A prospective endoscopic study of retropubic vascular anatomy in 121 patients undergoing endoscopic extraperitoneal inguinal hernioplasty

Vesico-obturator venous plexus - a rare termination of obturator vein

Obturator vein usually terminates into the internal iliac vein. Its variations are the cause major bleeding problems in pelvic surgeries. We observed a rare variation in the termination of the right obturator vein. There was a duplication of right obturator vein. Both obturator veins entered the pelvic cavity through the obturator foramen and joined with two vesical veins to form a vesico-obturator plexus. This plexus surrounded the internal iliac artery and terminated into the internal iliac vein. Awareness of this rare variation could be of importance to anatomists, radiologists, gynaecologists, urologists, and orthopaedic surgeons. The plexus might lead to hazardous bleeding in pelvic lymph node clearance procedures, hernia surgeries, gynaecological and orthopaedic procedures in this region. The pelvic fractures too can provoke dramatic retroperitoneal hematomas related to these veins injuries.

Corona mortis: clinical evaluation of prevalence, anatomy, and relevance in anterior approaches to the pelvis and acetabulum

PURPOSE

To evaluate the clinical prevalence, characteristics, and relevance of the corona mortis (CM) in anterior approaches to the pelvis and acetabulum.

METHODS

Retrospective analysis of 185 theater reports from patients (73 females; mean age 62.8 ± 17.2 years) who underwent surgeries for pelvic ring injuries, acetabular fractures, or combined injuries using anterior approaches (Modified Stoppa or Pararectus) at our institution between 01/2008 to 12/2022. During procedures, the CM was routinely identified, evaluated, and occluded. Bilateral exposure of the superior pubic branch in 25 cases led to 210 hemipelvises analyzed.

EXCLUSIONS

CM not mentioned in report and revisions via the initial approach.

RESULTS

In the 210 hemipelvises examined, the prevalence of any CM vessel was 81% (170/210). Venous anastomoses were found in 76% of hemipelvises (159/210), arterial in 22% (47/210). Sole venous anastomoses appeared in 59% (123/210), sole arterial in 5% (11/210). Both types coexisted in 17% (36/210), while 19% (40/210) had none. A single incidental CM injury occurred without significant bleeding. In ten cases, trauma had preoperatively ruptured the CM, but bleeding was readily managed. Females had a significantly higher CM prevalence than males (p = 0.001).

CONCLUSION

Our findings show a CM prevalence aligning more with anatomical studies than prior intraoperative series. Although we observed one incidental and ten trauma-related CM injuries, we did not encounter uncontrollable bleeding. Our data suggest that in anterior pelvic approaches, when the CM is actively identified and occluded, it is not associated with bleeding events, despite its high prevalence.

The Incidence and Variation of Corona Mortis in Multiracial Asian: An Insight from 82 Cadavers

Introduction

Corona Mortis (CMOR) is a term used to describe an anatomical vascular variant of retropubic anastomosis located posterior to superior pubic ramus. We aim to provide sufficient data on the incidence, morphology and mean location of 'crown of death' in Asian population. Other objectives include to assess the relationship between CMOR incidence with gender, race and age.

Materials and methods

This is a cross-sectional cadaveric study involving 164 randomly selected fresh multiracial Asian hemipelves (82 cadavers). Hemipelves were dissected to expose and evaluate the vascular elements posterior to superior pubic rami. Data were analysed using Chi-Square, t-test and with the help of IBM SPSS Statistics v26 software.

Results

CMOR was found in 117 hemipelves (71.3%). No new morphological subtype was found. The mean distance of CMOR to symphysis pubis was 54.72mm (SD 9.35). Based on the results, it is evident that precaution needed to be taken at least within 55mm from symphysis pubis during any surgical intervention. The lack of statistically significant correlation between CMOR occurrence and gender, race and age suggest that the incidence of CMOR could be sporadic in manner.

Conclusion

We conclude that CMOR is not just aberrant vessel as the incidence is high and this finding is comparable to other studies. The mean location of CMOR obtained in this study will guide surgeons from various disciplines in Asia to manage traumatic vascular injury and to perform a safe surgical procedure involving the pelvis area.

The anatomical variability of obturator vessels: Systematic review of literature

OBJECTIVE

To systematically assess available information about all variations of obturator vessels and to present the most surgically relevant types, their prevalence and calibre in order to provide a comprehensive overview for both anatomists and clinicians.

MATERIALS AND METHODS

A total of 2689 studies were found via searching the online databases. After applying exclusion criteria 44 studies were assessed. The cadaveric studies, CT angiographies, and clinical studies were included. Number of hemipelves, prevalence of each variation and calibre of identified vessels were studied. Each variation was classified as aberrant obturator artery/vein, aberrant accessory obturator artery/vein or anastomosis.

RESULTS

In included studies the average incidence of the variant obturator artery was 26% with the aberrant obturator artery being the most frequent type (with the mean calibre 2.10 mm, SD = 0.35 mm), while the overall incidence of the variant obturator vein was 55%. Presented venous structures had the mean calibre of 2.98 mm (SD = 0.56 mm).

CONCLUSIONS

According to reviewed studies, variant obturator vessels are present in a great number of patients. Due to their possible calibre larger than 3 mm they represent a structure of high clinical importance. It is important to unify the terminology and to stress out the significance to all clinicians.

Anatomical peculiarities of dissection in the transabdominal preperitoneal procedure for inguinal hernias

Inguinal hernia, a common surgical pathology, has substantial medical, social, and economic implications. Over time, various repair techniques have been explored to optimize outcomes, considering multiple postoperative factors beyond recurrence risk. This article aims to define anatomical and technical aspects impacting the immediate and late postoperative evolution of patients with inguinal hernia. Precise knowledge of anatomical structures and standardized surgical gestures result in the reduction of intraoperative and postoperative complications. Throughout history, the alloplastic procedure has demonstrated superiority over the anatomical approach, reinforcing the potential for ongoing advancements. Correct performance according to well-defined principles improves patients' quality of life after inguinal hernia surgery. These principles encompass the exact knowledge of anatomy, dissection steps, dissection limits, the sequence of dissection, and the prosthetic materials used. We describe our approach, with the laparoscopic method representing over 90% of cases at our clinic, indicating the shift towards minimally invasive techniques and emphasizing adherence to rigorous principles to achieve low perioperative complications.

Corona Mortise- anatomical variants and implications in pelvic-acetabular surgery: An evidence based review

Background

Corona Mortise is the name given to the anastomotic vessels forming a communication between external and internal iliac vascular systems. These channels have a high tendency to cause uncontrollable bleeding if injured and are particularly at risk during the anterior approach to acetabulum. While previous studies have described them as arterial or venous connections or both, there is still a lack of consensus regarding exact nature and location of these vessels, which make their timely identification all the more challenging.

Objective

The present review is aimed at performing a comprehensive review of existing literature and discuss the anatomy and implications of correct identification of Corona Mortise in pelvic-acetabular surgery.

Conclusion

Corona Mortise is more commonly venous than arterial. This not only makes haemorrhage control more challenging but also precludes the use of pre-operative angiography. However, most authors do not recommend a change in surgical approach for fear of damaging these vessels.

Morphodynamic study of the corona mortis using the SimLife® technology

PURPOSE

Open book pelvic ring fractures are potentially life-threatening, due to their instability and major hemorrhage risk. During the open reduction and internal fixation, the pelvic approach remains a technical challenge, as the surgeon wants to prevent any iatrogenic damage of the vascular loop located in the retro-pubic area called corona mortis (CMOR). Recently, the cadaver perfused SimLife^® technology has been developed to improve the surgeon training, out of the operating room. This study aimed to compare two models of cadaveric dissection, to assess the interest of the perfused SimLife^® in providing dynamic aspect of anatomy in the identification of CMOR and its topography.

METHODS

Twelve human cadaveric pelvises have been dissected, following two protocols. 12 hemi-pelvises of the dissections were performed without perfusion (Model A), whereas the 12 other hemi-pelvises have been prepared with the SimLife^® pulsatile perfusion (Model B). The prevalence and morphologic parameters determined: length, diameter and distance between the CMOR and the pubic symphysis.

RESULTS

The CMOR has been found in 66.67% of the cases. The length, the diameter, and the distance between the CMOR and the pubic symphysis were significantly higher in model B (respectively p = 0.029, p = 0.01, and p = 0.022).

CONCLUSION

These results suggest that the CMOR is easier to identify and to dissect with the SimLife^® perfusion. As part of the surgical training of any trauma surgeon, this model could help him to keep in mind the CMOR topography, to improve the open book lesion management.

A new approach to enter Retzius space in laparoscopic transabdominal preperitoneal bilateral inguinal hernia repair

BACKGROUND

To investigate the feasibility, safety and efficacy of the right-side approach to enter Retzius space in laparoscopic transabdominal preperitoneal bilateral inguinal hernia repair.

METHODS

Retrospective analysis was performed on 189 patients who were diagnosed with bilateral inguinal hernia preoperatively or intraoperatively and underwent selective TAPP in the General Surgery I Section of Shaanxi Provincial People's Hospital from January 2015 to September 2020. 94 cases were performed using the right-side approach (research group), and 95 cases with conventional approach (control group). Intraoperative and postoperative conditions of the two groups were observed and compared.

RESULTS

All operation were completed successfully. The operative time of research group was significantly shorter than that of control group (128.8 ± 35.4 vs 144.1 ± 40.9 min, P = 0.006). There were no significant differences in postoperative hospital stay, VAS score on first postoperative day, incidence of seroma and hematoma, urinary retention and other complications (P > 0.05). None of the patients occured hernia recurrence, mesh infection, intestinal obstruction and other complications.

CONCLUSIONS

The right-side approach to enter Retzius space is safe and feasible in TAPP surgery of bilateral inguinal hernia. Compared with the conventional approach, it can shorten the operative time and has certain advantages.

The Corona mortis is similar in size to the regular obturator artery, but is highly variable at the level of origin: an anatomical study

An enlarged anastomosis connecting the vascular territory of the external iliac and the obturator artery may replace most or all of the latter. This relatively common vascular variation, known as Corona mortis, can lead to death in the worst-case scenario if injured. Despite being well-known, exact anthropometric data are lacking. The purpose of this study was to determine diameters of the regular obturator artery, the Corona mortis and the inferior epigastric artery. In addition, the level of origin of the Corona mortis was quantified. The obturator artery and its norm variants were dissected bilaterally in 75 specimens (37 females, 38 males) and measured using two different methods. The Corona mortis was present in 36 of the 150 hemipelves (24%), presenting in one third of all cases bilaterally. Its level of origin measured from the commencement of the inferior epigastric artery was subject to high variability (4.4-28.3 mm). The mean diameters of the Corona mortis (mean 2.5 and 2.1 mm, respectively) and the regular obturator artery (mean 2.4 and 2.0 mm, respectively) were similar for both methods. There were no significant sex nor side differences. The diameter of the inferior epigastric artery was significantly smaller distal to the origin of the Corona mortis. The high incidence, non-predictable level of origin of the Corona mortis and its size similar to the regular obturator artery support its clinical relevance even to date. Clinicians should always be aware of an additional arterial vessel close to the pelvic brim.

A Bipartite Obturator Artery with Multiple Pelvic Branching-A Gynecologic Approach

BACKGROUND

The obturator artery (OA) often presents multiple anatomical variations. These can be an atypical origin, variable anastomosis, or abnormal course within the pelvis.

METHODS

This study aimed to report a rare arterial variation in a Puerto Rican female cadaver that showed two abnormal obturator arteries with multiple pelvic branches. The OA emerged from the anterior branch of the internal iliac artery, which typically runs anteroinferior along the lateral wall of the pelvis to the upper part of the obturator foramen.

RESULTS

The atypical OA described in this report provided two variant branches. Abnormal obturator artery I (AOAI) emerged first and gave rise to three additional branches, while abnormal obturator artery II (AOAII) emerged second and gave rise to two other branches.

CONCLUSIONS

Identifying these accessory arteries is essential for surgical interventions, particularly within the field of gynecology and urogynecology. Knowledge regarding anatomical variations within this region must be assessed preoperatively to decrease the risk of iatrogenic injury.

Clinical importance of variability in the branching pattern of the internal iliac artery - An updated and comprehensive review with a new classification proposal

The main aim of this study is to present, describe and compare the most significant anatomical classifications of the internal iliac artery (IIA) and its branches, their pros and cons, to relate them to clinical practice and note their clinical importance, and to offer a new classification based on number of main vessels origins. Many classifications covering the detailed morphology of the IIA have been developed, focusing on the destination of vessels making it possible to determine the name and type of branching precisely. However, because the allocation criteria are overdetailed and of doubtful accuracy, these classifications have become impractical for clinical practice and advanced statistical calculations. The argument of this research paper is that highly variable vascularized regions should be classified from either an anatomical point of view to determine detailed morphology aspects or a clinical perspective. Presented classification proposes unification of many branching types presented among various classifications, which look identical when determining the origin pattern from the main vessel and differ only in the destination point of the vessel, what brings clarity and increases the statistical usefulness of the collected data. This should translate into better cooperation between scientists and clinicians and thus benefit patients. The paper proposes a new, clinically useful classification based on the model of vessel origins from the main stem. The IIA is the main vascular supply to the pelvic region, so precise knowledge of origin and its branching pattern is essential for all clinicians, especially for general and orthopaedic surgeons, gynecologists, obstetricians and urologists.

Corona Mortis: A Systematic Review of Literature

Our systematic review evaluates surgically relevant information about corona mortis (CM), such as anatomical structure, size, laterality, incidence, and anthropometric correlations. This study aimed to provide data about anastomosis in an attempt to avoid iatrogenic damage during surgery. Articles were searched online using the descriptor "Corona Mortis" in PubMed, Biblioteca Virtual em Saúde (BVS) (Literatura Latino-Americana e do Caribe em Saúde [LILACS], MEDLINE, indice bibliografico espaãol en ciencias de la salud [IBECS]), and SciELO database. The time range was set between 1995 and 2020. The articles were selected according to their titles and later the abstracts' relation to our research purpose. All the selected articles were read entirely. A manual search based of the references cited in these articles was also conducted to identify other articles or books of interest. Forty references fulfilled the criteria for this review. The mean incidence of CM was 63% (the majority venous) among 3,107 hemipelvises. The incidence of bilateral CM was lower than that of unilateral variations based on the analysis of 831 pelvises. The mean caliber of the anastomosis was 2.8 mm among 1,608 hemipelvises. There is no consensus concerning the anthropometric influences in CM. Finally, we concluded that CM is not an unusual anatomical variation and that we must not underestimate the risk of encountering the anastomosis during surgery. Anatomical knowledge of CM is, therefore, essential in preventing accidents for surgeons who approach the inguinal and retropubic regions.

Frequency and Clinical Review of the Aberrant Obturator Artery: A Cadaveric Study

The occurrence of an aberrant obturator artery is common in human anatomy. Detailed knowledge of this anatomical variation is important for the outcome of pelvic and groin surgeries requiring appropriate ligation. Familiarity with the occurrence of an aberrant obturator artery is equally important for instructors teaching pelvic anatomy to students. Case studies highlighting this vascular variation provide anatomical instructors and surgeons with accurate information on how to identify such variants and their prevalence. Seven out of eighteen individuals studied (38.9%) exhibited an aberrant obturator artery, with two of those individuals presenting with bilateral aberrant obturator arteries (11.1%). Six of these individuals had an aberrant obturator artery that originated from the deep inferior epigastric artery (33.3%). One individual had an aberrant obturator artery that originated directly from the external iliac artery (5.6%).

The Anatomical Characteristics of Corona Mortis: A Systematic Review of the Literature and Its Clinical Importance in Hernia Repair

Background

Inguinal hernia repair is one of the most common daily operations in general surgery. However, the anatomical structures of the region, such as the corona mortis (the crown of death), make this procedure quite challenging. A comprehensive knowledge of its anatomy is essential, since massive hemorrhage may occur if the vessel is injured. The current review of the literature aimed to report the frequency and anatomical variations of vascular corona mortis.

Methods

A substantial study was coordinated through PubMed, Scopus and Google Scholar. The Prisma guidelines were used for the systematic review of the articles found. A total of 13 studies and 1,455 patients were included for the statistical analysis.

Results

The results showed that corona mortis was present in about half the hemi-pelvises, and to be more accurate, the prevalence was 46%. Venous corona mortis was more frequent than the arterial type (42% vs. 25%).

Conclusions

Considering the percentages mentioned above, every surgeon who schedules an operation on the retro-pubic area, especially during a hernioplasty procedure, should evaluate the possibility of the presence of corona mortis. Anatomical knowledge of the region is vital for attempting to eliminate the risk of injuring the corona mortis during surgery.

The Majority of Corona Mortis Are Small Calibre Venous Blood Vessels: A Cadaveric Study of North Indians

Purpose

Corona mortis is an abnormal arterial or venous anastomosis between the external iliac and the obturator system of vessels and may cause significant hemorrhage during pelvi-acetabular fracture surgeries, hernia repair and laparoscopic gynecological procedures. Previous studies have estimated a prevalence of corona mortis between 34% and 70%. This cadaveric study was conducted to estimate the prevalence of corona mortis in the North Indian population.

Materials and Methods

Twelve cadavers (24 hemipelvises; 11 males and 1 female) with a mean age of 68 (range, 54–82) years were included in this study.

Results

Corona mortis was observed in 14 hemipelvises (58.3%). A total of 19 (79.2%) vascular anastomoses of diameter greater than 1 mm were observed; 5 hemipelvises (20.8%) had corona mortis on the right side, 9 hemipelvises (37.5%) on the left side and bilateral in 5 (41.7%) cases. Two hemipelvises (8.3%) had an arterial connection. An aberrant obturator artery was observed in 1 (4.2%) hemipelvis. A venous connection was found in 14 specimens (58.3% of hemipelvises). The average distance of the connecting vein from the symphysis pubis was 41 (35–70) mm. A vessel diameter of greater than 4 mm was observed in 4/24 (16.7%) of hemipelvises.

Conclusion

The frequency of venous corona mortis was higher than arterial corona mortis and the majority (83.3%) were small calibre (<4 mm). The presentation pattern and the number of arterial or venous anastomoses were different in the majority of hemipelvises and dissimilar in both hemipelvises of the same cadaver in the majority of cases.

Study on Variations in the Origin and Branching Pattern of Internal Iliac Artery in Cadavers

The variations in blood vessels are common and have long received the attention of anatomists and surgeons. The true pelvic cavity usually refers to that part of pelvis, which has its bony walls, the sacrum and lower part of hip bone. This small area is well covered by bones and has important structures namely the pelvic viscera, pelvic floor muscles, vessels and nerves supplying it. The aim of the study was to know the branching pattern of internal iliac artery based on the Adachis classification, along with length and thickness of artery. The internal iliac artery was traced from its origin, course, branching pattern, length and thickness of the trunk of internal iliac artery was measured by using digital vernier calliper from its point of origin to bifurcation into anterior and posterior division. The length of right & left internal iliac artery ranged from 2.4 cm to 5.4 cm with average length of 3.943cm ± 0.859cm, whereas the length of left internal iliac artery ranged from 2.7cm to 4.7cm with average length of 3.610cm ± 0.626cm. Bilateral ligation of internal iliac artery is helpful in controlling postpartum haemorrhage. Applying ligatures on an anomalous blood vessel may lead to alarming haemorrhage. The most ideal point of ligation of internal iliac artery would be distal to its posterior division, since proximal ligation has been associated with buttock claudication and necrosis. Knowledge regarding the internal iliac artery and its branches is helpful in applying ligatures safely during pelvic surgeries.

Essentials of surgical anatomy and technique in TAPP repair of inguinal hernia

Laparoscopic hernia repair has opened a new era in hernia surgery shifting paradigms from anterior to posterior approaches. This has exposed surgeons to new anatomical perspectives, technical challenges and clinical implications all of which preventing the technique from becoming ubiquitous despite numerous advantages, limited contraindications and low recurrence rates. In order to address the difficult learning curve of the laparoscopic transabdominal preperitoneal hernia repair this paper presents the experience and points of view from a tertiary surgical department on the systematization of anatomical concepts pertinent to the TAPP repair technique, a decalogue of suggestions related to the surgical technique and a short reminder of the most common complications and how to avoid them. Revising the anatomy essentials and proposing a decalogue of the surgical technique and a memento on the most common complications will provide young surgeons with a scaffold of basic knowledge on TAPP hernia repair.

Corona Mortis: anatomical and surgical description on 60 cadaveric hemipelvises

OBJECTIVE

to report the prevalence of arterial corona mortis and to describe its surgical and clinical applicabilities.

METHODS

We dissected 60 hemipelvises (50 men and 10 women) fixed in a 10% formalin solution for the purpose of gathering information on corona mortis. We measured the caliber and length of the obturator artery and its anastomotic branch with the aid of a digital caliper and submitted the data to statistical analyzes and comparisons with the GraphPad Prism 6 software.

RESULTS

arterial corona mortis was present in 45% of the studied sample. The most common origin of the obturator artery was the internal iliac artery; however, there was one exceptional case in which it originated from the femoral artery. The caliber of the anastomotic branch was on average 2.7mm, whereas the caliber of the obturator artery was 2.6mm.

CONCLUSION

the vascular connections between the obturator, internal iliac, external iliac and inferior epigastric arterial systems are relatively common over the upper pubic branch. The diameter and a trajectory of the anastomotic artery may vary. Thus, iatrogenic lesions and pelvic and acetabular fractures can result in severe bleeding that puts the patient's life at risk.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Life-threatening hemorrhage from the corona mortis treated with balloon-assisted coiling technique

Isolated pubic ramus fractures are common and generally uncomplicated injuries in the elderly. However, pubic ramus fractures are closely related to important vascular structures. The corona mortis, located in the retropubis, has an important anastomotic value, as it serves as a communication between the internal and external iliac vessels. The following case report describes an 88-year-old male who was diagnosed with a right superior pubic ramus fracture, which led to a severe picture of hemodynamic instability. Emergent angiography demonstrated injury of the corona mortis. After super-selective embolization of the corona mortis artery with a balloon-assisted coiling technique, the patient progressed satisfactorily and was discharged after 7days.

A new concept and classification of corona mortis and its clinical significance

PURPOSE

The obturator artery and its accessory (aberrant) arising from different origins and crossing the pubic rami are vascular variations. The internal iliac artery usually provides the obturator artery which may communicates with the external iliac artery through either the accessory obturator or inferior epigastric artery. A collateral circulation between the external and internal iliac system is known as corona mortis. The aim of current study is to provide sufficient data of vascular variability crossing the pubic rami for clinical field.

METHODS

Present study includes 208 hemipelvises dissected in the Institution of Anatomy, Medical University of Graz. During dissection, the obturator artery and its accessory crossing the superior rami of pubic bone were found to have different origins.

RESULTS

The obturator artery arising from the external iliac artery and from the femoral artery accounts for 9.8% and 1.1% respectively. Therefore, it passes over the superior pubic rami in 10.9%. Further, the accessory (aberrant) artery arises only from the femoral artery in 1.1%. In present study, the vascular variation crossing the superior pubic rami with or without collateral circulation between external and internal iliac system referred as corona mortis is addressed. This study includes new classification of obturator and accessory obturator arteries as well as the corona mortis. It includes a comparison of corona mortis incidence in Austria population and other populations. The corona mortis found to be in 12% of Austrian population.

CONCLUSION

A great attention of clinicians, radiologists, surgeons, orthopedic surgeons, obstetricians and gynecologists has to be considered before pubic surgical procedures such as internal fixation of pubic fracture, an inguinal hernia repair. Further, traumatic pubic rami fracture may lead to massive hemor- rhage due to laceration of the obturator artery.

Variation in the Obturator Vasculature During Routine Anatomy Dissection of a Cadaver

The obturator artery normally originates from the internal iliac artery while the obturator vein drains into the internal iliac vein. During a routine gross anatomy dissection class for undergraduate students at the All India Institute of Medical Sciences, New Delhi, India, in 2016, a rare unilateral variation in the obturator vasculature was found in a female cadaver of approximately 55 years of age. In this case, the left obturator artery originated from the superior gluteal artery and the left obturator vein drained into the external iliac vein. Knowledge of such variations is necessary during hernia procedures, ligation of the internal iliac artery and muscle graft surgeries.

Low Pressure is Necessary to View and to Protect Corona Mortis During Totally Extraperitoneal Hernia Repair

BACKGROUND

The identification of retropubic vasculature is not easy under the pressure of insufflated gas during totally extraperitoneal (TEP) inguinal hernioplasty. We aimed to present the usefulness of a maneuver that allows the clear identification of retropubic vasculature.

METHODS

Vascular anatomy on the retropubic surface in 364 patients who underwent the TEP procedure from January 2005 to September 2015 was evaluated. In patients after July 2014, the pressure in the workspace was decreased from 14 to 8 mmHg before fixation of the mesh to clearly identify the veins. The results before and after July 2014 were compared.

RESULTS

Demographic features were not significantly different between two periods. The number of hemipelvises in the first and second periods was 398 and 77, respectively. The rate of identification of venous corona mortis was 31% in the second period, whereas it was 1.0% in the first period (P = .000). The identification of thick (5.5% versus 10.3%; P = .123) and thin (22.8% versus 36.3%; P = .014) arterial structures and their sum were increased in the second period (28.4% versus 46.7%; P = .002). The rate of retropubic bleeding was zero in the second period, while it was 1.5% in the first period.

CONCLUSIONS

During TEP hernioplasty, the pressure of insufflated gas more than 10 mmHg in the preperitoneal space hinders the correct identification of vessels on the retropubic surface. The proposed maneuver, to decrease the pressure in the workspace to 8 mmHg, can provide clear identification of all vessels, which decreases the potential risk of vascular injury.

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.

Corona mortis: in vivo anatomical knowledge and the risk of injury in totally extraperitoneal inguinal hernia repair

PURPOSE

Corona mortis (CMOR) is the arterial and/or venous vascular communication(s) between the obturator and external iliac vessels. Totally extraperitoneal (TEP) inguinal hernioplasty can be associated with vascular complications especially during the fixation of the mesh. Theoretically, CMOR is an important nominee. But, the data in literature are insufficient about CMOR injury. Additionally, most of the studies about CMOR have been usually performed on cadavers. We aimed to reveal the preperitoneal vascular anatomy of inguinal area and provide in vivo knowledge about CMOR. The risk of arterial injury was also evaluated.

MATERIALS

The data of preperitoneal vascular anatomy of 321 patients who underwent TEP procedure between January 2005 and July 2014 were retrospectively evaluated.

RESULTS

Mean age was 46 ± 8.9 years, 53 females vs 268 males. 391 hemipelvises were evaluated. Two types of arterial structure were identified; (1) an aberrant obturator artery forming an anastomosis with branches of ordinary obturator artery; (2) a pubic branch of inferior epigastric artery. The incidence of arterial CMOR was 28.4 % and of any arterial structure was 45.0 %. An arterial CMOR was considered as thick (≥2 mm) or thin (<2 mm). Injury of arterial CMOR during tack stapling on Cooper's ligament was seen in six cases (1.5 %). All of them were thin (<2 mm) in structure. Venous CMOR was visible only under low pressure in work space.

CONCLUSION

During TEP hernia repair, CMOR and/or pubic branch of inferior epigastric artery can be damaged. To prevent this complication, tacks should be stapled to Cooper's ligament close to symphysis pubis and dissection should be careful on the posterior surface of superior pubic ramus. Small caliber (<2 mm) arterial CMOR is more prone to be injured during TEP procedure. To explore venous structures properly, pressure in workspace should be kept as low as possible.

A Study of Variations in the Origin of Obturator Artery and its Clinical Significance

INTRODUCTION

The large number of organs and anatomical structures within the cramped pelvic cavity makes the study of vascular pattern and their variations of much importance in this particular anatomical region. Clear awareness of the vascular anatomy of pelvis is critical in surgeries performed here, which require ligation of the arteries concerned and also because such anomalous origins may cause profuse bleeding during surgical procedures. This is particularly true with regard to the variations in the origin of the obturator artery, while performing pelvic and groin surgeries.

AIM

The aim of the present study was to find out the prevalence of normal and aberrant origins of obturator artery and to describe its surgical implications.

MATERIALS AND METHODS

The study was carried out on fifty hemipelvises of embalmed cadavers and the origin and course of the arteries were traced and noted.

RESULTS

Of the 50 pelvic halves, in 27 specimens, the obturator took origin from the anterior division of internal iliac artery. Remaining 23 specimens showed variations. The origin of the obturator artery was from the inferior epigastric artery in 11 cases, from the common stem of the internal iliac artery and the external iliac artery in 2 cases each, from the posterior trunk of the internal iliac artery in 5 and one each from superior gluteal, inferior gluteal, and internal pudendal artery.

CONCLUSION

The present study indicates that the origin of the obturator artery is highly variable. It can take origin from the stem of the internal iliac artery or from its anterior or posterior division, or from one of the branches of the divisions. It can also take origin from external iliac artery or its inferior epigastric branch. Advancements in diagnostic and surgical techniques in obstetric procedures and urogenital interventions make it essential to have a clear-cut understanding of the vasculature in the abdomen and pelvis.

Incarcerated obturator hernia-laparoscopic repair with intraoperative view of the corona mortis

Obturator hernias are a rare form of abdominal wall hernias. We present a case of a patient with an obturator hernia diagnosed by the classical signs of lower abdominal pain, a positive Howship–Romberg sign (painful internal rotation of the hip) and a computed tomography scan showing a herniated loop of small bowel. During the emergency laparoscopic hernia repair (transabdominal preperitoneal approach) a variant vessel, the corona mortis, was detected.

Corona mortis: anatomical data and clinical considerations

BACKGROUND

Minimally invasive procedures, such as the TVT-Secur™, have been linked to injury to the corona mortis. Injury during the insertion of the TVT-Secur™ happens due to the vessel's position close to the place of the margin (25-30 mm from the symphysis pubis).

AIMS

Systematic description of the aberrant vessel anatomy so as to help gynaecologists determine the risk of peri- and postoperative complications during the TVT-Secur™ and related procedures.

METHODS

In a cadaver study, the lesser pelvis of ten female cadavers with venous or arterial coronae mortis was dissected. The origin, diameter and course of the aberrant vessels, as well as the distance from the symphysis pubis, were documented.

RESULTS

Arterial coronae mortis were found in eight hemipelvises. All vessels originated from the ipsilateral inferior epigastric artery and all crossed over the superior pubic rami. Average distance from the symphysis pubis was 52.4 mm. Average vessel diameter was 3 mm. Venous coronae mortis were identified in ten hemipelvises. Eight drained into the external iliac and four into the inferior epigastric artery. Nine vessels crossed over the superior pubic rami. Average distance from the symphysis pubis was 46.7 mm. Average vessel diameter was 3.13 mm.

CONCLUSION

Although individual variation makes direct contact with the vessel possible, in most cases there is a window of eight millimetres at least between the margin of the TVT-Secur™ and most aberrant veins. Possible aberrant arteries seem to lie even further.

Obturator artery revisited

INTRODUCTION AND HYPOTHESIS

The aim of this work is to analyse the variability of the obturator artery (oa), unify previous criteria and propose a simple classification for clinical use.

METHODS

A sample of 119 adult human embalmed cadavers was used. Origin and course of the oa in relation with the external iliac artery, internal iliac artery and inferior epigastric artery were studied. Chi-squared and t test were used for statistical comparison, and p < 0.05 was considered significant.

RESULTS

Based on the number of roots of origin, three different situations were observed. The oa shows a single origin (96.55%). The oa presents a double origin (3.02%), or the oa arises from three roots (0.43%). The first situation was subclassified into six types according to the oa origin. Equal vascular pattern in both hemi-pelvises was observed in 58.93%.

CONCLUSIONS

Almost 31% of oa passes over the superior pubic ramus implying an increased risk during some procedures.

Variability in the origin of the obturator artery

INTRODUCTION

General surgeons dealing with laparoscopic herniorrhaphy should be aware of the aberrant obturator artery that crosses the superior pubic ramus and is susceptible to injuries during dissection of the Bogros space and mesh stapling onto Cooper's ligament. The obturator artery is usually described as a branch of the anterior division of the internal iliac artery, although variations have been reported.

MATERIALS AND METHODS

The present study was conducted on 98 pelvic halves of embalmed cadavers, and the origin and course of the obturator artery were traced and noted.

RESULTS

In 79% of the specimens, the obturator artery was a branch of the internal iliac artery. It branched off at different levels either from the anterior division or posterior division, individually or with other named branches. In 19% of the cases, the obturator artery branched off from the external iliac artery as a separate branch or with the inferior epigastric artery. However, in the remaining 2% of the specimens, both the internal and the external iliac arteries branched to form an anastomotic structure within the pelvic cavity.

CONCLUSION

The data obtained in this study show that it is more common to find an abnormal obturator artery than was reported previously, and this observation has implications for pelvic surgeons and is of academic interest to anatomists. Surgeons dealing with direct, indirect, femoral, or obturator hernias need to be aware of these variations and their close proximity to the femoral ring.

Corona mortis: An anatomical study with clinical implications in approaches to the pelvis and acetabulum

The "corona mortis" is an anatomical variant, an anastomosis between the obturator and the external iliac or inferior epigastric arteries or veins. It is located behind the superior pubic ramus at a variable distance from the symphysis pubis (range 40-96 mm). The name "corona mortis" or crown of death testifies to the importance of this feature, as significant hemorrhage may occur if accidentally cut and it is difficult to achieve subsequent hemostasis. It constitutes a hazard for orthopedic surgeons especially in the anterior approach to the acetabulum. We carried out forty cadaver dissections (80 hemi-pelvises) through the ilioinguinal approach. A vascular anastomosis was found in 83% of specimens. Of these, 60% had a large diameter (>3 mm) channel along the posterior aspect of the superior pubic ramus. In clinical practice, however, 492 anterior approaches (to the best of our knowledge the largest series described) have been carried out over the last 15 years by the senior author (MB) and only five of these problematic vessels were discovered, and in only two cases was there troublesome bleeding. This study confirms a paradox: in anatomical dissections a large vessel was identified behind the superior pubic ramus, whereas in clinical practice this vessel does not seem to be as great a threat as initially perceived. Orthopedic surgeons planning an anterior approach to the acetabulum, such as the ilioinguinal or the intrapelvic approach (modified Stoppa), have to be cautious when dissecting near the superior pubic ramus. Despite the high prevalence of these large retropubic vessels in the dissecting room, surgeons should exercise caution but not alter their surgical approach for fear of excessive hemorrhage.

Anatomical pitfalls in the technique for total extra peritoneal laparoscopic repair for inguinal hernias

PURPOSE

The totally extraperitoneal laparoscopic approach for the treatment of inguinal hernia is a well-recognized technique with proven efficacy, low failure rate, and reduced post-operative pain. This laparoscopic technique is reputed to be a more difficult procedure to learn and practice than a laparoscopic trans-abdomino-pre-peritoneal procedure: we hope this is because many surgeons don't well know extra-peritoneal anatomy of groin. So we proposed a "step by step" anatomical analysis, with pitfalls to avoid, of a totally extraperitoneal laparoscopic approach for treatment of inguinal hernia.

METHODS

Our experience with totally extraperitoneal laparoscopic inguinal hernia repair with regard to the morphology of the inguinal-femoral region concerns 23 cadaver dissection and more than 400 surgical procedures, now permits clarification of a surgical technique that has hitherto not been well known.

CONCLUSION

Photographic representations of surgical views are displayed, and detailed descriptions applicable to anatomical structures are presented.