Inferior epigastric artery: Surface anatomy, prevention and management of injury

Anatomical characteristics of the inferior epigastric artery in Uygur and it's implication in the management of bleeding

OBJECTIVES

This study aimed to determine the locations of the inferior epigastric arteries in a group of Uygur by ultrasound and explore the anatomical characteristics of vessels in the management of inferior epigastric bleeding.

METHODS

The study included 61 patients. The locations of inferior epigastric arteries through ultrasound were determined at three levels, and the distance from the midline was correlated with patients' demographics by Pearson correlation coefficient.

RESULTS

This study included 52 males and nine females, with a mean age of 37.56 years (± SD 3.16) and a mean BMI of 24.34 kg/m2 (± SD 3.71). At the symphysis pubis level, the average distance from the inferior epigastric artery to the midline was 5.98 ± 0.13 cm on the right and 7.32 ± 0.15 cm on the left. At the anterior superior iliac spine level, the average distance of the inferior epigastric artery on the right was 4.12 ± 0.15 cm and 5.2 ± 0.15 cm on the left. The inferior epigastric arteries were 3.86 ± 0.17 cm on the right and 5.06 ± 0.16 cm on the left of the midline at the level midway between the umbilicus and anterior superior iliac spine.

CONCLUSION

Inferior epigastric arteries were located between 3.5 and 8 cm from the midline, with the right vessel being closer to the midline than the left. The invasive operations through the abdominal wall should avoid these areas to reduce vascular injury. The anatomical characteristics of inferior epigastric arteries may potentially manage inferior epigastric bleeding.

A case of severe bleeding and deep inferior epigastric pseudoaneurysm after peritoneal dialysis catheter removal

We present an unusual but severe complication of peritoneal dialysis (PD) catheter removal resulting in significant haemorrhage and hospitalisation. A patient presented for PD catheter removal under local anaesthesia in the interventional radiology suite and was noted to have a heavily calcified deep Dacron cuff. This cuff was intimately associated with a deep inferior epigastric perforating (DIEP) vessel. Removal of the catheter resulted in shearing of DIEP vessel and pseudoaneurysm formation. Despite attempted surgical management with ligation haemorrhage continued, requiring urgent angiographic embolisation to stop the bleeding. Intimate relationship between DIEP vessel and Dacron cuff due to calcification was the cause of this complication. This case report represents a rare but important complication associated with PD catheter removal, highlighting that when calcification is seen at the deep cuff, caution should be exercised and there should be access to angiography suite in case of complication.

Extraperitoneal tissue retraction technique: An effective assistant of extraperitoneal pure single-port robotic-assisted radical prostatectomy with the da Vinci Si surgical system

Objective

The limitations of tissue retraction and the amount of surgical working space have a great impact on extraperitoneal single-port robotic-assisted radical prostatectomy (sp-RARP) with the multiport robotic surgical system. We used an extraperitoneal tissue retraction technique to achieve tissue exposure and working space expansion. This study evaluated the safety, feasibility, and efficacy of the extraperitoneal tissue retraction technique in extraperitoneal pure sp-RARP with the da Vinci Si surgical system.

Methods

Data from 42 patients were analyzed retrospectively from December 2018 to February 2020. The extraperitoneal tissue retraction technique was not used in 20 patients (group I) and was used in 22 patients (group II). Preoperative, intraoperative, and postoperative data were collected. The oncological and functional data during late follow-up were recorded.

Results

All patients successfully underwent extraperitoneal pure sp-RARP. No patients required conversion to a multiport surgery or placement of additional assistant ports. The two groups were similar regarding baseline features. The median operation time in group I was significantly longer than that in group II (P < 0.001). The estimated blood loss volume in group I was significantly higher than that in group II (P < 0.001). There were no serious complications in either group. There were four cases of peritoneal tears in group I and none in group II (P = 0.043). The surgical margin and lymph nodes were negative in both groups. The oncological and functional outcomes were similar between the two groups 6 months after the procedure.

Conclusions

The extraperitoneal tissue retraction technique is safe and feasible. The technique promotes tissue exposure and expands the surgical working space, which is important for achieving extraperitoneal pure sp-RARP with the da Vinci Si surgical system, especially for beginners. The short-term oncological and functional outcomes were within acceptable ranges. The long-term effects of this technique need further evaluation.

Inferior epigastric artery pseudoaneurysm following abdominal paracentesis in a patient with chronic kidney failure: A case report and review of literature

Inferior epigastric artery (IEA) pseudoaneurysm is a rare complication following abdominal wall procedures near the artery. This is a case of inferior epigastric artery pseudoaneurysm after therapeutic paracentesis for large-volume ascites caused by chronic kidney failure. The patient was operated on, and the artery was ligated.

Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review

Almost all gynecological and general-surgical operations are - or can be - performed laparoscopically. In comparison to an abdominal approach, the minimally invasive access offers several advantages; however, laparoscopy (both conventional and robotic-assisted) can be associated with a number of approach-specific complications. Although the majority of them are related to the laparoscopic entry, adverse events may also occur due to the presence of pneumoperitoneum or the use of laparoscopic instruments. Unfortunately, a high proportion of complications (especially affecting the bowel and ureter) remain unrecognized during surgery. This narrative review provides comprehensive up-to-date information about definitions, classifications, risk factors and incidence of surgical complications in conventional and robotic-assisted laparoscopy, with a special focus on gynecology. The topic is discussed from various perspectives, e.g. in the context of stage of surgery, injured organs, involved instruments, and in relation to malpractice claims.

Management of intraoperative complications during laparoscopic left colectomy

INTRODUCTION

Minimally invasive surgery has gained a major role in the current management of colorectal disease since the introduction of laparoscopy in the early 1990s for colorectal procedures. The laparoscopic approach, in fact, is not exempt from the risk of intraoperative complications, some of which can occur outside the field of view. Aim of this chapter is to review the different types of complications that can happen during left colectomy, analyzing the causes, how to prevent them and what to do in case they occur.

EVIDENCE ACQUISITION

A literature search was carried out using the MEDLINE and PubMed databases for studies published between January 1980 and October 2020. The following terms were used for the search: complications, risk factors, colorectal surgery, colorectal resection, laparoscopy, left colectomy, intraoperative complications, splenic injury, intraoperative bleeding.

EVIDENCE SYNTHESIS

From our literature search we identified twenty-four studies, including two systematic reviews and metanalyses, that were the most pertinent to the subject.

CONCLUSIONS

Many different complications can occur during laparoscopic left colectomy. Maintaining control of the situation is important to provide a prompt solution to the occurred injury. Increasing the reporting rate of complications may help, in the future, to analyze the causes and improve management strategies, keeping in mind that the only surgeon who does not have complications is the one who does not operate.

Rare Intraoperative and Postoperative Complications After Transabdominal Laparoscopic Hernia Repair: Results from the Multicenter Wall Hernia Group Registry

Background: Inguinal hernioplasty is the most frequently performed operation in the Western world today. Although the laparoscopic approach for inguinal hernia repair has shown excellent results in terms of complications and recurrences, the anterior approach is still the most used. Postoperative pain and recurrences are the most widely studied complications in both approaches, but there is little information about the often more troublesome rare complications of laparoscopic surgery and their treatment. Methods: In the period from January 1, 2014 to December 31, 2019, 1874 hernioplasty operations were performed with the transabdominal approach and recorded prospectively in the Wall Hernia Group database. The mean follow-up was 47 months (range 3-64 months). All less frequent complications were analyzed and a literature review was carried out to assess the presence of similar cases and their treatment in other series. Results: Eight cases of rare complications were identified and subdivided according to the Clavien-Dindo classification. They included a bowel perforation, 4 cases of bleeding, 2 bowel obstructions, and an injury to the motor branch of the obturator nerve. The postoperative course in these patients was significantly longer than in patients with a regular postoperative course. In 2 cases the complication occurred during the first admission, while the remaining 6 patients had to be readmitted within 30 days after discharge. Conclusions: Although serious postoperative complications in laparoscopic inguinal hernioplasty are rare, all surgeons, also those who have completed the learning curve, should be aware of their possible occurrence.

Inferior epigastric artery pseudoaneurysm secondary to port placement during a robot-assisted laparoscopic radical cystectomy

Pseudoaneurysm occurs when the artery wall is damaged and the blood is contained by the surrounding tissues with the eventual formation of a fibrous sac communicating with the artery. We report a case of a 74-year-old man with inferior epigastric artery (IEA) pseudoaneurysm secondary to an 8-mm port placement during a robot-assisted laparoscopic radical cystectomy with ureteroileocutaneostomy. The pseudoaneurysm was initially diagnosed by contrast-enhanced ultrasound (CEUS); subsequently, a computed tomography (CT) scan and an angiography test were performed. The pseudoaneurysm was then treated successfully with embolization of the inferior epigastric artery. Awareness of this rare complication is of clinical importance to avoid excessive morbidity of affected individuals.

The Utility of Sonographic Assessment in Selecting Patients for Percutaneous Insertion of Peritoneal Dialysis Catheter

Background

Percutaneous insertion of peritoneal dialysis (PD) catheters by nephrologists is a safe and effective alternative to open surgical techniques. These patients are usually carefully selected due to anatomical considerations and medical comorbidities, with the current literature suggesting exclusion of patients with prior abdominal surgery.

Method

We conducted a retrospective cohort study of pre-dialysis patients who attended a preprocedural clinic in a tertiary center over 6 years. Procedural complications and catheter survival were assessed. Chi-squared test and Kaplan-Meier survival analysis were undertaken. Inpatient assessments were excluded.

Results

A total of 217 patients were assessed, of whom 171 (78.8%) were accepted for percutaneous PD catheter insertion by a nephrologist. The key exclusion criteria were: ( 1 ) the clinical presence of abdominal hernia ( p < 0.001), ( 2 ) ultrasound findings of skin to peritoneum depth of > 5.5 cm ( p < 0.001) and ( 3 ) ultrasound findings of impaired visceral slide test ( p < 0.001). Prior abdominal surgery was not a default exclusion criterion ( p = 0.1), as 63 patients (37%) with prior abdominal surgery, average of 1.3 prior surgeries per patient, were assessed as appropriate for the percutaneous procedure. There was no difference in the procedural complication rate and catheter survival between patients with and without prior abdominal surgery.

Conclusion

A comprehensive preprocedural assessment utilizing ultrasound permits an objective selection of patients for percutaneous insertion of PD catheters by nephrologists. This allowed for successful and safe percutaneous insertion of PD catheters in patients who may have otherwise been excluded, e.g., prior abdominal surgery, patients with large bilateral poly-cystic kidneys, and central obesity.

Ex vivo radiocontrast description of the caudal epigastric arteries in horses

OBJECTIVE

To determine the location of the deep and superficial caudal epigastric arteries in relation to 3 midline positions and the relationship between the location of these arteries, body circumference, and body condition score.

STUDY DESIGN

Descriptive anatomical study.

SAMPLE POPULATION

Nine horses, aged 1-28 years (mean 10.61 ± 8.89 SD).

METHODS

Body condition score and body circumference were measured prior to euthanasia. Angiographic studies of the deep and superficial caudal epigastric arteries were performed on resected abdominal walls. The distances between the deep and the superficial caudal epigastric arteries and 3 midline positions were measured. Correlations among these distances, body circumference, and body condition score were analyzed.

RESULTS

The location of the deep caudal epigastric artery correlated with body circumference and body condition score at the umbilicus (r = 0.53 and 0.68, respectively), midpoint landmark (r = 0.79 and 0.83, respectively), and prepubic tendon attachment (r = 0.69 and 0.78, respectively). The course of this artery could be estimated by multiplying body circumference by 0.04 ± 0.02 at the umbilicus, 0.07 ± 0.01 at the midpoint landmark, and 0.03 ± 0.015 at the prepubic tendon attachment. The course of the superficial caudal epigastric artery did not correlate with anatomic landmarks.

CONCLUSION

The course of the deep caudal epigastric artery could be estimated at 3 midline landmarks on the basis of body circumference and body condition score in equine cadavers.

CLINICAL SIGNIFICANCE

Predicting the course of the caudal epigastric arteries in the equine abdomen based on correlation among location, body circumference, and body condition score may prevent iatrogenic damage during creation of laparoscopic portals.