Aberrant Obturator Artery Research Articles

Analysis of Variation in the Origin of the Obturator Artery in Midwestern American Donor Bodies.

The obturator artery (OA) is typically a branch of the anterior division of the internal iliac artery. However, an aberrant obturator artery origin may lead to clinical complications. Because of its locationin the pelvic cavity, the OA is at high risk of injury or laceration during a variety of pelvic surgeries. Regarding this, variations in the origins of the OA may result in bleeding that can often be overlooked, rendering treatment ineffective. Our study aimed to assess the origins and course of the OA in Midwestern American donor bodies. Sixty-two donor bodies were obtained from the Gift of Body Donation Program at A.T. Still University's Kirksville College of Osteopathic Medicine. The origin of each OA was documented and photographed. The OA was identified by observing the vessel's passage through the obturator foramen. Of 132 OAs studied, 72 (54.5%) had an aberrant OA. Further, 22 (16.7%) had an aberrant OA origin from the inferior epigastric artery, 20 (15.2%) had an aberrant OA origin from the posterior division of the internal iliac artery, 22 (16.7%) had an aberrant OA origin from dual origins of the anterior division of the internal iliac artery and the inferior epigastric artery, and eight (6.1%) had other aberrant OA origins. Overall, our results indicated anatomical variations are common in the origins and course of the OA. These data highlight the importance of considering variations in the OA and the prevalence of those variations during vascular and orthopedic procedures.

The anatomical variability of obturator vessels: Systematic review of literature

ObjectiveTo systematically assess available information about all variations of obturator vessels and to present the most surgically relevant types, their prevalence and calibre in order to provide a comprehensive overview for both anatomists and clinicians. Materials and methodsA total of 2689 studies were found via searching the online databases. After applying exclusion criteria 44 studies were assessed. The cadaveric studies, CT angiographies, and clinical studies were included. Number of hemipelves, prevalence of each variation and calibre of identified vessels were studied. Each variation was classified as aberrant obturator artery/vein, aberrant accessory obturator artery/vein or anastomosis. ResultsIn included studies the average incidence of the variant obturator artery was 26% with the aberrant obturator artery being the most frequent type (with the mean calibre 2.10 mm, SD = 0.35 mm), while the overall incidence of the variant obturator vein was 55%. Presented venous structures had the mean calibre of 2.98 mm (SD = 0.56 mm). ConclusionsAccording to reviewed studies, variant obturator vessels are present in a great number of patients. Due to their possible calibre larger than 3 mm they represent a structure of high clinical importance. It is important to unify the terminology and to stress out the significance to all clinicians.

Bilateral Common Origin of Obturator and Inferior epigastric Arteries from the External Iliac Arteries, Accompanied by Venous Corona Mortis Duplicated on the Left Hemi-Pelvis

During the dissection of the pelvis of a 93-year-old female donor, aberrant obturator artery and inferior epigastric artery were found to arise by a common trunk from the external iliac arteries bilaterally. Both right and left AOAs descended into the lesser pelvis with a venous corona mortis and entered the obturator canal on its anterolateral wall where each artery is joined by two (superior and inferior) obturator veins (OVs) and the obturator nerve on the respective side. The bilateral venous corona mortis connected the superior obturator veins with inferior epigastric veins, while on left hemi-pelvis, a second venous corona mortis additionally connected the inferior obturator vein with external iliac vein. These variant pelvic vessels are prone to injuries by trauma during accidents, iatrogenic injuries during inguinal and femoral hernia operations, and other orthopedic, gynecologic and urologic procedures. Such injuries have high morbidity and mortality rate due to hemorrhagic shock, therefore, caution must be exercised to avoid excessive hemorrhage and other complications.

Internal and External Iliac Arterial Variations in a Single Human Cadaver: A Case Study

Introduction & ObjectiveThe common iliac arteries are the main source of blood supply to the pelvis, perineum, and gluteal region via the internal iliac arteries (IIAs) and lower limbs via the external iliac arteries (EIAs). While variation in the branching patterns of the IIA and EIA is common, previously documented studies only focus on one type of variation. The objective of this study was to document the combination of multiple IIA and EIA variations found in one human cadaver. During herniorrhaphies and other pelvic surgeries, surgeons must enter the retropubic space. This space often has significant variation in collateral circulation, making vasculature in the area susceptible to injury, especially those that cross or reside near the superior pubic ramus. Knowledge of variant IIA and EIA branching patterns will assist surgeons and interventional radiologists in modifying their approach to procedures involving the pelvic area and lower limb (e.g., hernia repairs, fixation of pelvic fractures, etc.), thereby improving patient morbidity and mortality.MethodsDetailed dissections of the IIA and EIA and their respective branches were performed in a single human cadaver following notation of bilaterally aberrant obturator arteries. All arterial variations were documented through notes, diagrams, and photography. An in‐depth literature review was performed to evaluate the significance and frequency of the observed variations.ResultsThe left lower extremity had the following variations: absence of an inferior gluteal artery, an aberrant path of the superior gluteal artery, the inferior epigastric artery sharing a common trunk with the obturator artery from the profunda femoris artery, and anomalous branching of the femoral artery consisting of three larger branches, one noted to be the medial circumflex artery and the other two noted to be unusually large muscular branches. The right lower extremity had a similar aberrant obturator artery, although the common trunk shared with the inferior epigastric artery arose from the EIA.Conclusion/SignificanceAdditional arterial variations of the EIAs and IIAs were found upon further dissection differing bilaterally. It is essential for these variations to be documented along with the many others discovered previously. Lack of knowledge about arterial variation can lead to complications, such as femoral head osteonecrosis or significant hemorrhage during herniorrhaphy, fixation of pelvic fractures, and other pelvic/lower limb procedures. Therefore, knowledge of possible arterial variations of the human body can improve patient morbidity and mortality during routine surgical procedures, emergent surgical procedures, and various injuries in patients with vascular anomalies such as those documented in this study.

A Morphometric Study on Anatomic Characteristics of Corona Mortis in South Indian Population

Introduction: The Corona Mortis or the “crown of death” is the vascular anastomosis between the external iliac and obturator vessels in the retropubic region. If injured accidentally during laparoscopic inguinal hernia repair and certain minimally invasive gynaecological procedures such as midurethral or pubovaginal sling, can result in inadvertent haemorrhage. Recognising the anatomic characteristics of the corona mortis vessel is needed in order to prevent bleeding catastrophe. Aim: To estimate the prevalence and location of corona mortis in South Indian population and to determine the frequency of occurrence and its morphometry in males and females. Materials and Methods: This was an observational cross- sectional study conducted between December 2020 to August 2021 in the Department of Anatomy, Rajarajeswari Medical College and Hospital, Bangalore, Karnataka, India. Dissection of 55 adult cadavers (42 male and 13 female hemipelvises) was performed and corona mortis was observed on pelvic surface of superior pubic ramus, number of venous and arterial anastomosis were noted and photographed. In addition to diameter of the anastomotic vessel, the distance of corona mortis vessel from the pubic symphysis was measured using electronic digital caliper. Demographic data was expressed as frequency and percentage and continuous data as mean and standard deviation. Z test and t-test were done using statistical software Statistical Package for the Social Sciences (SPSS) version 23.0 to deduce the results. A p-value of <0.05 was considered as significant. Results: The corona mortis was observed in 35 out of 55 specimens (63.64%). It was seen in 29 male (69%) and six female hemipelvises (46%). In all the specimens, venous anastomosis was observed between the obturator vein and inferior epigastric or external iliac vein. Consequently, in the present study all the determined corona mortis were venous. The mean distance of corona mortis vessel from the pubic symphysis was 5.26±1.2 cm in males and 5.63±0.94 cm in females with p-value= 0.48, thus the distance of the anastomotic vessel remains consistent in both the sexes. Furthermore, diameter of corona mortis vessel (greater than 1 mm) was measured in both the sexes and found to be statistically not significant. Besides there was incidental finding, aberrant obturator artery was more prevalent in females in comparison to males (p-value=0.013). Conclusion: Corona mortis was present in 63.64% of the South Indian population and no statistically significant difference was found in prevalence in males and females. The distance of corona mortis vessel and the diameter of the vessel was consistent in both males and females.

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%).

Anatomy of Corona Mortis: A High Risk Yet Rare Lesson for Medical Students

Introduction Knowledge ofretro-pubic pelvic vascular anatomy and in particular the “Corona Mortis” (CMOR) is important to prevent vascular catastrophes during surgery. It is not very uncommon to find CMOR in routine dissections and during surgeries. However, it being a harbinger of a surgical disaster is not known to many medical students. CMOR also known as “crown of death” is the space posterior to the superior ramus of the pubis where there is anastomosis between the external iliac, inferior epigastric and aberrant obturator vessels. Anomalous obturator vessels in the retro-pubic region are at risk of getting accidentally injured during groin or pelvic surgeries. Injury to these vessels can result in significant hemorrhage which may pose difficulty in achieving hemostasis. Hence, anatomical knowledge of these variations are important for surgeons and interventional radiologists. The aim is to increase the awareness of this important anatomical vascular landmark to medical students and highlight its clinical implications during surgical and radiological procedures. Materials and methods Among 38 hemisected pelvises dissected between years 2018-2020, the origin and course of the obturator artery as traced for anatomic variations. Anatomical illustrations of the retro-pubic area were created and digital subtraction angiography images were obtained to supplement the findings and further implicate the clinical importance of this region. Results We found aberrant obturator arteries in 8 pelvises (21.05 %). In 4 hemi-pelvises (9.5 %), the obturator artery originated from the inferior epigastric artery. The Computed Tomography (CT) and Digital Subtraction Angiography (DSA) images show the aberrant obturator artery arising from the inferior epigastric artery. Such obturator arteries are especially prone to injury during laparoscopic herniorrhaphy during dissection of the Bogros’ space and mesh stapling onto Cooper's ligament. Once cut, the obturator artery retracts into the retro-pubic space and results in hemorrhage that is difficult to control. In certain pelvic fractures with uncontrolled bleeding and hemodynamic instability, angio-embolization is the preferred modality of treatment. Knowledge of the aberrant obturator artery is essential for interventional radiologists in order to accurately identify and embolize the source of the bleeding. Conclusion Given the wide-scope clinical significance that CMOR exhibits across medical specialties, knowledge regarding this vascular anatomic variation of the obturator artery is a crucial teaching topic for medical students as well as clinicians who will likely be exposed to such cases during clinical rotations and residency,

Anomalous Origin of Obturator Artery from Inferior Epigastric Artery

During routine cadaver dissection at Oakland University William Beaumont School of Medicine, an aberrant Obturator artery (OBA) was observed originating from the inferior epigastric artery (IEA). Typically, OBA originates from the anterior division of the internal iliac artery (IIA). When it originates from the IEA, it passes over the pelvic brim and places the individual at risk for hemorrhage during surgery in that region or after pelvic trauma. This phenomenon is called ‘corona mortis.’ The objective of this study is therefore to characterize how many OBAs arise from IIA and how many arise from aberrant branching patterns, with a focus on those which arise from IEA. The origin of the OBA was studied in 24 formalin fixed cadavers (13 female, 11 male, average age 80) which had been dissected by first year medical students. To confirm identification, the obturator nerve was first identified passing into the obturator canal in each cadaver, and then the main arterial contribution passing into the obturator canal was identified. The OBA was found to originate from the anterior division of the IIA in 28 pelvic halves (58%). In 12 (25%) cases , OBA was found to arise from the IEA. In 7 (15%) cases, it arose from other locations such as the posterior division of the internal iliac artery (6) or as a branch of the superior gluteal artery (1). There was one hemisected pelvis in which the accessory OBA arising from the IEA was the same size as the OBA contribution from the anterior division of IIA. We found that 60% of the aberrant OBAs were on the right and 40% on the left. There were 13 aberrant OBAs in the female cadavers in contrast to 6 found in males. Literature review by the authors reveals widely varying estimates for the origin of OBAs. Jakubowicz et al (1996) describe incidence of OBA from IEA as only 2.6%, Mahato (2009) reports incidence at 8%, and Pai et al (2009) report incidence of 14%. Additionally, Pai et al found that this aberrance was more common in males than females, the opposite of the present findings. Furthermore, they demonstrated a similar pattern of variances of OBA arising from external iliac artery and IEA on the right (26.5%) vs left (16.3%).

Bilateral renal forniceal rupture due to retroperitoneal hematoma after femoral venous access

Retroperitoneal hematoma is a potential complication of femoral venous access that rarely leads to bilateral ureteral obstruction. We present the case of a 73-year-old woman who underwent an ablation procedure for atrial fibrillation complicated by laceration of an aberrant obturator artery during femoral venous cannulation, leading to a compressive retroperitoneal hematoma, bilateral ureteral obstruction, acute renal failure, and renal forniceal rupture. The patient was successfully treated with embolization of the inferior epigastric artery and aberrant obturator artery, hematoma evacuation, and ureteral stent placement. This case illustrates a rare complication of arterial laceration during femoral venous access without ultrasound guidance.

The Majority of Corona Mortis Are Small Calibre Venous Blood Vessels: A Cadaveric Study of North Indians.

PurposeCorona 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 MethodsTwelve cadavers (24 hemipelvises; 11 males and 1 female) with a mean age of 68 (range, 54–82) years were included in this study.ResultsCorona 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.ConclusionThe 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.

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

Corona mortis (CMOR) is the arterial and/or venous vascular communication(s) between the obturator and external iliac vessels. Totally extraperitoneal (TEP) inguinal hernioplasty can be associated with vascular complications especially during the fixation of the mesh. Theoretically, CMOR is an important nominee. But, the data in literature are insufficient about CMOR injury. Additionally, most of the studies about CMOR have been usually performed on cadavers. We aimed to reveal the preperitoneal vascular anatomy of inguinal area and provide in vivo knowledge about CMOR. The risk of arterial injury was also evaluated. The data of preperitoneal vascular anatomy of 321 patients who underwent TEP procedure between January 2005 and July 2014 were retrospectively evaluated. Mean age was 46±8.9years, 53 females vs 268 males. 391 hemipelvises were evaluated. Two types of arterial structure were identified; (1) an aberrant obturator artery forming an anastomosis with branches of ordinary obturator artery; (2) a pubic branch of inferior epigastric artery. The incidence of arterial CMOR was 28.4% and of any arterial structure was 45.0%. An arterial CMOR was considered as thick (≥2mm) or thin (<2mm). Injury of arterial CMOR during tack stapling on Cooper's ligament was seen in six cases (1.5%). All of them were thin (<2mm) in structure. Venous CMOR was visible only under low pressure in work space. During TEP hernia repair, CMOR and/or pubic branch of inferior epigastric artery can be damaged. To prevent this complication, tacks should be stapled to Cooper's ligament close to symphysis pubis and dissection should be careful on the posterior surface of superior pubic ramus. Small caliber (<2mm) arterial CMOR is more prone to be injured during TEP procedure. To explore venous structures properly, pressure in workspace should be kept as low as possible.

Incarcerated femoral hernia in men: Incidence, diagnosis, and surgical management

Incarcerated femoral hernia in men: Incidence, diagnosis, and surgical management

Aberrant Obturator Artery: A Hidden Threat after Pelvic Fracture

Aberrant Obturator Artery: A Hidden Threat after Pelvic Fracture

Aberrant Obturator Artery Is a Common Arterial Variant That May Be a Source of Unidentified Hemorrhage in Pelvic Fracture Patients

Similar to all pelvic arteries, the aberrant obturator artery (AOA) and its branches are at risk for injury when the pelvic ring is fractured; however, because of its unique origin, bleeding from this artery may be unrecognized and, thus, treatment ineffective. The purpose of this study was to describe the incidence of the AOA using angiography and determine the sensitivity of 64-slice computed tomography angiography (CTA) at identifying the AOA. Imaging from patients undergoing pelvic angiography, for any reason, during 2009 was retrospectively reviewed to determine the incidence of the AOA. The angiographically determined arterial anatomy was the compared with CTA findings. Pelvic angiography, performed in 174 patients, identified the AOA in 60.0% of males, 52.3% of females, 55.1% of all patients, and 38.4% of hemipelvises. The sensitivity/specificity of CTA at identifying the AOA is 90.0%/100% and 63.6%/92.3% in nonpelvic fracture and pelvic fracture patients, respectively; the sensitivity difference being significant (p=0.0351). Three of the 13 (23.1%) AOA identified in pelvic fracture patients demonstrated extravasation when the inferior epigastric artery was cannulated; however, flush angiography failed to demonstrate the extravasation. The AOA is a common arterial variant occurring in more than half of the population and, if present in pelvic fracture patients, commonly injured. Although CTA is effective at identifying the AOA in nonpelvic trauma patients, it is not as effective in pelvic fracture patients. Failure to consider this arterial variant may result in untreated arterial bleeding with the attendant consequences.

Vascular Injury by Tacks During Totally Extraperitoneal Endoscopic Inguinal Hernioplasty

Totally extraperitoneal laparoscopic hernioplasty is a consolidated approach for treating recurrent and bilateral inguinal hernias. However, it may be associated, albeit very rarely, with vascular lesions that can endanger the patient's life. A proper anatomic knowledge of the posterior aspect of the inguinal region and a perfect command of the laparoscopic technique are essential for avoiding and, if necessary, treating these lesions. We present an unusual case of an arterial lesion of the aberrant obturator artery of the corona mortis during fixation of the mesh with a tacker.

Variability in the Origin of the Obturator Artery

INTRODUCTIONGeneral surgeons dealing with laparoscopic herniorrhaphy should be aware of the aberrant obturator artery that crosses the superior pubic ramus and is susceptible to injuries during dissection of the Bogros space and mesh stapling onto Cooper’s ligament. The obturator artery is usually described as a branch of the anterior division of the internal iliac artery, although variations have been reported.MATERIALS AND METHODSThe present study was conducted on 98 pelvic halves of embalmed cadavers, and the origin and course of the obturator artery were traced and noted.RESULTSIn 79% of the specimens, the obturator artery was a branch of the internal iliac artery. It branched off at different levels either from the anterior division or posterior division, individually or with other named branches. In 19% of the cases, the obturator artery branched off from the external iliac artery as a separate branch or with the inferior epigastric artery. However, in the remaining 2% of the specimens, both the internal and the external iliac arteries branched to form an anastomotic structure within the pelvic cavity.CONCLUSIONThe data obtained in this study show that it is more common to find an abnormal obturator artery than was reported previously, and this observation has implications for pelvic surgeons and is of academic interest to anatomists. Surgeons dealing with direct, indirect, femoral, or obturator hernias need to be aware of these variations and their close proximity to the femoral ring.

Bilateral femoral hernia in a male cadaver with vascular variations: case report and review of the literature

Femoral hernia, which is a less common occurrence than inguinal hernia, is not congenital in most cases and is uncommon in young males. It is considered to be more common in females than in males due to an enlarged femoral ring in the former. A case of bilateral femoral hernia in a 64-year-old male cadaver is described within the framework of an anatomical approach. On the right side, the protrusion of the viscus appeared as a small intestine coil, whereas on the left side the protruded viscus appeared as a pelvic colon's appendix appiplocae. On both sides, the protruded viscus was located in front of an aberrant obturator artery, which oriented from the external iliac artery and not from the internal iliac artery as should be the case. The puberal branch of the inferior epigastric artery was absent. The cadaver's medical history and his skin examination excluded an abdominal surgery. In the literature, case reports of bilateral femoral hernia appear only seldom, especially those of male patients who had not undergone inguinal hernia repair surgery. In femoral hernias more often than in other types of hernia, the protruded viscus is strangulated and undergoes a tissue necrosis. Morbidity and mortality for complicated femoral hernia is high. Knowledge of vascular variation such as presented by the cadaver under study is extremely useful to the surgeon because any iatrogenic injury of the aberrant obturator artery during a laparoscopic repair may result in dangerous hemorrhage.

A prospective endoscopic study of retropubic vascular anatomy in 121 patients undergoing endoscopic extraperitoneal inguinal hernioplasty.

A sound knowledge of retropubic pelvic vascular anatomy is pivotal to the successful performance of endoscopic total extraperitoneal (TEP) inguinal hernioplasty. The objective of the current study was to evaluate the incidence and anatomy of iliopubic and aberrant obturator vessels. Between July 2001 and March 2002, a prospective endoscopic evaluation of retropubic vascular anatomy was performed on patients who underwent TEP. Endoscopic photographs of the vasculature overlying the superior pubic ramus in the recruited patients were captured on a computer. The retropubic vascular anatomy of 121 patients, who underwent either unilateral (n = 100) or bilateral (n = 21) TEP was examined. The iliopubic artery and vein were invariably present in every patient, and traversed along the iliopubic tract toward the pubic symphysis. The aberrant obturator artery was present in 31 pelvic halves, giving an overall incidence of 22%. The aberrant obturator vein existed between the external iliac and obturator venous system in 27% (n = 38) of the 141 pelvic halves examined. The overall incidence of corona mortis, in the form of either an aberrant obturator vein or artery, was 40% (n = 56). Iliopubic vein and artery are universal findings in every patient. Both aberrant obturator artery and vein cross the superior pubic rami, and are therefore susceptible to injuries during dissection of the Bogros space and stapling of the mesh onto Cooper's ligament. Awareness of these aberrant vessels will help to reduce bleeding and subsequent morbidity. Tracing along the aberrant vessel can easily identify the obturator foramen, which is an anatomic landmark that indicates an adequate inferior dissection of the preperitoneal space.

Hemorrhage Secondary to Pelvic Fracture:Coil Embolization of an Aberrant Obturator Artery

<b>Hemorrhage Secondary to Pelvic Fracture:</b>Coil Embolization of an Aberrant Obturator Artery