Pelvic Brim Research Articles

Results of modified stoppa approach for anterior column acetabular fractures

Introduction: Surgical management of displaced acetabular fractures has become the gold standard after the early work of Le tournel (1–4). The choice of operative approach is dependent on the fracture type, direction of displacement, skin situation at the surgical incision site, and duration from initial injury (5–7). The fractures with the main anterior displacement are approached anteriorly, while those with the main posterior displacement are approached posteriorly. A combined or extended approach is used if the displacement involves both the anterior and posterior parts of the acetabulum. This study presents our experience of internal fixation of the acetabular fractures and pelvic fractures using a newly modified Stoppa approach, which provides closer visualization to the entire anterior column, quadrilateral surface and the pelvic brim portion of the posterior column.Materials and methods: From February 2014 to April 2016, 29 cases of acetabular fractures were treated at our institution. The inclusion criteria for this study consisted of all simple and combined acetabular fracture types with main anterior displacement. And the patients with history of cesarean section, hysterectomy, bladder injury, prostatectomy, or bladder surgery were excluded. All the patients were regularly followed in out patient department at two weeks, six weeks, three months, six months, and one year postoperatively. AP pelvic and Judet radiographs were taken and reviewed by an independent orthopaedic trauma surgeon,Results: In this study 29 patients were followed up, out of which an anatomic reduction was obtained in 24 patients (82.8 %), a satisfactory reduction in four patients (13.8 %) and poor reduction in one patient (3.4 %). All iliac wing fractures were anatomically reduced (n = 29). The Harris hip score was more than 90 points in 11 patients (37.9 %), 80–89 in 16 (55.2 %) and less than 79 in two patients (9 %).Conclusion: Our experience using of the newly modified Stoppa approach for the treatment of acetabular fractures provides excellent access and visualization to the anterior column, quadrilateral surface and sciatic notch, while permitting good to excellent reduction and fixation.

Efficacy of robot-assisted laparoscopic ureteral reimplantation for primary obstructive megaureter in children

Objective To evaluate the clinical efficacy of robot-assisted laparoscopic ureteral reimplantation (RAUR) for primary obstructive megaureter (POM) in children. Methods Twenty-one patients who underwent RAUR for POM in Bayi Children’s Hospital between 2017 April and 2018 April were retrospectively analyzed. The study population consisted of 15 boys and 6 girls aged between 2 months and 11 years. Ten patients had left POMs, 9 had right POMs and two had bilateral POMs. All patients were preoperatively diagnosed with a POM based on urinary system ultrasonography, magnetic resonance urography, and diuretic renal dynamic imaging. Our main technique key steps include: Under general anesthesia, the patients were placed in a Trendelenburg position approximately 40 degrees from the horizon. An 8.5-mm camera port was placed at the level of the umbilicus. Followed by two 5-mm robotic Trocars placed under direct vision 6 cm to the camera port separately, a 5-mm assistant port was placed on the right upper abdominal quadrants which was located 3 cm from the camera and robotic port. The ureter was identified at the pelvic brim. The peritoneum covering the ureter was incised and the ureter was mobilized to the level of the vesico-ureteric junction. The bladder was filled with 60 ml saline and a 5 cm length and 1.5 cm wide submucosal detrusor tunnel was created. The ureter was transected at the bladder mucosa and the narrowed ureteral segment was discarded. The ureteroneocystostomy was performed using 6-0 absorbable suture. Dissecting the perivesical fascia appropriately and using down-top suturing approach, use of an apical stay stitch, and incorporation of the ureteral adventitia during detrusorraphy. Postoperative complications were analysed using the Clavien-Dindo classification. Success was defined as symptomatic relief, decreased hydronephrosis on ultrasound and no evidence of vesicoureteral reflux on voiding cystourethrography. Results All surgeries were successfully completed without conversion and no intra-operative complication was encountered. The mean operative time was 117.6±18.1(89-165)min, the mean estimated blood loss was 11.9±4.3(5-25)ml, the abdominal drainage tubes were removed after a mean of 4.9±1.1(3-8)days, and the mean postoperative hospital stay was 6.3±1.3(4-10) days. Postoperative complications (Clavien Ⅰ-Ⅱ) occurred in 9.5% (two patients had recurrent urinary tract infections postoperatively) children, no grade Ⅲ-Ⅳ complication was observed. The pre-operative symptoms in all patients disappeared. One patient had grade Ⅱ VUR on VCUG, who were followed conservatively. Ultrasound at postoperative follow-up showed that the hydronephrosis was disappeared in 20 ureters and significantly decreased in 3 ureters. The success rate was 95.7% at a mean follow-up of 16.3±4.0(10-23)months. Conclusion RAUR is a safe and feasible option for the treatment of POM in children with higher success rate and lower complication rate. Key words: Laparoscopes; Robot-assisted; Ureter reimplantation; Primary obstructive megaureter; Children

Posterolateral clamp placement on the pelvic brim provides optimal reduction of transtectal acetabular fractures fixed through the anterior intrapelvic approach.

To determine the optimal position of reduction clamps applied to reduce transtectal transverse acetabular fractures approached through the anterior intrapelvic route. Transtectal transverse fractures were created in sawbone hemipelvis models. Fractures were reduced and held with a large pointed reduction clamp with one tine centered on the quadrilateral plate and the other placed in one of nine various positions on the pelvic brim accessible from the anterior intrapelvic (AIP) approach. Reduction was assessed by measuring maximum gapping and step-off at the joint surface. The posterolateral pelvic brim clamp position provided the most accurate reduction with the smallest articular fracture gap (mean 1.09 ± 1.05 mm) and step-off (mean 0.87 ± 1.35 mm). This clamp position, compared with the other positions as a whole, also yielded the highest proportion of perfect reductions (0 mm maximum displacement) for both step-off (83% vs 34%; RR 2.4, 95% CI 1.7-3.2) and gap (88% vs 49%; RR 1.8, 95% CI 1.4 to 2.2). When clamping transtectal fractures through the AIP approach, positioning the clamp posterolaterally on the pelvic brim appears to provide the best reduction in this fracture model.

2198 New Laparoscopic Entry Port for Previous Surgery Cases: Jain Point

Study Objective Laparoscopy in previous surgery cases is a challenge due to risk of encountering adhesions during the first blind trocar entry. This study demonstrates the technique, and relative benefits of a new entry point. Design It is a retrospective study undertaken at a high volume tertiary care referral center for advanced gynecological laparoscopic surgery. Setting Tertiary Care Centre Patients or Participants The total number of patients from January 2011 to March 2019. Total 6830 laparoscopic cases were done between January 2011 to March 2019. In 1948 patients there was a history of previous abdominal surgeries. Interventions Working over the years we found that post surgical adhesions are encountered usually in the midline or right side. The left side is spared as the colon adheres at the pelvic brim and stomach and spleen lie higher up at T 10 level. So we developed a point which is at L4 level and on the left side. It is at the level of umbilicus on a straight line drawn vertically upwards from a point 2.5 cm medial to the anterior superior iliac spine. We first introduce the veress needle perpendicular to the abdomen and then the 5mm telescope from this point, and optimize the 10 mm telescope entry. Jain Point port doubles up as the main working port in due course of surgery. Measurements and Main Results All of the 6830 cases were entered by the Jain Point in an identical manner. Out of these 1948 case were of previous one or multiple surgeries. Conclusion Jain Point offers an alternate safe entry point in previous surgery cases, applicable to upper, mid and lower abdominal scars. Laparoscopy in previous surgery cases is a challenge due to risk of encountering adhesions during the first blind trocar entry. This study demonstrates the technique, and relative benefits of a new entry point. It is a retrospective study undertaken at a high volume tertiary care referral center for advanced gynecological laparoscopic surgery. Tertiary Care Centre The total number of patients from January 2011 to March 2019. Total 6830 laparoscopic cases were done between January 2011 to March 2019. In 1948 patients there was a history of previous abdominal surgeries. Working over the years we found that post surgical adhesions are encountered usually in the midline or right side. The left side is spared as the colon adheres at the pelvic brim and stomach and spleen lie higher up at T 10 level. So we developed a point which is at L4 level and on the left side. It is at the level of umbilicus on a straight line drawn vertically upwards from a point 2.5 cm medial to the anterior superior iliac spine. We first introduce the veress needle perpendicular to the abdomen and then the 5mm telescope from this point, and optimize the 10 mm telescope entry. Jain Point port doubles up as the main working port in due course of surgery. All of the 6830 cases were entered by the Jain Point in an identical manner. Out of these 1948 case were of previous one or multiple surgeries. Jain Point offers an alternate safe entry point in previous surgery cases, applicable to upper, mid and lower abdominal scars.

2643 Ovarian Remnant Resection in a Patient with History of Ureteral Re-Implantation

Video Objective This video describes a systematic stepwise approach for complete dissection of ovarian remnant in the setting of a previous ureteral re-implantation. Setting A 40 year old patient presenting with a history of ureteral injury during hysterectomy, followed by re-implantation. She had another ureteral injury during oophorectomy which required a secondary re-implantation. The patient then developed pelvic pain, and she was found to have a large pelvic mass. Hormonal assays confirmed premenopausal status consistent with ovarian remnant syndrome. The patient decided on medical management for several years, including progestational agents and GnRH agonists, but ultimately the pain became excessive, and she decided on surgery. Interventions Laparoscopic resection of ovarian remnant was performed in a systematic stepwise approach, with sealing and cutting of the ovarian vessels at the pelvic brim, and removing of the entire ovarian vessels pedicle together with the adherent pelvic side wall. Conclusion This stepwise approach for ovarian remnant resection provides a roadmap for the effective and safe excision of the ovarian remnant, while minimizing the risk of injury to the bladder, the ureters and the rectum.

1288 Robotic Assisted Ovarian and Fallopian Tube Transposition: A Video Presentation

Video Objective The objective of this video is to demonstrate the technique of performing an ovarian transposition using robotic assistance in order to preserve ovarian function in a patient who is planning to undergo pelvic radiation therapy. Setting The patient is a 29 y/o nulligravida with a history of stage 3B rectal adenocarcinoma. She is s/p neoadjuvant chemotherapy using Folfox and Capecitabine and is planning for pelvic radiation therapy. She elects to undergo a transposition procedure in order to reduce her risk of premature ovarian failure. Interventions The robotic trocars are placed in the standard gynecologic oncology robotic fashion in order to mobilize the ovaries above the pelvic brim and out of the radiation field. To avoid comprising the ovarian vasculature, retroperitoneal tunnels are created in the pelvic sidewalls bilaterally and the adnexa are pulled through. The ovaries are sutured in place superior to the anterior superior iliac spine and lateral to the psoas muscle. Surgical clips are placed at the border of each ovary for identification during radiation planning. Conclusion Pelvic radiation therapy is often required in the management of gynecologic and nongynecologic malignancies. The ovaries are extremely radiosensitive and very low doses can be associated with a high risk of ovarian failure. Premature menopause results in long-term deprivation of estrogen and can lead to increased risk of all-cause mortality, cardiovascular risk, and osteoporosis. Research indicates that many female patients diagnosed with cancer do not receive adequate information regarding ovarian preservation. One study reports that 50% of oncologists reported moderate to high confidence in knowledge of female fertility preservation. Laparoscopic ovarian transposition is a great surgical option for reproductive age women undergoing gonadotoxic radiation. Robotic assisted ovarian transposition has the advantage of improved visualization and articulation of wrist movements. Robotics can help to overcome the limitations of laparoscopy, especially in complicated procedures.

Laparoscopic Resection of Ovarian Vessel Coils and a Tubal Occlusion Device

Video Objective To describe the anatomy of the ovarian vessels cephalad to the pelvic brim. Setting A 45 year old multiparous woman presents with chronic right pelvic pain following hysteroscopic tubal sterilization. Bilateral ovarian vein embolization was performed for suspected pelvic congestion syndrome. Her pain worsened post-embolization. After an extensive pelvic pain evaluation, the decision was made to remove her embolization and tubal occlusion coils. Interventions Laparoscopic dissection and removal of the right ovarian vessels above the pelvic brim is described. Multiple steps are required for a safe and complete resection: 1- Retroperitoneal access; 2- Maintaining hemostasis; 3- Traction/counter-traction; 4- sharp and blunt dissection; 5- judicious use of electrosurgical energy. Conclusion Successful dissection/resection of ovarian vessels is feasible and safe with in-depth knowledge of neighboring structures cephalad to the pelvic brim.

Case Report: Ureteral Obstruction at the Time of Hysterectomy after Uterine Artery Embolization

Study Objective To report ureteral obstruction at the time of hysterectomy following uterine artery embolization (UAE). Design Case report. Setting Clara Maass Medical Center. Patients or Participants 42 year-old African-American woman. Interventions Hysterectomy following UAE. Measurements and Main Results Patient presented for total laparoscopic hysterectomy (TLH) for abnormal uterine bleeding and dysmenorrhea. Patient had a history of UAE two years prior, which resolved her symptoms. MRI during UAE showed no kidney abnormalities. Preoperative TLH evaluation included bimanual exam and transvaginal ultrasound, which showed a globular uterus. TLH with bilateral salpingectomy, adhesiolysis, and minor endometriosis excision were performed uneventfully. A routine post-procedural cystoscopy showed no jet from the right ureter. A stent was attempted, but obstruction was noted at the mid-ureter, 6 cm from the vesicoureteral junction. Retroperitoneal dissection showed a dilated distal ureter but no injury noted. Urology was consulted and intraoperative retrograde pyelogram showed dilated distal ureter with complete obstruction. Ureteroscopy showed a complete obstruction at the level of pelvic brim. Postoperative CT with IV contrast showed severe right renal atrophy. Labs showed normal BUN and creatinine levels, but a renal scan showed a non-functioning right kidney. Nephrology concluded that no surgery was needed to resect the atrophic kidney, and the patient was discharged on postoperative day one. Conclusion Our experience is similar to a 2005 Canadian case report, in which a patient had complete ureteral obstruction following UAE, requiring nephrectomy. Although ureteral obstruction that results in unilateral non-functioning kidney following UAE is rare, it is likely an under-reported complication. As the uterine arteries supply the lower ureters, embolization could lead to segmental infarction of the ureter. Similarly, as leiomyoma necrose following UAE, peri-ureteral inflammation and infarction could occur. Physicians should be aware of these potential complications, and renal imaging may be indicated before hysterectomy in patients with prior UAE.

Advances in surgical repair of ureteral injury

Ureteral injury can be classified as iatrogenic or traumatic, which represents a rare but challenging field of reconstructive urology. Due to their close proximity to vital abdominal and pelvic organs, the ureters are highly susceptible to iatrogenic injury, while ureteral injury caused by external trauma is relatively rare. The signs of ureteric injury are difficult to identify initially and often present after a delay. The treatment of ureteral injury, which is depended on the type, location, and degree of injury, the time of diagnosis and the patient's overall clinical condition, ranges from simple endoscopic management to complex surgical reconstruction. And long defect of the ureter presents much greater challenges to urologists. Ureterotomy under endoscopy using laser or cold-knife is available for the treatment of 2-3 cm benign ureteral injuries or strictures. Pyeloplasty is an effective treatment for ureteropelvic junction obstruction and some improved methods showed the possibility of repairing long-segment (10-15 cm) stenosis. Proximal and mid-ureteral injuries or strictures of 2-3 cm long can often be managed by primary ureteroureterostomy. When not feasible due to ureteral defects of longer segment, mobilization of the kidney should be considered, and transureteroureterostomy is alternative if the proximal ureter is of sufficient length. And autotransplantation or nephrectomy is regarded as the last resorts. Most of the injuries or strictures are observed in the distal ureter, below the pelvic brim, and are usually treated with ureteroneocystostomy. A non-refluxing technique together with a ureteral nipple or submucosal tunnel method, is preferable as it minimizes vesico-ureteral reflux and the risk of infection. In order to cover a longer distance, ureteroneocystostomy in combination with a psoas hitch (covering 6-10 cm of defect) or a Boari flap (covering 12-15 cm) is often adopted. Among various ureteral replacement procedures, only intestinal ureteral substitution, which includes ileal ureter, appendiceal interposition and reconfigured colon substitution, has gained wide acceptance when urothelial tissue is insufficient. Ileal ureter can be used to replace the ureter of >15 cm defect and even to replace the entire unbilateral ureter or bilateral ureter. Laparoscopic and robotic-assisted techniques are increasingly being employed for ureteral reconstruction and adopted with encouraging results.

Large pelvic tubercle in orangutans relates to the adductor longus muscle.

Orangutan pelves commonly exhibit a large, projecting tubercle in the iliopubic region, historically assumed to homologous to the pubic tubercle in humans. However, it is not clear whether this tubercle is a unique feature of Pongo, or if it is anatomically homologous with the human pubic tubercle when considered as a soft tissue attachment point. To clarify this issue, we dissected orangutan and other ape cadaveric specimens to evaluate the pelvic brim soft tissues and how they may relate to the tubercle (when present). We additionally conducted a broad osteological survey of pelvic brim morphology across 28 primate genera (n = 294 specimens) to document the presence of the tubercle in primate pelves. Cadaveric dissections revealed that the tubercle is exclusively associated with the proximal attachment of the adductor longus muscle tendon in orangutans. Our osteological survey confirms that the tubercle is both constantly present and very prominent in orangutans. We observed that the tubercle is consistently situated along the pectineal line, lateral to where the pubic tubercle in humans is found, thereby making its structural homology unlikely. The osteological survey documented the tubercle at polymorphic frequencies in all hominoid taxa, though generally less protuberant than observed in Pongo. We argue that this further excludes its possibility of homology with the pubic tubercle, and that it may therefore be more appropriately be considered an adductor longus tubercle. We discuss possible functional and phylogenetic implications for this feature.

Keep Your Landmarks Close and the Hypogastric Nerve Closer: An Approach to Nerve-sparing Endometriosis Surgery

ObjectiveExcisional techniques used to surgically treat deep infiltrating endometriosis (DIE) can result in inadvertent damage to the autonomic nervous system of the pelvis, leading to urinary, anorectal, and sexual dysfunction [1–4]. This educational video illustrates the autonomic neuroanatomy of the pelvis, identifying the predictable location of the hypogastric nerve in relation to other pelvic landmarks, and demonstrates a surgical technique for sparing the hypogastric nerve and inferior hypogastric plexus. DesignUsing didactic schematics and medical drawings, we discuss and illustrate the autonomic neuroanatomy of the pelvis. With annotated laparoscopic footage, we demonstrate a stepwise approach for identifying, dissecting, and preserving the hypogastric nerve during pelvic surgery. SettingTertiary care academic hospitals: Mount Sinai Hospital in Toronto, Ontario, Canada, and S. Orsola Hospital in Bologna, Italy. InterventionsRadical excision of DIE with adequate identification and sparing of the hypogastric nerve and inferior hypogastric plexus bilaterally was performed, following an overview of pelvic neuroanatomy. The superior hypogastric plexus was described and the hypogastric nerve, the most superficial and readily identifiable component of the inferior hypogastric plexus, was identified and used as a landmark to preserve autonomic bundles in the pelvis. The following steps, illustrated with laparoscopic footage, describe a surgical technique developed to identify and preserve the hypogastric nerve and the deeper inferior hypogastric plexus without the need for more extensive pelvic dissection to the level of the sacral nerve roots: (1) transperitoneal identification of the hypogastric nerve, with a pulling maneuver for confirmation; (2) opening of the retroperitoneum at the level of the pelvic brim and retroperitoneal identification of the ureter; (3) medial dissection and identification of the hypogastric nerve; and (4) lateralization of the hypogastric nerve, allowing for safe resection of DIE. ConclusionThe hypogastric nerve follows a predictable course and can be identified, dissected, and spared during pelvic surgery, making it an important landmark for the preservation of pelvic autonomic innervation.

Gross and Histologic Anatomy of the Pelvic Ureter: Clinical Applications to Pelvic Surgery.

To further evaluate relationships of the pelvic ureter to clinically relevant structures and to characterize the anatomy, histology, and nerve density of the distal ureter. In this observational cadaveric study, 35 female cadavers were examined, 30 by gross dissections and five microscopically. Ureter length and segments of pelvic ureter were measured. Closest distances between the ureter and clinically relevant points were recorded. The distal pelvic ureter and surrounding parametrium were evaluated microscopically. Nerve density was analyzed using automated quantification of peripheral nerve immunostaining. Average measurements of nerve density in the anterior and posterior quadrants surrounding the ureter were statistically compared using a two-tailed t test. Descriptive statistics were used for analyses with distances reported as mean±SD (range). Gross dissections revealed ureter length of 26.3±1.4 (range 24-29) cm (right), 27.6±1.6 (25-30.5) cm (left). Lengths of ureter from pelvic brim to uterine artery crossover were 8.2±1.9 (4.4-11.5) cm (right), 8.5±1.5 (4.5-11.5) cm (left) and from crossover to bladder wall 3.3±0.7 (2.4-5.8) cm (right), 3.2±0.4 (2.6-4.1) cm (left). Intramural ureter length was 1.5±0.3 (1-2.2) cm (right) and 1.7±1.2 (0.8-2.5) cm (left). Distances from the ureter to uterine isthmus: median 1.7 (range 1-3.0) cm (right) and 1.7 (1.0-2.9) cm (left); lateral anterior vaginal fornix 1.5 (1.0-3.1) cm (right) and 1.7 (0.8-3.2) cm (left); lateral vaginal apex 1.3 (1.0-2.6) cm (right) and 1.2 (1.1-2.2) cm (left) were recorded. Microscopy demonstrated denser fibrovascularity posteromedial to the ureter. Peripheral nerve immunostaining revealed greater nerve density posterior to the distal ureter. Proximity of the ureter to the uterine isthmus and lateral anterior vagina mandates careful surgical technique and identification. The intricacy of tissue surrounding the distal ureter within the parametrium and the increased nerve density along the posterior distal ureter emphasizes the importance of avoiding extensive ureterolysis in this region.

Displaced Descending Colon and Dolichosigmoid with Uncommon Sigmoidal Artery Branching Pattern

Sigmoid colon is a part of large intestine and normally measures 15” in length that extends from the pelvic brim to the third piece of the sacrum where it becomes the rectum. Dolichosigmoid or redundant sigmoid colon is a term used for sigmoid colon longer than its normal size. The present case had a displaced descending colon and a redundant part of sigmoid colon. During a routine dissection class for medical students, an anatomical variation related to sigmoid colon in an 87‐year‐old male cadaver was found. The colon was carefully dissected and studied in detail the position, attachment of sigmoid mesocolon, examination of viscera in close proximity and the blood supply to each part of the large intestine. A meticulous review of the literature was conducted as well. An anomalous displacement of descending and sigmoid colons was found. The descending colon is normal in length, retroperitoneal and lying close to the mid‐line leaving out a space to its left that was occupied by loops of jejunum and ileum. The sigmoid colon is composed of redundant ascending and normal descending parts. The redundant part of the sigmoid colon is centrally placed as a loop ascending into the peritoneal cavity reaching the splenic flexure at the level of T11 approximately. The descending part of the sigmoid colon crosses the midline at L1 and runs close to the right midclavicular line continuing as rectum. The total length of sigmoid colon measures 23.2”. The blood supply to the redundant part of the sigmoid comes from a common trunk arising from inferior mesenteric that splits into left colic and two additional sigmoidal branches. The blood supply to the descending part of sigmoid is supplied by sigmoidal artery coming directly from inferior mesenteric artery. The branching pattern of sigmoidal arteries compared to previous cases in the literature makes this case very unique. Embryology of gut development is complex and often unpredictable, leading to variations in length and position. The growth and rotation of midgut is divided into four stages. An excess of growth of the caudal segment of gut tube in stage 3 can cause redundant sigmoid. This variation could increase the chances of sigmoid volvulus, constipation and may pose risk as the loops may coil around and form a knot leading to obstruction. A redundant loop of sigmoid colon may be asymptomatic or it might lead to urinary, digestive and vascular complications. The descending colon is normal in length but lies close to the midline which may compress the aorta when loaded with feces. Radiologists and surgeons must be well aware of these variations to establish a correct diagnosis and assert the appropriate management when performing colonoscopy, sigmoidoscopy and abdominopelvic procedures.Support or Funding InformationDepartment of Anatomy Touro College of Osteopathic MedicineThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Close relationship between the short round ligament and the ovarian prolapsed inguinal hernia in female infants.

The aim of this study was to clarify the relationship between the length of the round ligament and the presence of a patent processus vaginalis (PV) based on the hypothesis that a short round ligament is the cause of ovarian inguinal hernia in female infants. Between April 2011 and March 2017, 132 girls underwent laparoscopic surgery for inguinal hernia. Before surgery, the presence of ovarian prolapse was diagnosed. We observed the internal inguinal ring laparoscopically and examined the diameter of the PV orifice as well as the round ligament length. Medical records and video records were reviewed to evaluate PV patency and round ligament length. Seventeen of the 132 cases had an ovarian inguinal hernia; all of them were infants. In all infants, with or without a prolapsed ovary, the round ligament was short, causing the ovary and fallopian tube to be close to the hernia orifice over the pelvic brim. In girlsaged over 12 months, the round ligament lengths on the hernia side, contralateral open PV side, and contralateral closed PV side were 33.0 ± 9.3, 36.8 ± 7.5, and 41.4 ± 8.5mm, respectively. The round ligament length in open PV was significantly shorter than in the closed PV, but the difference was smaller in older patients. The round ligament, which is the female gubernaculum in the fetus, was shorter in the open PV than in the closed PV in younger girls. The short round ligament results in the ovarian prolapsed hernia.

37: A 20-centimeter peritoneal inclusion cyst presenting as vaginal prolapse

This video shows the surgical evaluation and excision of a peritoneal inclusion cyst with laparoscopic repair of the pelvic floor. Our case is that of a 44-year-old female referred to urogynecology for pelvic organ prolapse. The patient reported bulge sensation for six months. On examination, a vaginal mass descended four centimeters outside of the introitus. The mass was reducible and unchanged while standing or straining. Dynamic MRI demonstrated a 20-centimeter intraabdominal cystic mass located between the uterus and the rectum and extending into the vagina. Robotic assisted laparoscopic evaluation showed endometriosis and a large peritoneal inclusion cyst extending from the pelvic brim to the rectovaginal septum. After the fluid was drained, redundant peritoneal tissue was excised. The distended posterior vaginal wall was then laparoscopically reduced using interrupted sutures of 2-0 PDS to imbricate the posterior vagina down to the perineal body. Uterosacral ligaments were plicated at the apex of the vagina with interrupted 2-0 PDS, suspending the posterior vaginal apex and uterus. Given the large peritoneal defect from the dissection, a culdoplasty was performed with purse string sutures using 2-0 monocryl. On repeat vaginal exam, restoration of normal anatomy was confirmed. At the six-week post-operative visit, the patient denied further bulge symptoms and had a normal vaginal exam. Pathology revealed benign simple mesothelial cyst without malignancy. We present a unique presentation of a large peritoneal inclusion cyst presenting as vaginal prolapse. Laparoscopic repair can be performed similarly to closing an enterocele. Consideration for laparoscopic repair of a high rectocele can be performed in specific cases when already working laparoscopically to avoid vaginal incisions. Further studies are needed to determine the efficacy of laparoscopic versus transvaginal rectocele repair.

Comparison of advantages and disadvantages of 4- and 6-arm mesh prostheses in reconstructive surgery of the urogenital prolapse in women

The study objective is to compare the effectiveness and safety of using 4-and 6-arm mesh prostheses in transvaginal correction of urogenital prolapse. Materials and methods . From 2013 to 2018, 164female patients with grade II—IV prolapse of the pelvic muscles underwent surgery. Reconstruction of the pelvic floor using 4-arm prosthesis Prolift anterior was performed in 54 (33 %) patients (group 1), 6-arm prosthesis OPUR — in 110 (67 %) patients (group 2). The patients’ age varied between 45 and 76years (mean age 56.3 years). All women previously delivered children (69 % delivered 2 or more children). In 73 % patients, labor was complicated by raptured cervix and/or groin, episioto-my, fetal skull remaining stationary above the pelvic brim. In 25 % of women, grade IV cystocele was diagnosed at the time of examination, in 62 % — grade III, in 13 % — grade II; grade IVhysteroptosis was diagnosed in 12 % of women, grade III — in 54 %, grade II — in 34 %. Results. In the group 1, cystocele was corrected in 90 % of cases, hysteroptosis — in 75 %. Mean blood loss was 150.0 + 69.6 ml. Operative time varied between 60 and 169 min. In the group 2, cystocele was corrected in 100 % of cases, hysteroptosis — in 98 %. Mean blood loss was 125.0 + 59.6 ml. Operative time varied between 38 and 143 min. Women noted decreased emotional tension during sex. Conclusion. Disadvantages of 4-arm meshes include worse correction of hysteroptosis and significant complications, rate and grade of which lead to a decrease in manufacture of the prosthesis. Modern 6-arm mesh prosthesis OPUR is safer and more effective. Its construction and method of implantation were developed with the goal to eliminate the main disadvantages of 4-arm prostheses.

3D statistical model of the pelvic ring - a CT-based statistical evaluation of anatomical variation.

The pelvic ring is a highly complex construct with a central role for human stability and mobility. The observable interindividual differences in skeletal anatomy are caused by anatomical variation in the innominate bones as well as the sacrum, further to differences in the spatial arrangement of these bones to each other. The aim of this study was to generate a 3D statistical model of the entire pelvic ring in order to analyse the observed interindividual differences and anatomical variation. A series of 50 anonymized pelvic CT scans of uninjured Japanese adults [30 males, 20 females, average age of 74.9years, standard deviation (SD) 16.9years] were processed and analysed, resulting in a 3D statistical overall mean model and separate male and female mean models. Principal component analysis (PCA) of the overall statistical model predominantly showed size variation (20.39%) followed by shape variation (14.13%), and a variation of the spatial arrangement of the sacrum to the innominate bones in different anatomical peculiarities (11.39 and 8.85%). In addition, selected internal and external pelvic parameters were manually measured with the objective of further evaluating and quantifying the observed interindividual as well as the known sex-specific differences. A separate statistical model of the grey value distribution based on the given Hounsfield unit (HU) values was calculated for assessing bone mass distribution, thus an indication of bone quality utilizing grey values as a quantitative description of radiodensity was obtained. A consistent pattern of grey value distribution was shown, with the highest grey values observed between the sacro-iliac joint and the acetabulum along the pelvic brim. Low values were present in the sacral ala, in the area of the iliac fossa as well as in the pubic rami next to the symphysis. The present model allows a differentiated analysis of the observed interindividual variation of the pelvic ring and an evaluation of the grey value distribution therein. Besides providing a better understanding of anatomical variation, this model could be also used as a helpful tool for educational purposes, preoperative planning and implant design.

Digital Anatomy to Improve Screw Insertion Techniques for Plate-Screw Fixation of the Pubic Body.

Objectives This study aims to investigate screw insertion sites on the pubic body and the safe screw insertion parameters of a plate-screw fixation system based on the premise of avoiding damage to the inguinal canal and disruption of the rectus abdominis at the pubic symphysis and pubic crest. Research Methods Excluding cases with poor image quality, tumors, malformations, and fractures, the data of 80 healthy adults (40 males and 40 females aged from 21 to 83 years old, with an average age of 51.65 years) undergoing a computed tomography (CT) scan of the pelvis between January and June of 2017 were collected from Shandong Provincial Hospital. The CT scans were imported to Mimics® software to reconstruct three-dimensional pelvic models. A 3.5 mm pelvic reconstruction plate was placed starting at the outer edge of the pubic tubercle and along the pelvic brim. The two innermost screw insertion sites were marked. The safe range for the screw insertion sites was then determined. The screw insertion plane was selected to measure the safe screw insertion parameters. The length of the screw, the direction of insertion, and intersex differences were then explored via statistical analyses. Results The medial inclination angles (MIAs) of the screw insertion plane for males and females were 30.42±7.95° and 32.88±10.65°, respectively, with no statistically significant differences. For the medial screw, the maximum anterior inclination angle (MAIA), the maximum screw length, and the maximum posterior inclination angle (MPIA) were 46.51±4.01°, 12.40±9.53 mm, and 11.78±10.22° on average, respectively, with no significant differences by gender (P>0.05). For the lateral screw, the MAIA was 10.35±9.46° and showed no gender differences (P>0.05), but the male group had a greater MPIA (male 11.80±11.00° vs. female 6.23±7.91°, P<0.05) and maximum screw length (male 55.71±6.36 mm vs. female 48.68±8.65, P<0.001). For the tangential screw, the maximum screw length, MIA, and anterior/posterior inclination angle (APIA) were 52.19±8.33 mm, 31.65±9.42°, and 7.53±10.18°, respectively, with no significant differences in the angles by gender (both P>0.05), although the screw length in the male group was significantly longer than that in the female group. Conclusions Insertion of two screws into the pubic body through a plate from the lateral side of the pubic tubercle is safe and can maintain the origin of the rectus abdominis and the integrity of the inguinal canal compared to traditional plate-screw fixation. Considering that the pubic body is thinner on the lateral side, we suggest a more medial inclination angle for the lateral screw.

Shoulder dystocia: incidence, mechanisms, and management strategies.

Shoulder dystocia can lead to death or brain damage for the baby. Traction on the head can damage the brachial plexus. The diagnosis should be made when the mother cannot push the shoulders out with her own efforts with the next contraction after delivery of the head. There should be no traction on the head to diagnose shoulder dystocia. McRoberts’ position is acceptable but it should not be accompanied by any traction on the head. If the posterior shoulder is in the sacral hollow then the best approach is to use posterior axillary traction to deliver the posterior shoulder and arm. If both shoulders are above the pelvic brim, the posterior arm should be brought down with Jacquemier’s maneuver. If that fails, cephalic replacement or symphysiotomy is the next step. After shoulder dystocia is resolved, one should wait 1 minute or so to allow placental blood to return to the baby before cutting the umbilical cord.

CT pelvimetry of variant pelvis and child birth prognosis

The aim of this study was to determine the threshold values of pelvimetry by scanning and to evaluate the ability of the pelvimetry alone to diagnose a fetal-pelvic disproportion. It was an observational retrospective study on 410 pregnant women who had a scanner pelvimetry for any reasons. Based on the fetal presentations, two subgroups (breech and cephalic -others) have been defined. Measurements of the main obstetric diameters (promonto-retropubic, median transverse and dual sciatica) were taken. The 5th and 10th percentile were calculated as well as the 90th and 95th to determine the threshold values of pelvimetry by scanner. The scanner values found on CT were compared with the standard X ray pelvimetry values. Referring to extreme values obtained by pelvimetry scanner, some pathological pelvic brim were reconstructed in 3D. Moreover, the delivery prognostic was analyzed by crossing the pelvic inlet dimensions (Magnin index) and pelvic outlet dimensions (bi-sciatic diameter) with the outcome of the delivery. The mean values of the scanno-pelvimetry measurement in our series were:m12,39 cm (± 1) for the promonto-retropubic diameter, 12.88 cm (± 1.01) for the transverse median diameter and 11 cm (± 1.32) for the bi-sciatic diameter. These measurements provided an accuracy less than 1 cm compared to the standard ray pelvimetry. Although Magnin index at 23 allows a vaginal delivery, 51% of oursample have failed. Moreover, for the Magnin index at 24 and 25, the vaginal delivery failure rate remains high:45.1% and 39.61% respectively. Compared to classical pelvimetry, pelvimetry by scanner provides additional precision and allows to study the geometry of the basin. However, the pelvimetry alone could not be effective to establish the prognosis of vaginal delivery.Keywords: scanno-pelvimetry, prognosis, delivery