A Meandering External Iliac Artery: Potential Doom Outside the Triangle

Abstract

dentification of the normal anatomy during total extraeritoneal inguinal hernia repair can be challenging. An natomic region in the preperitoneal space, the “Triangle of oom,” is bounded medially by the vas deferens and latrally by the testicular vessels; its base is formed by the eritoneal reflection (A).The triangle typically contains the xternal iliac artery (EIA) and external iliac vein (EIV). ooper’s ligament (CL) is shown for reference. Knowledge of vascular anatomic variances is critical to voiding catastrophic hemorrhage during operations of the elvic preperitoneal space. Aberrant anastomoses between he obturator and external iliac arterial systems, deemed the orona mortis, are well described, are present up to 25% of he time, and are a frequent potential hazard during preeritoneal surgery. Other less common vascular variances ose similar risks, but are unfamiliar to many surgeons. uring total extraperitoneal inguinal hernia repair we enountered an aberrantly located left external iliac artery. The patient presented electively for repair of bilateral inguial hernias. Both a fat-containing right inguinal hernia (RIH) nd left inguinal hernia (LIH) are shown in the CT scan (B). t operation the patient had bilateral indirect hernias. On the eft a large pulsating vessel was identified medial to the iliac ein and outside the boundaries of the Triangle of Doom (C). t gave off the deep inferior epigastric artery and returned to its ormal position lateral to the external iliac vein before proeeding deep to the iliopubic tract. Review of the CT scan (D, highlighted in green) conirmed the vascular structure encountered at operation. he left external iliac artery (EIA) and internal iliac artery IIA) were in their normal anatomic location (D, 1). The eft external iliac artery coursed medially to the external liac vein (D, parts 2 to 7) and returned to its normal ocation in the groin (D, parts 8 to 10). This variant is etter conceptualized in the artistic rendering of the paient’s anatomy (E). Familiarity with the normal anatomy of the preperitoneal pace and careful dissection avoids injury of the external iliac rtery. The meandering external iliac artery is one vascular ariation of which the surgeon should be cognizant.