Study of the course of inferior epigastric artery with reference to laparoscopic portal

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.

Total laparoscopic hysterectomy four-handed ergonomic technique: description of an original surgical procedure for the reduction of learning curve

The aim of this study was to propose the four-handed technique for total laparoscopic hysterectomy (TLH), with or without adnexectomy. From our point of view this is a more ergonomic, efficient, and effective technique that can contribute to the training of specialists in obstetrics/gynecology. In fact, teacher and learner have both an active role on the surgical field using two laparoscopic instruments each. They are alternately, mutually, and symmetrically first operator and assistant, reducing number of attempts needed for laparoscopic hysterectomy learning curve. The detailed description of all the surgical steps of TLH, "four-handed technique" (FHT), with or without adnexectomy, make sure that it can be effectively reproduced step by step safely, by transposing "FHT" surgical steps of laparotomic approach. This may allow easy access to anatomical spaces inserting trocars in different ways. By clearly knowing the steps of TLH, "FHT" it is possible to favor minimally invasive routes so that patients benefit from its multiple proven benefits. Operating this way, operative time, blood loss, use of analgesics and hospitalization can be significantly reduced. In conclusion benefits of TLH have already been widely demonstrated in literature. It is a real opportunity that young specialists become confident with this innovative "FHT," a procedure that allows them to be surgeon first assistant, and in which they can learn faster real intraoperative stereotaxis and surgical steps sequence, familiarizing with the anatomy of retroperitoneal space.

Salvage of a DIEP Flap after Injury to the Inferior Epigastric Vessels after Laparoscopic Surgery

The problem of previous laparoscopic scars specifically endangering the DIEP flap harvest for breast reconstruction has not been described yet. Even though in our center, preoperative imaging by means of an magnetic resonance angiography (MRA) is routinely performed before a bilateral DIEP-flap reconstruction, it may not correspond with the intraoperative findings. This case was presented to increase awareness among plastic surgeons about the complications after laparoscopic surgery and to emphasize the importance of thorough history taking when performing a DIEP flap breast reconstruction after previous laparoscopic procedures.

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.

Double direct hernia, triple indirect hernia, double Pantaloon hernia (Jammu, Kashmir and Ladakh Hernia) with anomalous inferior epigastric artey: Case report

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First kind of case report in literature.

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A unique case with double direct and triple indirect type of inguinal hernia.

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Named as Jammu Kashmir and Ladakh Hernia.

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Inferior epigastric artery may traverse an anomalous course in inguinal canal.

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Presence of multiple hernia sacs ,if undetected, is risk for recurrence.

Introduction

Double direct and triple indirect type hernia in unilateral inguinal hernia is unique. Anomaly of pathway traversed by inferior epigastric artery is always of surgical importance. Meticulous exploration of the groin is mandatory for diagnosis of rare hernia.

Case report

A 46 year old male presented with the right groin swelling. An inguinal hernia having two direct types separated by anamalous inferior epigastric artery and three indirect types of hernia were present. There was one bubonocele and two funicular types of indirect type of hernia present on the single cord. Anamalous inferior epigastric artery lying superficially at midpoint of inguinal canal was buttresed in the posterior wall to prevent its entrapping in mesh. Individual ligation of the indirect sacs and Lichtenstein repair was done.

This is first kind of unique case report with the new type of hernia reported in the English literature after searching Pubmed, Medline, Google Scholar and Embase database. This new hernia, Double Pantaloon hernia, as a mark of respect and unity, is named after its State of origin, “Jammu, Kashmir and Ladakh” so called as “Jammu Kashmir and Ladakh Hernia”.

Conclusion

Double direct and triple indirect type hernia in a unilateral inguinal hernia is unique. Presence of multiple hernia sacs in the inguinal hernia is a risk for recurrence, if not detected. Inferior epigastric artery in inguinal canal may traverse an aberrant course.

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.

Location of the Deep Epigastric Vessels in the Resting and Insufflated Abdomen

STUDY OBJECTIVE

To determine whether the location of the superior and inferior epigastric vessels (deep epigastric vessels) change with abdominal insufflation.

DESIGN

Descriptive study (Canadian Task Force classification III).

SETTING

Tertiary care academic institution.

PATIENTS

Patients undergoing gynecologic laparoscopic surgery were recruited. A total of 35 subjects were enrolled.

INTERVENTIONS

Subjects underwent color Doppler ultrasound assessment of deep epigastric vessel location preoperatively and intraoperatively following abdominal insufflation. The deep epigastric vessels were identified at 5 points along the abdomen (pubic symphysis, anterior superior iliac spine [ASIS], umbilicus, xiphoid, and midpoint from umbilicus to xiphoid), with the distance from vessels to midline measured. Paired t tests and split-plot analysis of variance were used as appropriate.

MEASUREMENTS AND MAIN RESULTS

The mean patient age was 45.6 ± 16.5 years, and mean BMI was 29.8 ± 7.2. A significant difference between vessel location in the resting abdomen and insufflated abdomen was noted bilaterally at the ASIS, umbilicus, and midpoint from the umbilicus to the xiphoid. At each of these points, the deep epigastric vessels were found more laterally after insufflation on average, ranging from 0.6 ± 0.9 cm (p < .001) more laterally at the midpoint between the umbilicus and xiphoid to 1.1 ± 0.8 cm (p < .001) more laterally at the umbilicus. The most lateral location of the deep vessels after insufflation was seen at the ASIS (10.6 cm) and the umbilicus (10.9 cm). In a subanalysis of subjects grouped by body mass index (obese vs nonobese), deep epigastric vessels were more lateral in the insufflated abdomen of obese subjects compared with that of nonobese subjects at the ASIS, umbilicus, and midpoint from umbilicus to xiphoid (p < .05 for each point bilaterally).

CONCLUSION

The deep epigastric vessels shift laterally with abdominal insufflation, and may be found as far as 10.9 cm from the midline; this is more lateral than previously described and is clinically significant. Obesity is associated with a more lateral location of the deep epigastric vessels.