Anterosuperior Iliac Spine Research Articles

Posttraumatic Scrotal Reconstruction with a Pedicled "Extended" Superficial Circumflex Iliac Artery Perforator Flap: A Case Report.

The superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has been used for scrotal reconstruction after Fournier's gangrene, skin cancer, or infections. However, there are few publications with regard to penoscrotal reconstruction after a traumatic injury with this flap. In this article, we propose a new SCIP flap variation, the "extended" or "direct" SCIP flap, to effectively reconstruct a wide scrotal defect after a traumatic injury. The "extended" SCIP flap is designed medial and cranial to the anterosuperior iliac spine (ASIS) using the superficial branch of the SCIA as the main pedicle.

Prevention ofmotor ascending branch ofthe rectus femoris injuries inBernese periacetabular osteotomy: a cadaveric study.

The Bernese periacetabular osteotomy (PAO) is a surgical procedure used to treat hip dysplasia in young adults, but it carries the risk of neurological complications, including injury to the motor ascending branch of the rectus femoris (MABRF). This study aimed to describe anatomical considerations to prevent MABRF injuries during PAO. A cadaveric study was conducted on seven specimens. The original and modified PAO approaches were used, with and without disinsertion of the rectus femoris muscle origin. The femoral nerve was dissected in all specimens from the endopelvic position to the MABRF origin (T-point). The average distance from the anterosuperior iliac spine to the T-point was 10.2 ± 0.4 cm. To protect the MABRF, a safety zone was identified for the osteotome placement during the ischial cut. The osteotome was slid over the joint capsule, deflecting the iliocapsularis muscle medially and distally. This manoeuvre shields the MABRF with the iliocapsularis muscle, reducing the risk of neurological injury. Both the original and modified PAO approaches were considered safe techniques with low risk to the rectus femoris innervation. These findings offer valuable insights for surgeons performing PAO, emphasizing the significance of understanding anatomical relationships and implementing protective measures to enhance patient outcomes and minimize complications. In conclusion, implementing these anatomical considerations can help prevent MABRF injuries during PAO, contributing to safer and more successful surgical interventions for hip dysplasia in young adults.

Surgical management of iliac wing fractures: Proposal of a new classification system

IntroductionIsolated fractures of the iliac wing are a rare injury, usually occurring in high-energy trauma, and are associated with other non-musculoskeletal and soft tissue injuries that could compromise the patient's life. Surgical indications are unclear, and there is limited information on the most frequent fracture patterns. MethodsA descriptive multicenter case series study of isolated fractures of the iliac wing treated surgically in three referral trauma hospitals in Latin America. The different fracture patterns are described, the "iliac ring" concept is proposed, and a classification is made. ResultsTwenty-eight patients were included; 24 were male, the median age was 31 years RIQ (24–46), the most frequent trauma mechanism was a traffic accident, and in 14 patients, the ISS >16. The most frequent associated injury was to the appendicular skeleton at another level in 13 patients. In the new classification, according to the number of fragments, 11 patients were classified as type A (1 fragment), ten patients as type B (two fragments), and seven patients as type C (three or more fragments). The most compromised anatomical area was the crest and anterosuperior iliac spines in 26 patients, followed by the fossa and anteroinferior iliac spine in 17 and 8 patients, respectively. DiscussionThe patterns of isolated fractures of the iliac wing allow the identification of three types of fractures. Identifying these patterns can help the surgeon decide to perform surgery in these scenarios and choose the fixation technique according to the number and location of the fragments.

Internal Versus External Pelvimetry: A Validation Study With Clinical Implications

INTRODUCTION:Investigating the correlations between external pelvimetry variables and actual birth canal dimensions has important implications for clinical practice, especially for predicting dystocia. This validation study tests external and internal pelvimetry correlations.METHODS:This single-centered retrospective study included 142 women with records of computed tomography pelvimetry. The correlations between four internal variables (obstetric conjugate, transverse diameters of inlet, midplane, and outlet) and five external variables (intertrochanteric, inter anterosuperior iliac spines, external conjugate, transverse diagonal, and prepubic) were first studied individually. Then, the correlations between each internal variable and the seven external variables were jointly evaluated after adjusting for body mass index.RESULTS:As expected, the external conjugate correlated with the obstetric conjugate (r= .65;p< .01) but only weakly with the transverse outlet (r= .21;p< .05). In the simple correlation analysis, the intertrochanteric measure is also correlated with the transverse inlet (TRi), midplane (TRm), and outlet (TRo;r =.542–.672). The transverse diagonal measure marginally correlated with the TRi (r= .29;p< .01). In the multiple regression models, the intertrochanteric measure is associated with the TRi, TRm, and TRo, while the transverse diagonal is associated with the TRi (B= .27;p= .01). The prepubic diameter was not a predictor of birth canal dimensions in either simple or multiple regression models.CONCLUSION:Our study confirms that the reduction of the birth canal in some dimensions (i.e., obstetric conjugate and transverse diameters) is predictable with external, accessible pelvic diameters (e.g., external conjugate, transverse diagonal, and intertrochanteric).

Open Surgery for Spiegel's Hernia

Spiegel's hernias are uncommon anomalies in the Spiegel's aponeurosis, which runs between the rectus muscle and the semilunar line. They are most commonly found in the "Spigel's hernia belt" between the navel and the interspinal line (a horizontal line connecting the anterosuperior iliac spines). We recommend open repair for individuals who arrive with an acute Spiegel's hernia, especially if there is a risk of high-grade blockage, strangulation, intra-abdominal infection, and/or the necessity for bowel resection. Furthermore, open repair may be required due to the surgeon's lack of expertise with and/or experience with laparoscopic methods, or when laparoscopy is contraindicated due to an inability to tolerate pneumoperitoneum or securely access the peritoneal cavity. Sutures or mesh can be used to repair an open Spiegel's hernia. Given the risk of recurrence, we only do suture repair in cases of contamination when mesh implantation is contraindicated and may enhance morbidity.

V-040 LAPAROSCOPIC TRANS-ABDOMINAL PREPERITONEAL PROCEDURE (TAPP) FOR RIGHT INGUINAL HERNIA WITH HANDXTM HOOK AND NEEDLE HOLDER

Abstract AIM HandX™ is a handheld, powered laparoscopic device with interchanging single-patient fully articulating instruments. It is electromechanically controlled, and, as the manual interface is handled by the surgeon, beside the patient's bed, the movements of the surgeon's wrist and fingers are translated to the instrument-articulating tip. This report is to show the feasibility and safety of this technology applied in inguinal hernia repair. MATERIALS AND METHODS We report the case of the laparoscopic repair of a right inguinal hernia using HandXTM instruments. RESULTS The index case was a 55-year-old, otherwise healthy male, with an inguinal right hernia. Three trocars were used: one 10 mm umbilical and two of 5 mm, approximately 4 cm laterally from the umbilicus and 1 cm under the level of the horizontal umbilical line. The dissection started with peritoneal cut, from the antero-superior iliac spine to the medial umbilical ligament, into the preperitoneal avascular plane. The anatomical landmarks (epigastric vessels, Cooper and Gimbernat ligaments, the corona mortis and external iliac vessels) were identified and well exposed. A polypropylene mesh was inserted from the optical trocar, placed in the appropriate position and fixed with three separated stiches handled with the articulating needle holder. The peritoneal flap was closed with a readsorbable running suture handled with the HandX instrumentation. No blood loss nor intraoperative or post-operative complications were recorded CONCLUSIONS The report showed how the HandX technology could be safely adopted to obtain both a safe dissection and an ergonomically advantageous suture in laparoscopic TAPP.

Periacetabular Tumour Resection under Anterosuperior Iliac Spine Allows Better Alloprosthetic Reconstruction than Above: Bone Contact Matters.

Background: Periacetabular resections are more affected by late complications than other pelvic resections. Reconstruction using bone allograft is considered a suitable solution. However, it is still not clear how the bone-allograft contact surface impacts on mechanical and functional outcome. Materials and methods: This paper presents the results of a retrospective analysis of 33 patients with resection of the entire acetabulum and reconstruction with an allograft-prosthetic composite for the period 1999 to 2010. Patients were divided in two groups, based on type of resection. In Group 1. patients had resections under anterosuperior iliac spine allowing the highest bone-allograft surface contact in reconstruction, while in Group 2 patients had resections over it. Results: Mechanical survival of the implant and Musculoskeletal Tumor Society functional score were calculated. Impact of age and artificial ligament were investigated as well. Patients in Group 1 had 38% mechanical failure rate of the implant while patients in Group 2 had 88%. Average functional score was higher in Group 1 compared with patients in Group 2. An artificial ligament was shown to have non-significant impact on survival of the reconstruction in Group 1, while significantly improving survival of reconstruction in Group 2. Conclusion: Bone-allograft contact matters: resection under anterosuperior iliac spine allows better mechanical survival and offers better reconstruction functional scores.

The extended SCIP flap: An anatomical and clinical study of a new SCIP flap design

We describe a variation of the superficial circumflex inguinal artery perforator (SCIP) flap, based the superficial branch of the superficial circumflex inguinal artery (SCIA) METHODS: The vascular supply of the SCIP flap was prospectively studied in 91 preoperative CT angiograms in patients undergoing reconstruction with other flaps, and verified randomly with a hand-held doppler in 20% of them. Based on the results, a new SCIP flap was designed medial and cranial to the anterosuperior iliac spine (ASIS) using the superficial branch of the SCIA. This flap was used in 39 patients to reconstruct lower limb and head and neck defects RESULTS: The superficial branch of the SCIA was found in all patients and its exit point through Hesselbach's fascia was located within a 21mm-radius circumference drawn 18mm medial and 17mm distal to the ASIS in 90% of the patients. Reconstruction with this SCIP flap was successful in 92.3% of the patients. Complications were present in 17.9% of the patients CONCLUSIONS: The design of the SCIP flap can be displaced cranially to obtain a larger flap with a long and constant vascular pedicle that is based on the main trunk of the SCIA. This facilitates the reconstruction of large and complex three-dimensional defects that require thin and pliable tissue, such as those located in the head and neck or limbs. Furthermore, supramicrosurgical expertise is not required. IV.

Cadaveric investigation of the minimum effective volume for ultrasound-guided suprainguinal fascia iliaca block

BackgroundThis cadaveric dose-finding study investigated the minimum effective volume of dye in 90% of cases (MEV90), required to stain the femoral, lateral femoral cutaneous and obturator nerves for ultrasound-guided suprainguinal...

Taux de consolidation en tomodensitométrie au recul d’un an des différents sites d’ostéotomie après réorientation acétabulaire par ostéotomie curviplane

BackgroundCurved periacetabular osteotomy (CPO) is a joint-preservation surgery to treat acetabular dysplasia. It is performed via an anterior approach with the osteotomy of the anterosuperior iliac spine (ASIS). One of the complications associated with CPO includes non-union of the osteotomy sites. However, all osteotomy sites including the ASIS have not been simultaneously evaluated. Therefore, we investigated: (1) the bone union status of all osteotomy sites, and (2) the predictors of non-union at one year after CPO based on computed tomography (CT). HypothesisThe bone union status may be different in each osteotomy site. Patients and MethodsThis retrospective review included 147 hips of 124 patients with symptomatic acetabular dysplasia who underwent CPO from 2011 to 2018. At one year postoperatively, we evaluated the bone union status of all osteotomy sites: the ASIS, ischium, pubis, and ilium using CT and investigated the predictors for achieving bone union. ResultsBone union was confirmed in both the ASIS and ilium in all cases. In contrast, ischial and pubic non-union was confirmed 15/147 hips (10.2 %) and 42/147 hips (28.5 %), respectively. The multivariate analysis revealed that the predictors of ischial non-union were both large width of the gap at the pubic osteotomy site and small postoperative acetabular roof obliquity, and that the predictor of pubic non-union was large width of the gap at the pubic osteotomy site. DiscussionAt one year after CPO, both the ASIS and ilium obtained complete bone union, while ischial and pubic non-union were observed. Large width of the gap at the pubic osteotomy site was the predictor of both ischial and pubic non-union. In CPO, sufficient bone union can be achieved at the ASIS and the ilium, while it is necessary to reduce the width of the gap at the pubic osteotomy site to prevent ischial and pubic non-union. Level of evidenceIV; retrospective study.

Hip apophyseal injuries in soccer players: can MRI findings be useful to define when to return to play?

To describe magnetic resonance imaging (MRI) findings in professional soccer players with acute apophyseal injury of the hip and to assess their relationship with return to sports. Adolescent soccer players with diagnosis of apophyseal injury in the anterosuperior and anteroinferior iliac spine were retrospectively evaluated between 2008 and 2016. All athletes underwent hip MRI examination within 4days after onset of clinical complaint. Images were independently analyzed by two radiologists. Medical records were reviewed to obtain clinical data. Mean displacement of the apophysis was 4.8 ± 4.6mm. Bone edema was present in 82% of athletes and muscular edema in 41%. The mean time to return to sports was 37.3 ± 14.7days. The difference between the measurements of the two radiologists was close to zero with agreement limits below 1.0mm (p < 0.001). There was a significant correlation between displacement of the apophysis and return to sports, as well as between both and the presence of muscular edema. A displacement of the apophysis of 3.0mm might serve as a parameter to predict return to sports/activity before 40days, with a sensitivity of 92% and specificity of 96%, considering conservative physiotherapy treatment. Displacement of the apophysis and presence of muscular edema evaluated by MRI showed a significant correlation with return to sports in athletes with acute apophyseal injuries of the anterosuperior and anteroinferior iliac spines.

Bone union status of all osteotomy sites one year after curved periacetabular osteotomy based on computed tomography

BackgroundCurved periacetabular osteotomy (CPO) is a joint-preservation surgery to treat acetabular dysplasia. It is performed via an anterior approach with the osteotomy of the anterosuperior iliac spine (ASIS). One of the complications associated with CPO includes non-union of the osteotomy sites. However, all osteotomy sites including the ASIS have not been simultaneously evaluated. Therefore, we investigated: (1) the bone union status of all osteotomy sites; and (2) the predictors of non-union at one year after CPO based on computed tomography (CT). HypothesisThe bone union status may be different in each osteotomy site. Patients and methodsThis retrospective review included 147 hips of 124 patients with symptomatic acetabular dysplasia who underwent CPO from 2011 to 2018. At one year postoperatively, we evaluated the bone union status of all osteotomy sites: the ASIS, ischium, pubis, and ilium using CT and investigated the predictors for achieving bone union. ResultsBone union was confirmed in both the ASIS and ilium in all cases. In contrast, ischial and pubic non-union was confirmed 15/147 hips (10.2%) and 42/147 hips (28.5%), respectively. The multivariate analysis revealed that the predictors of ischial non-union were both large width of the gap at the pubic osteotomy site and small postoperative acetabular roof obliquity, and that the predictor of pubic non-union was large width of the gap at the pubic osteotomy site. DiscussionAt one year after CPO, both the ASIS and ilium obtained complete bone union, while ischial and pubic non-union were observed. Large width of the gap at the pubic osteotomy site was the predictor of both ischial and pubic non-union. In CPO, sufficient bone union can be achieved at the ASIS and the ilium, while it is necessary to reduce the width of the gap at the pubic osteotomy site to prevent ischial and pubic non-union. Level of evidenceIV; retrospective study.

Measurement of the maximum corridor parameters of infra acetabular screw and evaluation of the feasibility of screw insertion by digital analysis

To measure the maximum corridor parameters of the infra acetabular screw and evaluate the feasibility of screw insertion through digital analysis of the acetabular structure. The pelvic CT data of 100 patients who received plain pelvic CT scan from April 2013 to June 2015 were retrospectively analyzed. There were 50 males, aged 20 to 84 years, with an average age of (48.42±17.48) years, and 50 females, aged 18 to 87 years, with an average age of (55.02±19.54) years. Patients with acetabular fractures, hip dysplasia, and metal implants in the acetabulum were excluded. Import CT data into Mimics software in DICOM format to generate a three-dimensional model, and find the axialprojection of the infra-acetabular corridor in the middle of the pubis ramus in the inlet view. A virtual screw was placed in the infra-acetabular space and measure the parameters including the diameter and the length of the maximum corridor, the distance from the insertion point to the pubic symphysis, to the anterosuperior iliac spine and to the medial edge of the pelvis. Then import the pelvic model into 3- matic software, establish the pelvic model anterior pelvic plane and median sagittal plane, and measure the angle between the screw axis and the two planes. A minimum corridor diameter of at least 5 mm was defined as a cutoff for placing a 3.5 mm screw, and calculate the screw insertion rate. In 100 cases, 49% of patients had a infra acetabular corridor with a diameter ≥5 mm, and the rate of screw placement in men was significantly higher than that in women. The average diameter of the maximum corridor of infra-acetabular screw was (4.86±1.72) mm, the average length was (94.04±8.29) mm, the average distance from the insertion point to the pubic symphysis was (60.92±4.84) mm, to the anterosuperior iliac spine was (85.15± 6.85) mm, and to the medial edge of the pelvis was (6.12±3.32) mm. The mean angle between the axis of the screw and the median sagittal plane was (-1.38±4.74)°, and the mean angle between the axis of the screw and the anterior pelvic plane was (56.77±7.93)°. There are significant differences between male and female measured parameters, except for the angle between the screw axis and the anterior pelvic plane. There was no statistically significant difference in the maximum corridor parameters of infra-acetabular screw on both sides of the pelvis. This study shows that the insertion rate of infra-acetabular screws is low in local patients, and the feasibility of screw insertion should be fully evaluated before surgery.

Formulas for estimating living stature based on bony pelvic measurements reconstructed from computed tomography images

Introduction: A major challenge in anthropology is the estimation of human stature based on human bones since the stature of cadavers is slightly different from that of living humans. This study aimed to investigate the feasibility of estimating living stature in Japanese subjects based on sacral and coccygeal lengths as measured on three-dimensional (3D) models of the femur and pelvis reconstructed from cross-sectional computed tomography (CT) images. Subjects and methods: For this cross-sectional study, 106 healthy Japanese subjects (54 men and 52 women) were recruited. We measured the distances from the anterosuperior iliac spine (ASIS) to the most posterior point of the ischial spine (IS) (ASIS-IS), and from the ASIS to the most inferior point of the ischial tuberosity (IT) (ASIS-IT) on 3D bone models reconstructed from multi-slice CT images. Correlations of living stature with ASIS-IS and/or ASIS-IT on the left and right sides of the pelvis were evaluated. Multiple regression equations were derived and used as formulas for living stature estimation. Results: In men, living stature had strong correlations with ASIS-IS + ASIS-IT on both the left and right sides; Pearson's correlation coefficients were 0.717 and 0.706, respectively. In contrast, in women, living stature showed stronger correlations with all of the studied parameters; Pearson's correlation coefficients were highest for ASIS-IS + ASIS-IT on both the left and right sides (r = 0.753 and 0.744, respectively) compared with those in men. Formulas based on ASIS-IS + ASIS-IT provided the best estimation in both men and women, while ASIS-IS alone demonstrated a better estimation than ASIS-IT on both the left and right sides. Conclusions: This study revealed that ASIS-IS and ASIS-IT measured from CT images were reliable predictors of living stature in the Japanese population. Our estimation formulas were derived from measurements of living stature that were not affected by the physiological changes observed in cadavers. To the best of our knowledge, this is the first study to derive estimation formulas based on living stature. Our method may be useful in the identification of disaster victims, wherein long bones are usually not found intact but pelvic bones are. Furthermore, the findings could be relevant to the field of anthropology for estimating living stature.

Is Greater Trochanteric Pain Syndrome Influenced by Pelvic Anatomy? A Radiological Review

Introduction: Greater trochanteric pain syndrome (GTPS) is one of the common causes of hip pain, which can be difficult to treat. The incidence of GTPS is highest in the middle aged and the elderly. The iliotibial band (ITB) acts as a tension band over the concave lateral surface of the femur. We postulate that those with wider pelvic morphology have higher tension though the ITB which predisposes to developing GTPS. Aim of the Study: The aim of the study is to evaluate the relationship between pelvic anatomy and GTPS. Methodology: A total of 89 patients underwent steroid injection in a district general hospital for the clinical diagnosis of GTPS between February 2013 and December 2014. We performed a retrospective radiological analysis of their pelvic morphology. We measured intertrochanteric distance and the bispinal distance between both anterosuperior iliac spines on anteroposterior pelvis radiographs. A ratio of intertrochanteric to bispinal distance was calculated. Femoral neck angle and offset were also recorded. Student's t-test was used for statistical analysis. Results: The average intertrochanteric distance and bispinal distance of patients with GTPS and control group were 362 mm and 341 mm, respectively. Intertrochanteric to bi spinal average ratio of 1.06 was found in GTPS group compared to 1.04 in the control group. Patients with GTPS had more varus femoral necks and a larger femoral offset. Intertrochanteric distance, neck-shaft angle, and offset were also statistically significant. Conclusion: We postulate that risk factors for GTPS include female sex, increasing age, and a wider pelvis. To allow for magnification of radiographs, we would suggest the use of the intertrochanteric to bispinal ratio in assessing patients with suspected trochanteric bursitis. We believe a figure of &gt;1.06 would be supportive of the condition.

Percutaneous image-guided double oblique anterior approach to the acetabulum for cementoplasty

To report the technique of percutaneous double oblique anterior access to the acetabulum and evaluate its feasibility and safety. Pelvic computed tomography (CT) examinations of 60 patients (30 men and 30 women; mean age 62.6±13.2 years) were retrieved randomly from the picture archiving and communication system (PACS). A virtual intraosseous trajectory was defined on both sides on the axial CT images with the entry point marked 1 cm above the anterosuperior iliac spine and the endpoint defined just above the level of the ischial spine at the midpoint of the posterior acetabulum. Patient age, sagittal oblique angulation, axial oblique angulation, length of intraosseous trajectory, distance from the hip joint, thickness of the iliac bone cortex, and intervening structure(s) between the skin and the bone entry points were recorded. The mean sagittal and axial oblique angulations were 34.2±4.5° and 31.5±6.7°, respectively, and mean length of the intraosseous trajectory was 11.8±0.9 cm. The axial oblique angle and length of the intraosseous trajectory were significantly lower in the female than the male population (p<0.05). None of the virtual trajectories traversed the hip joint. In 112/120 trajectories (93.3%), there were no cortical breaches in the iliac bones. In eight trajectories in four patients, the virtual trajectory crossed either the medial iliac cortex (4/120; 3.3%) or the medial iliac cortex and the iliacus muscle (4/120; 3.3%). The anterosuperior iliac and ischial spines can be used safely and reliably as landmarks to perform the double oblique anterior approach.

The Effect of Reduction Mammaplasty on Body Posture: A Preliminary Study.

Excess breast volume can lead to changes in the postural pattern that may result in pain. This causes women to seek reduction mammaplasty, a surgical procedure that reduces breast volume and may provide relief from symptoms. The objective of this study was to evaluate whether reduction mammaplasty can influence the posture of women. The postures of women with breast hypertrophy were evaluated using postural assessment software and photographic recording performed on the day of surgery and 3 months after the procedure. After surgical breast reduction, the patients had statistically significant changes in their postural patterns related to the horizontal alignment of the anterosuperior iliac spines and the angle of the acromion and anterior superior iliac spines. The analysis of the results showed statistically significant data on postural changes in the patients 3 months after the surgical procedure.

Use of free sensate SCIA flap for reconstruction of distal limb defects of moderate size

Recent attempts have been made to direct the sensory neurotisation of free superficial circumflex iliac artery (SCIA) flaps. However, donor nerves enabling sensory recovery are limited. We report our findings in fifteen patients who underwent distal limb defect reconstruction using a sensate SCIA flap, including the lateral cutaneous branch of the subcostal nerve (LCSN), between August 2017 and September 2018. The distance from the anterosuperior iliac spine to the point where the LCSN crossed the iliac crest ranged between 6.5 and 10cm. The diameter ranged between 1.5 and 4.0mm. The flap size ranged between 8×4 and 13×10cm2. All of the flaps survived uneventfully. Tests of sensory modalities, including the Semmes-Weinstein (SW) touch, vibration, pinprick, temperature and static two-point discrimination (s2PD) tests were applied in nine regions of each flap post-operatively. One or more modalities were present in at least one region at 6 months post-operatively, and the recovery of vibration perception was more consistent than that of SW touch and pinprick perception. The recovery of s2PD was noted in 4 cases over a follow-up period of more than 12 months. A reliable sensate flap with the LCSN can be considered as an attractive option for the sensory reconstruction of distal limb defects of moderate size.

Laparoscopic Reverse Technique for Posterior Rectovaginal Deep Endometriosis Nodule Step by Step

To demonstrate the application of the so-called reverse technique to approach deep infiltrating endometriosis nodules affecting the retrocervical area, the posterior vaginal fornix, and the anterior rectal wall. In Video 1, the authors describe the complete procedure in 10 steps in order to standardize it and facilitate the comprehension and the reproduction of such a procedure in a simple and safe way. A case report. A private hospital in Curitiba, Paraná, Brazil. A 32-year-old woman was referred to our service complaining about cyclic dysmenorrhea, dyspareunia, chronic pelvic pain, and cyclic dyschezia. Transvaginal ultrasound with bowel preparation showed a 2.4-cm endometriotic nodule at the retrocervical area, uterosacral ligaments, posterior vaginal fornix, and anterior rectal wall, infiltrating up to the muscularis 10 cm far from the anal verge. Not applicable. Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her lower limbs in abduction. Pneumoperitoneum was achieved using a Veress needle placed at the umbilicus. Four trocars were placed according to the French technique as follows: a 10-mm trocar at the umbilicus for the 0 degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions (step 1). The implants located at the ovarian fossae were completely removed (step 2). The ureters were identified bilaterally, and both pararectal fossae were dissected, preserving the hypogastric nerves (step 3). The lesion was separated from the retrocervical area, and the posterior vaginal fornix was resected (reverse technique), leaving the disease attached to the anterior surface of the rectum (step 4). The lesion was shaved off the anterior rectal wall using a harmonic scalpel (step 5). The anterior rectal wall was closed using X-shaped stitches of 3-0 polydioxanone suture in 2 layers (step 6). The specimen was extracted through the vagina (step 7). The posterior vaginal fornix was reattached to the retrocervical area using X-shaped sutures of 0 poliglecaprone 25 (step 8). A pneumatic test was performed to check the integrity of the suture (step 9). At the end of the procedure, hemostasis was controlled, and the abdominal cavity was irrigated using Lactate ringer solution (step10). The laparoscopic reverse technique is an alternative approach to face retrocervical or rectovaginal nodules infiltrating the anterior rectal wall.In this technique, the separation of the nodule from the rectal wall is performed at the end of the surgery and not at the beginning as performed within the traditional technique. This enables the surgeon to perform a more precise dissection of the endometriotic nodule from the rectal wall because of the increased mobility of the bowel. The wider range of movements serves as an ergonomic advantage for the subsequent dissection of the lesion from the rectum, allowing the surgeon to decide the best technique to apply for the treatment of the bowel disease (rectal shaving or discoid or segmental resection).

Forget the Greater Trochanter! Hip Joint Access With the 12 O’clock Portal in Hip Arthroscopy

Most surgeons rely on the greater trochanter as the reference point to establish the anterolateral portal. Nevertheless, we believe that the anterosuperior iliac spine is a more reliable landmark. Unlike the greater trochanter, it is unaffected by leg rotation and is more easily identified by palpation. Abiding by the central tenet of medicine to “do no harm,” the technique described herein presents in detail the concept of the 12 o’clock portal placement, a hip joint access method based on identifying specific anatomic points under fluoroscopy and by palpation. To accomplish this goal, this Technical Note presents a step-by-step approach, including tips and pearls for patient positioning and fluoroscopic guidance. We believe this method ensures a reproducible and safe way to start hip arthroscopy in the supine position.