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

A study of the incidence of the corona mortis within a South African patient sample using computerized tomographic angiography

INTRODUCTION

Retropubic hematomas are a common development in cases of pelvic ring trauma and post- operative repair of fractures to the anterior column of the pelvis. Early detection and diagnosis of such events using computed tomography angiography (CTA) are critical for successful intervention and patient recovery, especially when bleeding is a result of injury to the corona mortis (CM). The CM is the communication between the obturator vessels and the external iliac vessels typically via an accessory obturator vessel. This communication of vessels is identified as a major hindrance in anterior approaches to the pelvis.

MATERIALS AND METHODS

This study investigated the incidence of CM and mapped out safe zones for the anastomosis in a South African sample using 73 adult angiograms from the Department of Diagnostic Radiology, Universitas Academic Hospital. After careful observation of the iliac system, the incidence of CM was documented. The distance from the CM to clinically relevant bony landmarks were recorded to formulate safe zones.

RESULTS

The incidence of CM was observed in 33.1 % of the sample, with 20 % being venous and 13.1 % being arterial anastomoses. Statistically significant differences between the sexes were noted for safe zones between all landmarks except for the pubic tubercle (p ≥ 0.26). The safe zone between the CM and the pubic tubercle were documented as 46.88 mm and the average diameter for all anastomotic vessels was noted as 2.83 mm (Range: 1.75 - 4.61 mm).

CONCLUSION

The inconsistencies presented in angiogram studies compared to cadaver studies suggest that angiograms should be limited to a diagnostic and therapeutic role of identifying the CM or injury thereof in the retropubic region. However, measurements concerning safe zones should rather be extracted from cadaveric studies.

Encountering the corona mortis vessel during laparoscopic totally extraperitoneal mesh hernioplasty and its significance

Corona mortis (CM) is an anastomotic vessel between the inferior epigastric or external iliac vessels and the obturator or internal iliac vessels. The Latin meaning of it is 'crown of death' which corresponds to massive haemorrhage caused by injury to this vessel during surgery. The incidence of this vessel is around 50% in the hemipelvis. We are presenting an intraoperative video of a right laparoscopic totally extraperitoneal mesh hernioplasty demonstrating a CM artery in the right hemipelvis. Care was taken to prevent injury to this vessel. CO2 insufflation pressure was reduced to less than 10 mm Hg to see any venous variant of this vessel. Carefully, polypropylene mesh was placed without a fixation device. Anatomical knowledge of the CM vessel is therefore essential in preventing injury for surgeons who approach the inguinal and retropubic regions.

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.

Imaging and endovascular management of traumatic pelvic fractures with vascular injuries

This paper will give an overview of the relevant anatomy, management and imaging, aspects as well as therapeutic aspects of traumatic pelvic fractures with vascular injuries.