrent pelvic arterial hemorrhage does occur. We identified a subgroup of patients with pelvic fractures who are at increased risk of recurrent pelvic arterial hemorrhage and should be considered for early repeat angiography for signs of ongoing hemorrhage.

Anastomotic vessels in the retropubic region: corona mortis.

Anastomosis between the pubic rami of the inferior epigastric and the obturator arteries has been referred to as the corona mortis. Because anomalous vessels in the retropubic region are at risk in groin or pelvic surgeries, they have an importance not only for general surgery but also for orthopaedics. Because it is hard to distinguish these vessels, they can be injured during ilioinguinal incision, which can lead to massive uncontrolled bleeding. For this purpose, 54 cadaver halves were dissected to determine the occurrence and location of the corona mortis anastomosis. We found venous corona mortis in 11 halves (20.37%). Additionally, in 8 halves (14.81%), the obturator artery originated from the inferior epigastric artery.

[Obturator shunting in suppuration of vascular prostheses]. / Obturatornoe shuntirovanie pri nagnoenii sosudistykh protezov.

An experience with using obturatory shunts in 10 patients with suppurations of vascular prostheses after reconstructive operations on the aorto-iliac segment for its occlusive lesion is presented. The authors have come to a conclusion that extra-anatomical shunting through the closing inlet of the pelvis when combined with resection or removal of the infected vascular prosthesis, local and general antibacterial therapy is an effective method of treatment of the pathology in question. The modified method of shunting facilitates performing the operation in most critical patients. Good results were obtained in 7 of 10 patients operated upon. Two patients died. The amputation of the extremity was fulfilled in 1 patient.

Vascularized pedicled pubic graft. A topographical anatomical study in human cadavers.

The topographical anatomy and the vascular variety of the pubic arch was studied on ten fresh human cadavers (15 hemipelves). The idea was to obtain a pedicled vascularized bone graft to be used in the hip region and as an alternative to an iliac crest pedicled graft. The size of the possible graft and the length of the pedicle were measured and evaluated.

[The anatomic and radiologic picture of the acetabulum (author's transl)]. / Zum anatomischen und röntgenologischen Bild der Hüftpfanne

The basic shape of the facies lunata shows at the inner margin of each of the three participating bones a dell into which the floor of the acetabulum progresses. These dells originate in nutritive vessels which enter the bone and claim this place. There always are groups of vessels and wide channels which may be visible on radiographs. The so far unexplained picture of a vascular canal in the roof of the acetabulum corresponds to the canal leading into the body of the ilium. Due to its position there is often restructuring leading to filling or covering of the canal. The entrance to this canal is shown as a gap in the arc of the acetabular cavity which would have to be added to that of the "tear figure" known so far. The closed arc, as always drawn, reults only when this entry has been filled up.