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

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.

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.

Anatomy in the daily practice of the gynecologist, essential or just window dressing?

Traditionally, anatomy was one of the basic pillars of medical training. However, due to the expansion of medical science and medical knowledge in general, anatomy teaching has steadily declined and the way anatomy is taught has changed. These changes go hand in hand with growing literature about a perceived and proven lack of anatomical knowledge. While anatomy is important for all doctors, these developments seem to be more worrying for surgical residents. At the same time, little is known about how clinicians use anatomy in daily practice. The primary aim of this study was to increase understanding of the role of anatomy in the daily practice of gynecologists. An explorative qualitative study was performed to answer the question "What is the tangible utility of solid anatomical knowledge in the daily practice of the gynecologist"? Semi-structured interviews with gynecologists and obstetrics and gynecology (ObGyn) residents from Belgium and the Netherlands were held and the responses were analyzed using a phenomenographic inductive coding approach. Anatomical knowledge was important and used for technical skills and non-technical achievements in the daily practice of gynecologists, and three themes were distinguished. Specifically, anatomical knowledge was important and used (1) for daily activities, (2) for the feeling of self-efficacy, and (3) to gain a respected name as a doctor. These findings are discussed in light of (perceived) insufficient anatomical knowledge, and recommendations are made for the postgraduate education of ObGyn doctors.

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.

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.

Mesh-fixation technique for inguinal hernia repair: umbrella review

BACKGROUND

Mesh-based repair is the standard of surgical care for symptomatic inguinal hernias. Many systematic reviews and meta-analyses (SRMAs) addressed various aspects of these procedures. This umbrella review aimed to report the evidence from all previous SRMAs for open and laparoscopic inguinal hernia repair.

METHODS

SRMAs were identified from MEDLINE, Scopus, Cochrane, Embase, DARE, PROSPERO, CINAHL, JBISRIS, EPPI-Centre, Wiley Online Library and ScienceDirect database according to PRISMA guidelines. Data including mesh-fixation techniques and surgical approach were extracted from selected SRMAs. The corrected covered area was calculated to address study overlap across reviews, and an excess significance test was used to assess potential bias. The outcomes of interest were hernia recurrence, chronic groin pain, operating time, postoperative pain, duration of hospital stay, return to daily life activities, and postoperative complication.

RESULTS

Thirty SRMAs were included between 2010 and 2019: 16 focused on open repair, and 14 focused on laparoscopic repair, with a high degree of overlap (open repairs, 41 per cent; laparoscopic repairs, 30-57 per cent). Sufficient evidence was available on hernia recurrence, chronic groin pain, and operative time. Effects of glue on hernia recurrence were inconclusive in open and laparoscopy approaches, P = 0.816 and 0.946 respectively. Glue was significantly associated with lower persistent groin pain, in open repair (versus suture) and in laparoscopic repair (versus tack). SRMAs suggested that self-gripping mesh was associated with shorter operating time in open surgery, although with only a few minutes of improvement (0.36-7.85 min, P < 0.001).

CONCLUSION

In this umbrella review, chronic groin pain and operating time were the only outcomes for which there was sufficient evidence supporting the effectiveness respectively of glue and self-gripping mesh.

Post-surgical pseudoaneurysm of the corona mortis artery treated by arterial embolization from two arteries: A case report

Post-surgical pseudoaneurysm in the pelvis is rare. However, when it does occur, it may cause life-threatening hemorrhage. Hemostatic treatment for pelvic pseudoaneurysms may be complicated because the blood vessels in the pelvis may present with various anastomoses. Herein, we describe a case of a pseudoaneurysm that necessitated embolization of two arteries. A 47-year-old woman had undergone a total hysterectomy, a bilateral adnexectomy, and a pelvic lymphadenectomy for endometrial cancer; 13 days after surgery, she complained of sudden abdominal pain. Contrast-enhanced computed tomography revealed a retroperitoneal hematoma and a pseudoaneurysm with contrast leakage. The pseudoaneurysm had two feeding arteries (from the external and internal iliac systems). The first feeding artery was the obturator artery, which arose from the anterior trunk of the internal iliac artery. The second feeding artery was the aberrant obturator artery, which arose from the medial femoral circumflex artery. Both feeders were embolized and hemostasis was achieved. Pseudoaneurysms in the pelvis may have double origins from the external and internal iliac systems, and the aberrant obturator artery may arise from the medial femoral circumflex artery. Therefore, radiologists should be aware of these variations to effectively address post-surgical pseudoaneurysms of the corona mortis artery.

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.

What is the reality in outpatient vs inpatient groin hernia repair? An analysis from the Herniamed Registry

INTRODUCTION

Groin hernia repair is performed increasingly more often as an outpatient procedure across the world. However, the rates are extremely different and vary between below 10% and above 90%. The outpatient procedure appears to negatively impact the proportion of laparo-endoscopic repairs. To date, only very few studies have compared inpatient vs outpatient groin hernia repair.

METHODS

All outpatient and inpatient primary elective unilateral groin hernia repairs performed between 2010 and 2019 were identified in the Herniamed Registry and their treatment and outcomes compared.

RESULTS

The 737 participating hospitals/surgeons performed a total of 342,072 primary elective unilateral groin hernia repairs from 2010 to 2019. The proportion of outpatient repairs was 20.2% in 2013 and 14.3% in 2019. Whereas the proportion of laparo-endoscopic repairs among the inpatient cases was 71.9% in 2019, the last year for which data are available, it was only 34.3%.for outpatient repairs. In outpatient groin hernia repairs, the rates of patients aged ≥ 60 years, with ASA score III and IV and risk factors were highly significantly lower. Given this rigorous patient selection for outpatient groin hernia repair, a more favorable perioperative outcome was achieved. At 1-year follow-up there were no significant differences in the pain and recurrence rates.

CONCLUSION

With an appropriate patient selection, outpatient primary elective unilateral groin hernia repair can be performed with acceptable risks and good outcomes. Since to date no studies have compared inpatient vs outpatient groin hernia repair, the impact of a higher rate of outpatient groin hernia repair cannot currently be evaluated.

Case Report: How an Iliac Vein Lesion During Totally Endoscopic Preperitoneal Repair of an Inguinal Hernia Can Be Safely Managed

Inguinal hernia repair is a common surgical procedure with an acceptably low complication rate. However, complications with potentially life-threating consequences may occur in rare cases. These complications might be very challenging to manage, even more in laparo-endoscopic interventions compared to open repair. One of these challenges can be the treatment of an intraoperative injury to the iliac vein. To the best of our knowledge, a lesion of the iliac vein during TEP (totally endoscopic preperitoneal) for inguinal hernia repair, and a safe technique for its management have not been reported yet. We report the case of a 75-year-old male patient with previous abdominal surgery scheduled for TEP repair of an inguinal hernia. During surgery, the iliac vein was damaged. If we had performed a laparotomy in this situation, the potentially life-threatening condition of the patient could have deteriorated further. Instead, to avoid a potential CO₂ associated embolism, the preperitoneal pressure was gradually reduced, and the positive end expiratory pressure (PEEP) was increased in the manner that a balance between excessive bleeding and potential development of a CO₂ embolism was achieved. The injured vein was sutured endoscopically, and in addition a hemostatic patch was applied. We then continued with the planned surgical procedure. Thrombosis of the sutured vein was prevented by prophylactic administration of low molecular weight heparin until the 14th postoperative day. We conclude that in case of major vein injury during TEP, which might happen irrespective of prior abdominal surgery, the preperitoneal pressure and PEEP adjustment can be used to handle the complication.

Anatomical position of the corona mortis relative to the anteroposterior and inlet views

PURPOSE

Although pubic ramus fractures are common in the elderly, resultant hemodynamic instability is a rare complication. The corona mortis, a vascular anastomosis between the obturator vessels and the external iliac vessels in the retropubic space, is occasionally damaged by fractures of the pubic ramus, causing significant hemorrhage. The purpose of this study was to evaluate the incidence and anatomical position of the corona mortis on the anteroposterior and inlet views.

METHODS

Sixty-one cadavers (122 hemipelvizes) were dissected and the incidence of the corona mortis was evaluated. Photographs were then taken simulating anteroposterior and inlet radiographs, and labeled as the anteroposterior and inlet views. The distance from the pubic symphysis to the corona mortis was measured on each of the two views.

RESULTS

The corona mortis was present in 76.1% of hemipelvizes. The corona mortis traverses along the periosteum of the dorsal surface of the pubis. The incidence of arterial corona mortis was 28.3% and that of venous corona mortis was 76.1%. The distance from the superior margin of the symphysis pubis to the corona mortis measured 47.7 ± 9.9 (45.9-49.6) mm on the anteroposterior view, and 59.4 ± 9.2 (57.3-61.5) mm on the inlet view.

CONCLUSIONS

In order to predict possible hemodynamic instability of the corona mortis following pubic ramus fractures, it is of clinical significance to precisely establish the anatomical position of the corona mortis on the anteroposterior and inlet views.

Embryological Development and Topographic Anatomy of Pelvic Compartments-Surgical Relevance for Pelvic Lymphonodectomy

Background: The oncological outcome of surgery for the treatment of pelvic malignancies can be improved by performing pelvic lymphonodectomy. However, the extent and regions of lymph node harvest are debated and require profound knowledge of anatomy in order to avoid collateral damage. Methods: The embryological development and topographic anatomy of pelvic compartments in relation to pelvic lymphonodectomy for rectal, uterine, and prostate cancer are reviewed. Based on pre-dissected anatomical specimens, lymph node regions and drainage routes of the posterior and urogenital pelvic compartments are described in both genders. Anatomical landmarks are highlighted to identify structures at risk of injury during pelvic lymphonodectomy. Results: The ontogenesis of urogenital and anorectal compartments and their lymphatic supply are key factors for adequate lymphonodectomy, and have led to compartment-based surgical resection strategies. However, pelvic lymphonodectomy bears the risk of injury to somatic and autonomic nerves, vessels, and organs, depending on the regions and extent of surgery. Conclusion: Embryologically defined, compartment-based resection of pelvic malignancies and their lymphatic drainage routes are based on clearly delineated anatomical landmarks, which permit template-oriented pelvic lymphonodectomy. Comprehensive knowledge of pelvic anatomy, the exchange of surgical concepts between specialties, and minimally invasive techniques will optimize pelvic lymphonodectomy and reduce complications.

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.

The arterial blood supply of the symphysis pubis - Spatial orientated and highly variable

BACKGROUND

Open surgical treatment of the pubic region and adductor related pathologies require an exact knowledge of the arterial blood supply of the symphysis pubis that seems furthermore important to explain the hematogenous occurrence of symphysitis. Pubic bone marrow oedema (PBME) is a frequent occurring magnetic resonance imaging finding in groin pain. However, even asymptomatic athletes present PBME and a correlation to the physical activity or higher blood flow was suggested. Data on the vascular anatomy of the symphysis pubis are rare.

METHODS

Ten formaldehyde-embalmed cadavers were dissected, and the arterial blood supply was investigated and photographically documented.

RESULTS

In the majority of cases the following pattern was determined: superior-inferior epigastric artery (n=12 hemipelves), inferior - dorsal artery of the penis/dorsal artery of the clitoris (n=16), posterior- obturator artery (n=16 hemipelves), anterior- deep external pudendal artery (n=14 hemipelves). Besides variations for the deep external pudendal artery anteriorly, we observed a highly variable arterial supply, especially superior. Superior in 4/10 cadavers, inferior in 0/10 cadavers, posterior in 2/10 cadavers and anterior in 5/10 cadavers side variations were found.

CONCLUSION

The symphysis pubis has a spatial and rich organized arterial blood supply with several variations. Despite the symphysis pubis is recognized as bradytroph, the high number of vessels is presumably required in stress situations for example in heavy training.

Prevalence and Utilization of Obturator Artery Anatomic Variant in Autologous Breast Reconstruction

BACKGROUND

 The objective of this study is to quantify the prevalence and describe the utilization of an anatomic vascular variant in which the obturator artery (OA) arises from the trunk of the deep inferior epigastric artery (DIEA) in stacked/dual-pedicled autologous breast reconstruction. When this variant is identified preoperatively on computed tomography angiography (CTA), it may be utilized in a "flow-through" fashion to direct antegrade internal mammary artery (IMA) flow into a second free flap to facilitate anastomotic arrangement and optimize perfusion.

METHODS

 Preoperatively obtained abdomen/pelvis CTA imaging of 121 autologous breast reconstruction patients were retrospectively reviewed for the unilateral or bilateral presence of the OA branch arising from the DIEA (OA variant). The results were analyzed using descriptive statistics.

RESULTS

 Our analysis revealed the presence of the OA variant in 60 of the 121 (49.6%) breast reconstruction candidates, either unilaterally or bilaterally. Out of these patients, the variant was present unilaterally in 33 (55%) and bilaterally in 27 (45%) patients. Of the unilateral variants, 12 (36.4%) patients demonstrated right-sided laterality, while 21 (63.6%) patients demonstrated left-sided laterality. Clinically, this anatomic variant has been utilized in several cases of autologous breast reconstruction with flap survival in all cases.

CONCLUSION

 Utilization of this anatomic variant in stacked or dual-pedicled autologous breast reconstruction results in antegrade IMA perfusion of both primary and secondary flaps, as well as improved size match compared with other anastomotic options. Knowledge of the vascular anatomy and variations in the inferior epigastric system is crucial to both preventing complications and optimizing flap planning and outcome.

A Phylogenetic and Ontogenetic Perspective of the Unique Accumulation of Arterial Variations in One Human Anatomic Specimen

Background and objectives: Anatomical dissection is an indispensable means of acquiring knowledge about the variability of the human body. We detected the co-existence of several arterial variations within one female anatomic specimen during routine anatomical dissection. The aim of this study was to evaluate if this status is a regular pattern in any of other vertebrates. Materials and Methods: Besides of a meticulous anatomic dissection, we performed a literature review concerning the frequency, the phylogenesis, and ontogenesis of all of these variations. Results: Exceptionally, the middle colic artery arose from an extraordinarily divided celiac trunk. The kidneys received three polar arteries. On the left side, a corona mortis replaced the obturator artery. The aortic arch gave rise to a bicarotid trunk, and the right subclavian artery originated and coursed as a typical lusorial artery leading to a non-recurrent laryngeal nerve on the right side. Furthermore, variations of the branches of the thyrocervical trunk were found to be present. Extraordinarily, in their cervical portion both internal carotid arteries gave rise to two arteries each. All of these variations developed within two to three weeks, around the sixth week of gestation. It was not possible to ascribe all or even one of the variations to a singular species of vertebrates. Conclusion: Apparently, arterial variations are frequently a result of random development. Medical professionals must always be aware of anatomical variations; the absence of such awareness would create major difficulties during surgery. The present case confirms the relevance of anatomical dissection, particularly for medical students.

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.

Usefulness of repair using Hem-o-lok™ for peritoneal tear as a complication of totally extraperitoneal repair: Case series

Introduction

Peritoneal tear (PT) is a frequent intraoperative event during totally extraperitoneal repair (TEP). We aimed to introduce our surgical technique for PT during TEP to avoid the more difficult TEP procedure.Methods

One surgeon with 10 years of experience performed our TEP method in 147 TEP cases from January 2012 to June 2019. We investigated the repair time of each repair technique using endoscopic suturing (suturing group, SG) and endoscopic Hem-o-lok stapling (CG).

Results

Twenty-three (15.6%) PT cases occurred as TEP complication. The mean repair times (with standard deviation) of the PT were 16.2 ± 13 and 7.6 ± 7.0 min in the SG and CG, respectively, indicating a significant difference (P = 0.043). The repair time of the PT using Hem-o-lok (Teleflex, Wayne, PA, USA) stapling was shorter than that using endoscopic suturing, which was significantly different despite the length of the PT.

Conclusion

Hem-o-lok stapling is feasible in case of PT during TEP.

•

The peritoneal tear repair time when using Hem-o-lok stapling was shorter than that using endoscopic suturing.

•

Hem-o-lok stapling is very effective for peritoneal tear during extraperitoneal repair.

•

The technique is simple and can possibly replace metal stapling.

The fascial connections of the pectineal ligament

In clinical settings, the pectineal ligament forms a basic landmark for surgical approaches. However, to date, the detailed fascial topography of this ligament is not well understood. The aim of this study was to describe the morphology of the pectineal ligament including its fascial connections to surrounding structures. The spatial-topographical relations of 10 fresh and embalmed specimens were dissected, stained, slice plastinated, and analyzed macroscopically, and in three cases histological approaches were also used. The pectineal ligament is attached ventrally and superiorly to the pectineus muscle, connected to the inguinal ligament by the lacunar ligament and to the tendinous origin of rectus abdominis muscle and the iliopubic tract. It forms a site of origin for the internal obturator muscle, and throughout its curved course, the ligament attaches to both the fasciae of iliopsoas and the internal obturator muscle. However, dorsally, these fasciae pass free from the bone, while the pectineal ligament itself is adhered to it. The organ fasciae are seen apart from the pectineal ligament and its connections. The pectineal ligament seems to form a connective tissue junction between the anterior and medial compartment of the thigh. This ligament, however, is free to other compartments arisen from the embryonal gut and to the urogenital ridge. These features of the pectineal ligament are important to consider during orthopedic and trauma surgical approaches, in gynecology, hernia and incontinence surgery, and in operations for pelvic floor and neovaginal reconstructions. Clin. Anat. 32:961-969, 2019. © 2019 Wiley Periodicals, Inc.

Mesh fixation technique in totally extraperitoneal inguinal hernia repair - A network meta-analysis

Laparoscopic totally extra-peritoneal inguinal hernia repair is the standard option for inguinal hernia treatment. However, there are various types of mesh fixation and their relative uses are still controversial. This network meta-analysis was conducted to compare and rank the different fixations available for TEP. Medline and Scopus databases were search until February 1, 2017 and using randomized controlled trials comparing outcomes between different mesh fixation techniques were included. The results demonstrated that fifteen RCTs (n = 1783) were eligible for pooling. Five types of mesh fixation were used; metallic tack, no-fixation, absorbable tack, suture, and glue. Network meta-analysis that use metallic tack as the reference, indicated that suture and glue both carried a lower risk of recurrence with pooled risk ratios (RR) of 0.29 (95% CI 0.00, 18.81) and 0.29 (0.07, 1.30), respectively. For overall complications, absorbable tack had lower risk (0.63, 95% CI: 0.02, 16.13). However, none of these estimates reached statistical significance. So, this network meta-analysis suggests that glue and absorbable tack might be best in lowering recurrence risk and complications. However, a large scale RCT is still needed to confirm these results.

Where and what arteries are most likely injured with pelvic fractures?: The Influence of Localization, Shape, and Fracture Dislocation on the Arterial Injury During Pelvic Fractures

Blood vessels passing through pelvic region come into intimate contact with pelvic bone and can be injured by the sharp edges of the dislocated fracture fragments. The aim of the study was to evaluate the influence of localization, shape, and dislocation of individual pelvic ring bones' fractures on arterial injuries. The study group consisted of 474 patients enrolled in a 1-year prospective multicenter study. The pattern of pelvic fracture lines was characterized and recorded on a planar diagram of the subjected side of the pelvis. The diagram was subdivided into 11 designated areas. Frequency of injury at each 11 areas was recorded. The course of individual arteries in the 11 areas was also recorded in relation to each type of pelvic fractures. Out of the 474 investigated patients, the highest proportion of fractures occurred in the areas of the superior (62%) and inferior (59%) ramus of the pubis as well as in the lateral part of the sacrum (19%). These locations can be associated with injuries of the external iliac, obturator, internal iliac, and aberrant obturator arteries. The highest risk of arterial injuries was associated with vertically displaced fractures in the middle part of the superior and inferior pubic rami, along the ischial ramus, in the apex of the greater sciatic notch and in the vicinity of the ventral part of the sacroiliac joint, where the artery runs at a distance of less than 1 cm from the bone. Clin. Anat. 32:682-688, 2019. © 2019 Wiley Periodicals, Inc.

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.

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.

Inguinal Hernia: Mastering the Anatomy

The success of an inguinal hernia repair is defined by the permanence of the operation while creating the fewest complications at minimal cost and allowing patients an early return to activity. This success relies and depends on the surgeon's knowledge and understanding of groin anatomy and physiology. This article reviews relevant anatomy to inguinal hernia repair and technical steps to open tissue and mesh repairs as well as minimally invasive approaches.

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.

Risk factors for perioperative complications in inguinal hernia repair - a systematic review

The current literature suggests that perioperative complications occur in 8%–10% of all inguinal hernia repairs. However, the clinical relevance of these complications is currently unknown. In our review, based on 571,445 hernia repairs reported in 39 publications, we identified the following potential risk factors: patient age, ASA score, diabetes, smoking, mode of admission (emergency vs. elective surgery), surgery in low resource settings, type of anesthesia, and (in men) bilateral and sliding hernias. The most commonly reported complications are bleeding (0.9%), wound infection (0.5%), and pulmonary and cardiovascular complications (0.2%). In 3.9% of the included publications, a reliable grading of the reported complications according to Clavien-Dindo classification was possible. Using this classification retrospectively, we could show that, in patients with complications, these are clinically relevant for about 22% of these patients (Clavien-Dindo grade ≥IIIa). About 78% of all patients suffered from complications needing only minor (meaning mostly medical) intervention (Clavien-Dindo grade <III). Especially with regard to the low incidence of complications in inguinal hernia repair, future studies should use the Clavien-Dindo classification to achieve better comparability between studies, thus enabling better correlation with potential risk factors.

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.