Corona Mortis Research Articles

The Presence of a Variant Obturator Artery: The Corona Mortis

INTRODUCTIONThe obturator artery (OA) is a vessel of variable origin with anterior‐lateral direction on the wall of the pelvis. It is followed by the obturator vein and nerve leaving the pelvis through the obturator canal1. This vessel is often a branch of the internal iliac artery, however, it is subject to important anatomical and surgical variations 2,3. The most important variation is referred to corona mortis4 (Crown of Death). The aim of this study is to verify and quantify the OA different origins and to determine the presence of conora mortis.METHODForty cadavers of Brazilian decent (27males and 13 females) were dissected in order to observe the presence or absence of anatomical variations of OA. The study was conducted in the Laboratory of Anatomy of the Estácio de Sá University (Joao Uchoa Campus), Rio de Janeiro, Brazil. The data analysis was conducted using SPSS software.RESULTSThe corona mortis (Figures 1 and 2) was found in 22.5% of subjects (55,6% Males and 44,4% females) (Tables 1 and 2). The external iliac artery had a common trunk that originated the obturator and inferior epigastric arteries.DISCUSSIONThe presence of the corona mortis is very relevant for surgery because it is a common variation of the obturator artery. The knowledge of this variation is important because of the possibility of injury during surgical interventions especially when staples are used for endoscopic repair of inguinal and femoral hernias2,3,4,5,6.CONCLUSIONThe presence of corona mortis variation was significant, demonstrating that the knowledge of this variation, is important to surgery.Support or Funding InformationOwn financing and support from Estácio de Sá UniversityThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

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.

The incidence and clinical significance of corona mortis vessel

Objective To explore the incidence and clinical significance of corona mortis vessels. Methods From December 2015 to December 2017, 48 patients with pelvic acetabular fractures were treated with the Stoppa approach, including 36 males and 12 females, aged 30 to 67 years, with an average age of 47.2±8.2 years. There were 52 sides of hemipelvis in the all including 44 cases of unilateral pelvic acetabular fractures and 4 cases of bilateral pelvic acetabular fractures. In the 48 patients, there were 6 pelvic fractures, 40 acetabular fractures and 2 pelvic combined with acetabular fractures. According to Judet-Letournel classification: there were 6 cases of anterior column fracture, 4 cases of anterior column with anterior wall fracture, 2 cases of anterior column with posterior transverse fracture, 4 cases of transverse fracture, 6 cases of T shape fracture and 20 cases of double column fracture. According to Tile classification, there were 2 cases of B1 type, 2 cases of B3 type, 2 cases of C1 type, and 2 cases of C2 type. The time from injury to surgery was 5 to 16 days, with an average of 8.3±2.8 days. All patients were treated with the Stoppa approach for reduction and fixation. The incidence, number and type of corona mortis vessels across the superior pubic branch, and the diameter and the distance between the vessels and the pubic symphysiswere detected and recorded. Results In the 52 hemi pelvis, there were 46 sides with an anastomotic blood vessel, and no anastomotic blood vessel was found in 6 sides, with the incidence of corona mortis vessels of 88.5% (46/52). Among them, 36 cases were venous type, with the incidence of 78.3% (36/46); 8 cases were arterial type, with the incidence of 17.4% (8/46); 2 cases were mixed type, with the incidence of 4.3%(2/46); corona mortis venous blood vessel diameter was 1.8-3.7 mm, with an average of 2.9±0.5 mm; arterial blood vessel diameter was 2.4-3.0 mm, with an average of 2.7±0.3 mm; the distance between the vessels and the pubic symphysis was 48-71 mm, with an average of 56.9±5.8 mm. Conclusion The corona mortis vessels are common, with the incidence through Stoppa approach about 88.5%. In the clinical treatment of pelvic acetabular fractures, we should pay attention to careful separation of pubic branches exposed by the Stoppa approach, especially when using ilioinguinal approach to avoid corona mortis vessels injury and haemorrhage. Key words: Pelvis; Acetabulum; Fractures, bone; Blood vessels

Fixation of Displaced Acetabular Fractures With an Anatomic Quadrilateral Surface Plate Through the Stoppa Approach.

Satisfactory fixation for displaced acetabular fractures involving the quadrilateral surface remains difficult to obtain with conventional reconstruction plates. To achieve minimally invasive management of fractures of the quadrilateral surface, the authors designed a type of anatomic quadrilateral surface plate (AQSP). A retrospective study to assess the therapeutic results of the AQSP was performed at their institution. A total of 26 patients with quadrilateral surface fractures fixed with an AQSP through the Stoppa approach from February 2014 to February 2015 were included in this study. There were 16 men and 10 women with a mean age of 37.5 years. The patients were followed for a mean of 28.81 months (range, 24-36 months). The mean operative time was 98.85±16.08 minutes, and the mean intraoperative blood loss was 353.85±124.84 mL. Postoperative radiographs and computed tomography scans showed that anatomic and good reductions were obtained in 88.46% (23 patients) and 11.54% (3 patients) of the patients, respectively. Screw loosening was not observed. All of the fractures healed well at a mean of 3.54 months. Two cases of obturator nerve injury and 1 case of corona mortis rupture were observed. However, permanent complications were not observed. The mean Merle d'Aubigné score at final follow-up was 16.38±1.33 points. The authors conclude that satisfactory fixation with the AQSP system can be achieved through the Stoppa approach. [Orthopedics. 2019; 42(2):e180-e186.].

Anomalous origin of the obturator artery in a Goan population: A study linked with hernia reduction surgery

Introduction: The “corona mortis” or “crown of death” occurs when an accessory obturator artery (OA) is also present, having rich anastomosis with the normal OA around the obturator canal. The OA can take origin from various arteries such as the common iliac, anterior or posterior divisions of the internal iliac, inferior epigastric, superior or inferior gluteal, internal pudendal, or even external iliac arteries. Accessory OA has an incidence of 30%–40% in earlier studies.To find out the incidence, location, and dimensions of aberrant, retropubic, anastomosing vessels and the corona mortis that connects the external iliac and obturator vessels and to determine their interference with various surgical approaches. Material and Methods: Twenty-five cadaveric pelvises were dissected in the pelvic and retropubic inguinal regions. The origin and course of the OA and the presence of venous plexuses were recorded. We studied the frequencies of occurrence of abnormal obturator vessels and also their variant patterns of origin from and drainage into the iliac vessels. Student's t-test was the statistical analysis used. Results: We found a higher incidence, i.e., 44% of internal iliac artery branching pattern as Group Ia. Vasa corona mortis was seen in two pelvises showing an arterial connection around the superior pubic ramus, whereas venous corona mortis was seen in twenty pelvises and five hemipelvises showing an aberrant OA. Discussion and Conclusions: Cadaveric dissections have shown a vascular connection between the obturator, external iliac, and inferior epigastric vessels, and these variations are important specially when doing pelvic and groin surgeries.

The Pararectus Approach: A New Concept.

Even 50 years after the introduction of the extrapelvic ilioinguinal approach for open reduction and internal fixation of acetabular fractures involving predominantly the anterior column, this approach is still acknowledged as being the so-called gold standard1. The pattern of acetabular fractures has changed within the last 10 to 20 years2,3, with a greater prevalence of quadrilateral plate fractures that is due in part to the increase in elderly trauma. The intrapelvic approach, also called the modified Stoppa approach4-6, was introduced as a less invasive alternative to the extrapelvic ilioinguinal approach, mostly combined with the first window of the ilioinguinal approach. The Pararectus approach also offers intrapelvic surgical access and has demonstrated safe surgical dissection with enhanced exposure and favorable outcome compared with the Stoppa approach7-10. The skin incision runs along the lateral border of the rectus abdominis muscle to develop the anterior rectus sheath. The retroperitoneal space lateral to the rectus abdominis muscle is entered and the inferior epigastric vessels and the round ligament in females or the spermatic cord in males are identified. The superior pubic ramus and the iliopectineal eminence are exposed. If the corona mortis vessels (a vascular anastomosis between the obturator vessels and the external iliac artery) are present, they are ligated. The obturator nerve and vessels are exposed. The dissection is then directed posteriorly under retraction of the external iliac vessels with further subperiosteal exposure of the pubic ramus, the quadrilateral plate, and the posterior column. Any nonessential iliolumbar vessels are ligated. Residual displacement is assessed with fluoroscopic views. For reduction of a medially displaced femoral head, longitudinal extremity soft tissue or lateral skeletal traction (optional), with a Schanz pin in the greater trochanter, is used. For disimpaction of acetabular dome fragments and grafting of a supra-acetabular void (optional), a fluoroscopy unit is used to assess reduction and identify the void; in addition, arthroscopy can be used. The scope is introduced through the fracture gap to check for reduction without any water or specific setup. For reduction and fixation of extra-articular components (iliac wing posteriorly and superior pubic ramus anteriorly), the posterior column, and the quadrilateral plate, the fluoroscopy unit is used. The anterior lamina of the rectus sheath is sutured, and a layered closure performed. The ilioinguinal or modified Stoppa approach might be used instead. The Pararectus approach combines the advantages of the ilioinguinal approach and the Stoppa approach. The Pararectus approach facilitates surgical access directly above the hip joint, which is comparable with the access obtained through the second window of the ilioinguinal approach, but without dissection of the inguinal canal. Moreover, the Pararectus approach provides intrapelvic visualization that is at least equivalent to that offered by the Stoppa approach but without losing any direct access to the hip joint.

Corona mortis variant of the obturator artery: a systematic study of 300 hemipelvises by means of computed tomography angiography.

PurposeThe purpose of the present study is to systematically assess the prevalence and characteristics of the corona mortis (CM) variant of the obturator artery by means of computerised tomography angiography (CTA).Material and methodsA total of 150 consecutive patients (112 males, average age 73 years) referred to CTA for lower limb arterial evaluation were included in this retrospective study. Patient demographics, anastomosis incidence, artery diameter, distance from the symphysis pubis, Kellgren-Lawrence score, and pelvic size were evaluated.ResultsIn this study 40.6% of patients presented at least one competent CM arterial anastomosis. In the 300 evaluated arteries, 90 arterial anastomoses were found (30%), 40 on the right side (average diameter 1.63 mm) and 50 on the left side (1.78 mm). In 32 cases there was only one anastomosis, while in 29 cases the CM was bilateral. No anastomoses were detected in 89 patients. Mean distance from the symphysis was 50 mm. No relevant association with hip osteoarthrosis was found for CM. Mean pelvic size was 213 mm.ConclusionsThe evidence from this study suggests that CM is a common variant that needs to be acknowledged before pelvic intervention.

The prevalence and morphology of the corona mortis (Crown of death): A meta-analysis with implications in abdominal wall and pelvic surgery

PurposeCorona 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. MethodsAn 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. ResultsA 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%). ConclusionsAs 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.

Corona Mortis: anatomical and surgical description on 60 cadaveric hemipelvises.

to report the prevalence of arterial corona mortis and to describe its surgical and clinical applicabilities. 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. 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. 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.

Corona mortis anastomosis: a three-dimensional computerized tomographic angiographic study.

We evaluated the corona mortis (CM) anatomy by means of three-dimensional computerized tomography angiographic (CTA). Patient demographic, anastomosis incidence, artery diameter, artery distance from the symphysis pubis, and pelvic size (distance between both acetabular upper labrum) parameters were assessed. The 100 patients included 66 males and 34 females (average age of 67.8years). There were 66 (33%) arterial anastomoses in the 200 evaluated arteries, 30 in the right side and 36 in the left side, 36 unilaterally and 15 bilaterally. No anastomoses were detected in 49 patients. The average diameter was 2.4mm for the right-sided arteries and 2.24 in the left-sided ones. The distance was 55.2mm from the right symphysis and 57.2 from the left symphysis (greater for females, 62.2 versus 55.85mm [p=0.037] only on the left side). The artery disappears in smaller-sized pelvises. There was a non-occluded arterial pattern in 47 (71%) and a partially occluded one in 19 (29%, all with peripheral vascular disease). One-third of the evaluated CTAs revealed competent CMs. CMs were more lateral in females than in males and were absent in small-sized pelvises. It is highly recommended that the radiologist and the surgeon should be familiar with CM existence for decision-making with regard to emergency radiology imaging and intervention as well as when operating in proximity of that anatomic site.

Anatomical considerations on surgical implications of corona mortis: an Indian study

The blood vessels traversing the superior pubic ramus are usually vascular connections between obturator and external iliac systems of vessels. Dislocated fractures or iatrogenic injury can cause life threatening bleeding and hence these vascular anomalies are referred to as corona mortis meaning ‘crown of death’. Except for a case report, no study on corona mortis has been attempted in India so far and hence the present study was intended at exploring the possible variations, both morphological and topographical, of these vascular connections in Indian population through cadaveric dissection. 24 adult cadavers dissected bilaterally (48 hemipelves) and 19 random hemipelves available in the Department of Anatomy were considered for the study.The vascular connections observed were classified as arterial, venous or both (Types I, II and III). Type III was further classified into subtypes a, b, c, d and e based on various combinations of the first two types. In a total of 67 pelvic halves corona mortis was detected in 56 (83.58%) specimens: arterial 7/56 (12.5%), venous 34/56 (60.7%) and both arterial and venous in 15/56 (26.78%) specimens respectively. 22 hemipelves had an artery on the superior pubic ramus out of which in 7 cases there was only an artery whereas in 15 cases both an artery and a vein were present. Commonest source of obturator artery was inferior epigastric artery 15/22 (68.18%) followed by external iliac artery 4/22 (18.18%). 49 of the 56 corona mortis positive specimens had a vein on the superior pubic ramus. In 34/56 specimens only a vein was present.12/49 (24.48%) veins drained into external iliac vein, 3/49 (6.12%) into inferior epigastric vein. A venous anastamosis was found between obturator vein and external iliac vein in 21/49 (42.85%) cases and between obturator and inferior epigastric vein in 10/49% (20.40%) cases. Corona mortis was observed in a significant percentage of specimens, venous corona mortis being more common than arterial. Every surgeon dealing with hernias or fractures of the region needs to be aware of the possible variations and ligate vessels if corona mortis presents itself or else it becomes difficult to control bleeding if a cut vessel retracts into the pelvis.

Vascular anatomical relationships of the retropubic space and the sacrospinous ligament, using three-dimensional imaging

Pelvic anatomy is complex and intimate knowledge of variabilities in anatomical relationships is critical for surgeons to safely perform surgical procedures. Three-dimensional Imaging provides the opportunity to analyze undisturbed anatomical relationships. The authors hypothesized that three-dimensional models created from pelvic computed tomography angiograms could be used to obtain vascular anatomical measurements, and that the measurements obtained from three-dimensional models would be similar to those from cadaver studies. We included all pelvic computed tomography angiograms that were acquired in female patients older than 18years at our institution within the previous 5years. Three-dimensional models were created using the Invivo5 software based on the Digital Imaging and Communications in Medicine files. Structures of interest were virtually dissected and measured replicating previous cadaver studies. Statistical analysis of demographics and measurements was performed. The final analysis included 87 studies. The average age of the subjects was 66.9years and their average BMI was 26.1kg/m2. Of the 87 subjects, 12.6% had a history of hysterectomy, 2.3% a history of a continence procedure, and 1.1% a history of a prolapse procedure. The range of distance between the ischial spine and the pudendal artery was 3-17mm. The closest vessels to the lower edge of the symphysis pubis were the obturator vessels. The aberrant corona mortis vessel was present in 27.9% of the subjects. Prior hysterectomy was associated with changes in the measurements of the obturator arteries with minimal changes in other measurements. Our results indicate that this technology provides similar measurements to those found in previous unembalmed cadaver studies. This technology offers a great opportunity to study anatomical relationships in a native undisturbed state.

A digital anatomical study of the corona mortis in females

It was a different study from traditional anatomy to construct three-dimensional (3D) model of the corona mortis (CMOR) through contrasted enhanced computed tomography (CT) scanning. This will provide an aid for the understanding of the fine anatomy of CMOR, as well as surgical produces. A medical image processing system was used to process computed tomography scanning data collected from 330 cases of woman patients. Accurate digital 3D models of the CMOR were used to study the incidence, location, and the morphological patterns. These models have a rotation of 360° and allow displaying from different views. The incidence was 51.1% for the venous CMOR, 14.1% for the arterial CMOR in the 660 sides pelvic wall and vessel models. The mean distance from the symphysis pubis for the venous CMOR was 66.87 mm, and 59.60 mm for the arterial CMOR. The morphological patterns we identified were classified in three types (I-III). The model of CMOR serves as a useful tool for the learning and investigation of the CMOR. In the future, the digital anatomical data can be beneficial to illustrating the operation approach and decreasing the surgical complications.

Prevention and treatment of vascular complications of inguinal hernia repair

Objective To explore the prevention and treatment of complications of vascular injury after inguinal hernia repair. Methods The retrospective cross-sectional and descriptive study was adopted. The clinical data of 22 patients with vascular injury after inguinal hernia repair who were admitted to the First Affiliated Hospital of Chongqing Medical University between June 2005 and March 2016 were collected. Observation indicators included: (1) the vascular complications after inguinal hernia repair: vascular injury, peritoneal interstitial hemorrhage or hematoma formation, thrombosis and vascular embolization, (2) treatment, (3) follow-up. Patients were followed up by telephone interview at 15 days after discharge up to April 2016, and conditions of patients, recovery of symptoms and subsequent pharmacotherapy were detected. Results (1) The vascular complications after inguinal hernia repair: of 22 patients, peritoneal interstitial hemorrhage or hematoma formation was detected in 8 patients (vascular injury of corona mortis in 2 patients, inferior epigastric artery injury in 3 patients and unexplained peritoneal interstitial hemorrhage in 3 patients), femoral vein injury in 3 patients, femoral artery injury in 1 patient, deep vein thrombosis of the double lower limbs in 8 patients (including 2 with pulmonary embolism) and femoral and popliteal artery embolism in 2 patients. (2) Treatments: 20 of 22 patients had good therapeutic effect, 1 patient with arterial embolism received timely treatment avoiding the necrosis of limbs, 1 ischemic necrosis of partial toes and the other patients had good effect through vascular repair or construction. One patient with inferior epigastric artery injury and 1 with femoral vein injury died of hemorrhagic shock. (3) Follow-up: 20 of 22 patients were followed up for 2 weeks, with good conditions. Patients′ hemorrhage had been improved. The symptoms of patients with deep vein thrombosis and arterial embolism of lower limbs didn′t become obviously aggravated, and they took the medicine as medical advice. Conclusion The different treatments are conducted according to the occuring characteristics of vascular complications, with better outcomes. Key words: Inguinal hernia; Hernia repair; Iatrogenic injury; Vascular injury; Therapy

Low Pressure is Necessary to View and to Protect Corona Mortis During Totally Extraperitoneal Hernia Repair.

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. 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. 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. 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.

Variations in the obturator artery around the obturator foramen assessed by three-dimensional computed tomographic angiography and prevention of vascular-related complications in rotational acetabular osteotomy.

The aims of this study were (1) to evaluate the anatomical variations and locations of the obturator artery at the obturator foramen using computed tomographic (CT) angiography images and (2) to evaluate the pubic osteotomy site in rotational acetabular osteotomy using postoperative CT images in order to assess the relationship between the obturator artery and the pubic osteotomy site. We examined a total of 196 hips in 98 consecutive Japanese patients for aim (1), and 38 consecutive patients who underwent rotational acetabular osteotomy for aim (2). The prevalence of arterial anastomosis of the obturator artery (corona mortis) was 14.3%, with the obturator artery being located closer to the superior pubic ramus and the osteotomy site in these subjects. Extensive care should be taken during rotational acetabular osteotomy in patients showing variations of the obturator artery with corona mortis.

A new concept and classification of corona mortis and its clinical significance

PurposeThe obturator artery and its accessory (aberrant) arising from different origins and crossing the pubic rami are vascular variations. The internal iliac artery usually provides the obturator artery which may communicates with the external iliac artery through either the accessory obturator or inferior epigastric artery. A collateral circulation between the external and internal iliac system is known as corona mortis. The aim of current study is to provide sufficient data of vascular variability crossing the pubic rami for clinical field. MethodsPresent study includes 208 hemipelvises dissected in the Institution of Anatomy, Medical University of Graz. During dissection, the obturator artery and its accessory crossing the superior rami of pubic bone were found to have different origins. ResultsThe obturator artery arising from the external iliac artery and from the femoral artery accounts for 9.8% and 1.1% respectively. Therefore, it passes over the superior pubic rami in 10.9%. Further, the accessory (aberrant) artery arises only from the femoral artery in 1.1%. In present study, the vascular variation crossing the superior pubic rami with or without collateral circulation between external and internal iliac system referred as corona mortis is addressed. This study includes new classification of obturator and accessory obturator arteries as well as the corona mortis. It includes a comparison of corona mortis incidence in Austria population and other populations. The corona mortis found to be in 12% of Austrian population. ConclusionA great attention of clinicians, radiologists, surgeons, orthopedic surgeons, obstetricians and gynecologists has to be considered before pubic surgical procedures such as internal fixation of pubic fracture, an inguinal hernia repair. Further, traumatic pubic rami fracture may lead to massive hemorrhage due to laceration of the obturator artery.

Transobturator surgery in presence of corona mortis: a study in 13 women.

Severe and life-threatening bleeding has been reported in the literature after retropubic mid-urethral slings procedure, due to corona mortis damage. The aim of this study is to evaluate safety of transobturator passage of the tape in stress-urinary incontinence (SUI) correction and anchoring the mesh in pelvic-organ prolapse (POP) repair in the presence of corona mortis. Thirteen women with a pre-operatory contrast-enhanced abdominal multidetector computed tomography were prospectively enrolled in the study between January 2009 and December 2014. Eight women underwent a Monarc® and one a Spark® Sling System procedures for SUI correction, and three an Elevate® Anterior and Apical prolapse system and one a Perigee procedure to repair anterior/apical POP. All procedures were performed by a single experienced pelvic surgeon. Surgery was uneventful in all cases. No major bleeding was seen during surgery. No pelvic hematoma was identified 24 hours after the procedure. All women were discharged 1 day after surgery. Transobturator surgery seems to be a safe way in the presence of the corona mortis. However, further studies are needed to confirm these preliminary findings.

A South Indian cadaveric study on obturator neurovascular bundle with a special emphasis on high prevalence of ‘venous corona mortis’

Surgical procedures in the pelvic region are very challenging because of the complex anatomy of this region. “Corona mortis” is a term used to describe retro-pubic anastomosis between the obturator and external iliac vessels. It is considered as a key structure as significant haemorrhage may occur if the vessels are cut accidentally during pelvic surgeries. Earlier studies have documented a high frequency of venous anastomosis compared to its arterial counterpart. The objective of our study was to document the prevalence of venous corona mortis in South Indian human adult cadaveric pelvises. We conducted this study on 73 cadaveric pelvic halves. Out of the 73 hemi pelvises, 36 were normal without any variations of the obturator vessels while 37 hemi pelvises (51%) showed the presence of abnormal obturator vessels which proves to be a very high incidence in terms of variations. Out of the 37 hemi pelvises, 25 (68%) showed the presence of 2 obturator veins, out of which 1 was normal and the other was an abnormal obturator vein. 8 hemi pelvises (22%) had only abnormal obturator vein. Most of the abnormal obturator veins drained into the external iliac vein, while two veins drained into inferior epigastric veins. Venous corona mortis is said to be frequently encountered during surgery and is considered to be as important as arterial corona mortis in its clinical implications. Individual evaluation of this risky anatomical structure should be done prior to any surgical interventions.

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.