Pubic Tubercle Research Articles

Unilateral absence of external oblique musculo-aponeurotic complex during routine inguinal hernia repair.

IntroductionThe isolated absence of the external oblique musculo-aponeurotic complex in adults is an extremely rare anomaly. This complex is an important contributor to the strength of the inguinal canal. The present case report describes the unilateral absence of the external oblique muscle in a patient.Case presentationA 40-year-old male patient presented with a history of intermittent lower abdominal pain for 5 years which had increased over the past 6 months. Abdominal examination revealed unilateral reducible, incomplete, left sided direct inguinal hernia.Clinical discussionElective unilateral Lichtenstein's mesh hernioplasty was planned for the patient. Intraoperatively, there was no evidence of the external oblique aponeurosis and the spermatic cord was noted deep to the thickened membranous fascial layer. The inguinal ligament was thin and atrophic and was attached to the pubic tubercle medially and anterior superior iliac spine laterally. There was no evidence of any superior aponeurotic connection to the inguinal ligament. A postoperative ultrasound examination of the abdomen confirmed the unilateral absence of the external oblique musculo-aponeurotic complex.ConclusionThe possibility of such an anomaly should be considered in patients without other risk factors for hernia.

Comparison of USG-guided or landmark approach fascia iliaca compartment block for positioning in elderly hip fracture patients with spinal anesthesia: a randomized controlled observational study.

Currently, the elderly population in the world is rapidly increasing due to technological developments and convenient access to health services. Due to comorbidities in elderly patients, hip fractures are frequently observed after exposure to environmental trauma. To reduce pain during positioning in spinal anesthesia, fascia iliaca compartment block (FICB) can be applied easily and reliably. In our study, we aimed to compare the analgesic effects and duration of fascia iliaca compartment blocks performed with USG guidance or the landmark approach methods for relieving spinal anesthesia position pain. Our study included 100 patients undergoing operations due to hip fracture and administered spinal anesthesia after FICB. The group with USG-guided FICB (USG) had the blockage needle advanced to the compartment under the fascia iliaca, and 15 mL bupivacaine + 10 mL 2% lidocaine was administered. They were placed in sitting position for spinal anesthesia 20 min later and procedure duration and numerical rating scale (NRS) scores were recorded. In the group with landmark approach FICB (LAND), the spina iliaca anterior superior (SIAS) and pubic tubercle were connected with a line. The same amount of local anesthetic was administered to the external 1/3 portion of this line with the double pop technique. Procedure duration and NRS scores were recorded. There was no statistically significant difference between the two groups in terms of NRS scores (p: 0.073). There was a statistically significant difference in duration of FICB administration between the two groups (p < 0.001). Both USG-guided and landmark approach FICB methods provide adequate and similar analgesia for positioning in spinal anesthesia. However, in cases where there is no problem with access to the ultrasound device or time, safer blockage can be provided by imaging neurovascular structures with ultrasound.

Danger zone - The spermatic cord during anterior plating of the symphysis pubis

Background: Distances between anatomic landmarks and anatomic structures at risk are often underestimated by surgeons.Purpose: The goal of the study was to evaluate the distances between anatomic landmarks and the spermatic cord in case of anterior plating of the symphysis.Methods: A total of 25 pelves (50 hemipelves) of male embalmed cadavers were dissected. A 5-hole 3.5mm locking compression plate (Synthes GmbH) was fixed from directly anterior on the symphysis. Measurements were taken 1) distance between the tips of both pubic tubercles, 2) horizontal interval between the lateral border of the plate and the medial margin of the SC (bilateral), 3) distances between the medial border of the SC and the tip of the pubic tubercle (bilateral), 4) distances between the medial border of the SC and the lateral basis of the pubic tubercle (bilateral).Results: The distance between the pubic tubercles was 60.3mm in average (SD: 5.7). The interval between the lateral border of the plate and the medial margin of the SC was on average 4.5mm (SD: 1.9) on the right and 4.7mm (SD: 2.6) on the left side. The distance between the tip of the pubic tubercle and the medial border of the SC was in average 11.2mm (SD: 2.7) on the right, and 11.0mm (SD: 2.7) on the left side. The average distance between the medial border of the SC and the lateral basis of the pubic tubercle was 8.1mm (SD: 2.4) on the right and 8.2 mm (SD: 2.4) on the left side.Conclusion: The SC is at risk not only during dissection but also during anterior plating of the symphysis, because of its close relation to the SC.Clinical Relevance: Average distances between the palpable pubic tubercle and the SC are below one finger breadth (as reference).

The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis

The 3-piece inflatable penile prosthesis includes an easy-to-use pump and fluid filled reservoir which is placed in either the space of Retzius (SOR) or in an alternative ectopic location. Reservoir placement in the SOR is a blind procedure despite the SOR being surrounded by many critical structures. To date only a handful of cadaveric studies have described the relevant anatomy. To use magnetic resonance imaging (MRI) as an in-vivo model to study relevant retropubic anatomy critical for SOR reservoir placement. The study population included men with elevated prostate specific antigen or biopsy proven prostate cancer who (i) underwent pelvic MRI, (ii) without prior pelvic or inguinal surgery, and (iii) without pelvic radiation therapy. All MRIs were completed with a 3-Tesla scanner and endorectal coil. Both T1 and T2 weighted images were captured in both axial and sagittal planes. All images were reviewed by 2 independent reviewers under the supervision of a dedicated body MRI radiologist. Bladder volume was calculated using an ellipsoid formula. Relevant measurements included (i) the distance between the external inguinal ring (EIR) at the level of the pubic tubercle to the external iliac vein (EIV), (ii) the distance from the EIR at the pubic tubercle to the bladder (accounting for bladder volume) and (iii) the distance from the midline pubic symphysis to the bladder (accounting for bladder volume). Pearson correlation was used to determine correlated measurements. A total of 24 patients were included. Median participant age was 63 years (interquartile range, 59-66). The mean EIR-EIV distance was 3.0 ± 0.4 cm, the mean EIR-bladder distance was 1.8 ± 1.0 cm and the mean distance from the superior pubic symphysis to bladder was 0.9 ± 0.3 cm. There was a weak correlation between bladder volume and distance between the EIR and bladder (r = -0.30, P = .16). The use of MRI as an in-vivo model is a high-fidelity tool to study real time unaltered anatomy and allows for surgical preparation, diagnosis of anatomic variants and acts as a valuable teaching tool. This is the first in-vivo model to report relevant retropubic anatomy in penile implant surgery. Our study is limited by sample size and inclusion of participants with no history of prior pelvic intervention. We demonstrate the utility of MRI as an in-vivo model, as opposed to cadaveric models, for the understanding of relevant retropubic anatomy for implant surgeons.

Use of the Vertical Profunda Artery Perforator Flap to Capture the Dominant Perforator: A Cadaver Dissection and Imaging Study.

While the originally described transverse profunda artery perforator (tPAP) flap is designed to capture the first profunda perforator, our group hypothesized the dominant perforator may not always be captured in this configuration. This study maps the location of dominant profunda perforators using imaging and cadaveric dissections to determine the probability of capturing dominant perforators with the transverse flap design versus the vertical PAP (vPAP) variant. Fifty preoperative magnetic resonance angiogram or computed tomographic angiogram scans (100 total extremities) were examined from autologous breast reconstruction patients between 2015 and 2019. Profunda perforator characteristics that were examined included the distance from the pubic tubercle to the infragluteal fold (IGF), the distance of the perforators from the IGF, distance posterior to the gracilis, the diameter of the perforator at fascial exit, and total number of perforators present. Profunda perforator dissection was performed in 18 cadaveric extremities. Analysis included mean distance from pubic tubercle, distance posterior to the gracilis, diameter at fascial exit, and total number of perforators. In imaging analysis, the mean distance from the IGF to the fascial exit of all dominant perforators was 7.04 cm. The mean diameter of the dominant perforator at the fascial exit was 2.61 mm. Twenty-six thighs (26%) demonstrated dominant perforators that exited the fascia greater than 8 cm below the IGF. In cadaver dissections, the mean distance from the pubic tubercle to the fascial exit of all the dominant perforators was 10.17 cm. Nine cadaver specimens (50%) demonstrated perforators that exited the fascia greater than 8 cm below the estimated IGF. The dominant perforator can often be missed in the traditional tPAP design. The vPAP incorporates multiple perforators with a long pedicle, excellent vessel diameter, and favorable donor-site.

The Profunda Artery Perforator Flap: A Versatile Option for Head and Neck Reconstruction.

Although the profunda artery perforator flap has gained popularity in breast reconstruction, it has not been well described for reconstruction of head and neck defects. The authors report their experience with free profunda artery perforator flaps in postoncologic head and neck reconstruction. A retrospective review of all free profunda artery perforator flaps used for head and neck reconstruction from 2016 to 2019 was performed. Overall, 61 profunda artery perforator flap reconstructions were performed: 45 single independent flaps, 12 in conjunction with a second free flap, and four in combination with two other free flaps. The profunda artery perforator flaps were most commonly used for reconstruction of the tongue (n = 19), cheek (n = 11), parotid (n = 10), and maxilla (n = 6). The profunda artery perforator flaps averaged 7.1 × 12.1 × 1.9 cm, with a mean pedicle length of 11.5 cm. The A, B, and C perforators were located at mean distances of 7.4 cm (range, 4 to 11.5 cm), 11.7 cm (range, 8 to 18 cm), and 16.1 cm (range, 14 to 20.5 cm) from the pubic tubercle along the axis of the adductor longus muscle and 7.9 cm (range, 7 to 11cm), 7.6 cm (range, 7 to 15.5 cm), and 7.2 cm (range, 6 to 16 cm) posterior and perpendicular to the axis. There were three partial flap losses. Eight patients (13 percent) had recipient-site complications necessitating operative intervention: four for vascular compromise of the profunda artery perforator flap, two for hematoma evacuation, and two for infection. Donor-site complications were noted in seven patients (11 percent), two of whom required operative intervention. The profunda artery perforator flap is a versatile and reliable flap with consistent anatomy and a low complication rate. The profunda artery perforator flap seems to be a reasonable alternative for reconstruction of head and neck defects. Therapeutic, IV.

Endoscopic Hernia Repair: A Novel Technique for the Repair of Inguinal Hernia in a Cadaver Model.

The techniques of total extraperitoneal and transabdominal preperitoneal hernia repair have been conducted for laparoscopic repair of inguinal hernia since long. However, they offer significant disadvantages of requiring general anesthesia, producing negative cosmetic outcomes, and other serious complications. We examined the feasibility of applying an endoscopic method alternative to total extraperitoneal and transabdominal preperitoneal for laparoscopic repair of inguinal hernia in a cadaver model so as to overcome the disadvantages of the presently available techniques. A total of 4 male and 2 female cadavers [aged 18 y and above, body mass index (BMI) <40 kg/m2], who were planned for a routine autopsy between January 24 and 26, 2020 were selected for the present study conducted at the Forensic Medicine Institute. Twelve laparoscopic repair surgeries of inguinal hernia were performed in 6 of these cadavers using both the inguinal areas. We conducted a total of 12 surgeries on 4 male (mean age: 43.25 y; BMI: 29.05 kg/m2) and 2 female cadavers (mean age: 76.50 y; BMI: 26.60 kg/m2). A 7×5-cm-shaped mesh was used for both the sexes. For the fixation of the mesh, a titanium tacker was used in pubic tubercle and tendon conjoint, whereas for the fixation of ligamentum inguinale, 2/0 PDS was used in 3 surgeries, 2/0 15-cm V-Loc was used in another 3 surgeries, and titanium tacker was used in 6 surgeries. We demonstrated that the technique of endoscopic surgery that offers the advantages of open inguinal surgery in a cadaver model can be combined with the presently used laparoscopic intervention so as to combine all the advantages, especially for patients who are not suitable for general anesthesia, who are experiencing a recurrence after laparoscopic intervention, and who do not want any visible scares resultant from the surgery. For future studies, we suggest that the proposed technique be applied to inguinal hernia patients to ascertain clearer results.

Imaging Anatomy and Surface Localization of External Control Device-Targeted Arteries for Noncompressible Torso Hemorrhage.

External hemorrhage control devices (EHCDs) are effective in reducing the death risk of noncompressible torso hemorrhage (NCTH), but the pressurized area is too large to prevent serious organ damage. This study aims to establish the surface localization strategy of EHCDs based on the anatomical features of NCTH-related arteries through CT images to facilitate the optimal design and application of EHCDs. Two hundred patients who underwent abdominal CT were enrolled. Anatomical parameters such as the length of the common iliac artery (CIA), the external iliac artery (EIA), and the common femoral artery were measured; positional relationships among the EHCD-targeted arteries, umbilicus, anterior superior iliac spine (ASIS), and pubic tubercle (PT) were determined. The accuracy of surface localization was verified by the 3D-printed mannequins of 20 real patients. Aortic bifurcation (AB) was 7.5 ± 8.6 mm to the left of the umbilicus. The left CIA (left: 46.6 ± 16.0 mm vs. right: 43.3 ± 15.5 mm, P = .038) and the right EIA (left: 102.6 ± 16.3 mm vs. right: 111.5 ± 18.8 mm, P < .001) were longer than their counterparts, respectively. The vertical distance between the CIA terminus and the ipsilateral AB-ASIS line was 19.6 ± 8.2 mm, and the left and right perpendicular intersections were located at the upper one-third and one-fourth of the AB-ASIS line, respectively. The length ratio of EIA-ASIS to ASIS-PT was 0.6:1. The predicted point and its actual subpoint were significantly correlated (P ≤ .002), and the vertical distance between the two points was ≤5.5 mm. The arterial localization strategy established via anatomical investigation was consistent with the actual situation. The data are necessary for improving EHCD design, precise hemostasis, and EHCD-related collateral injuries.Trial registration: Ratification no. 2019092. Registered November 4, 2020-retrospectively registered, www.chictr.org.cn.

Hip Adductor Longus Tendon Origin Anatomy Is Consistent and May Inform Surgical Reattachment

PurposeTo define the topographic anatomy of the footprint of the adductor longus origin on the pubis and its underlying bony morphology to better inform surgical repair of adductor longus tendon injuries.MethodsFive cadaveric pelvis specimens were dissected, making 10 adductor footprints available for analysis. The adductor longus tendon origin was isolated and the surrounding tissue debrided. The circumference of the tendinous attachment to the pubic crest was marked before excising the tendon and fibrocartilage enthesis from the pubis. Radiopaque paint was prepared by mixing 30 mL of all-purpose acrylic paint (Anita’s no. 11150 Island Blue; Rust-Oleum Corp, Vernon Hills, IL) with 15g of E-Z-HD 98% w/w barium sulfate (Bracco Diagnostics Inc., Anjou Quebec, Canada) and applied to the marked footprint. The specimens underwent a 1.0-mm slice computed tomographic scan with 3-dimensional reconstructions. Synapse PACS (FujiFilm, Valhalla, NY) software for measurements of the tendon footprint and underlying bone.ResultsAverage age and weight of the specimens at the time of death was 37 years and 204.6 ± 48.7 lbs, respectively. The width and length of the tendon origin was 12.0 ± 1.1 mm and 10.9 ± 1.1 mm, respectively. The distance of the center of the footprint from the center of the pubic tubercle was 8.5 ± 1.4 mm lateral and 12.2 ± 0.4 mm caudal. The osseous thickness underlying the footprint was 18.7 ± 3.7 mm at an angle of 34.5 ± 1.5° in relation to the sagittal plane. The correlation between specimen body weight and the thickness of the bone underlying the footprint was strongly positive (r = 0.92).ConclusionsWe found that there is a consistent angle from the center of the adductor longus tendon footprint to the point of maximal underlying bony thickness, as well as a positive correlation between body mass index and osseous thickness, which may inform anatomic reattachment of this tendon.Clinical RelevanceOur findings will assist surgeons in identifying the footprint of the adductor longus tendon and safely perform anatomic repair of adductor longus tendon avulsions.

New Four-fold Technique to Spread the Self-Gripping Mesh in Open Inguinal Hernia Surgery

Self-gripping mesh can be difficult to handle during spread to the inguinal floor because it can stick or adhere to the undesired structures because of micro-grips available on its underneath surface. This article aims to describe a new technique; we named it a four-fold technique to spread the self-gripping mesh to avoid this problem. The present study was a prospective comparative study between self-gripping mesh (polyester mesh with polylactic acid grips) and sutured mesh (polypropylene) in open inguinal hernioplasty under spinal anesthesia. This study was conducted from 1 November 2018 to 31 March 2020 in ABVIMS & Dr. R.M.L. Hospital, New Delhi. The potential candidates for the study were patients of 18 years age and above, presenting with a unilateral uncomplicated inguinal hernia that underwent open inguinal hernioplasty under spinal anesthesia. Sixty patients were alternatively allotted to group A (30 patients) and group B (30 patients) for comparison between self-gripping and sutured mesh. We used a 14 × 9-cm-size self-gripping mesh, which has semi-resorbable surface on one side and resorbable micro-grips on the other side to provide immediate fixation. Mesh was folded four times in a specific sequence before placing it, thus hiding the majority of the absorbable micro-grips. In this way, only the lower medial half of the mesh has the micro-grips exposed, and the mesh can now be fixed to the inguinal ligament without fixation to unintended tissues and structures underneath. Once the mesh is placed over the pubic tubercle and medial part of the inguinal ligament, it can be unfolded in the reverse order. The four-fold technique is an excellent method to spread the self-gripping mesh in inguinal hernia surgery to avoid sticking with undesired tissues.

Comparison of USG-guided or landmark approach fascia iliaca compartment block for positioning in elderly hip fracture patients with spinal anesthesia: a randomized controlled observational study

Currently, the elderly population in the world is rapidly increasing due to technological developments and convenient access to health services. Due to comorbidities in elderly patients, hip fractures are frequently observed after exposure to environmental trauma. To reduce pain during positioning in spinal anesthesia, fascia iliaca compartment block (FICB) can be applied easily and reliably. In our study, we aimed to compare the analgesic effects and duration of fascia iliaca compartment blocks performed with USG guidance or the landmark approach methods for relieving spinal anesthesia position pain. Our study included 100 patients undergoing operations due to hip fracture and administered spinal anesthesia after FICB. The group with USG-guided FICB (USG) had the blockage needle advanced to the compartment under the fascia iliaca, and 15 mL bupivacaine + 10 mL 2% lidocaine was administered. They were placed in sitting position for spinal anesthesia 20 min later and procedure duration and numerical rating scale (NRS) scores were recorded. In the group with landmark approach FICB (LAND), the spina iliaca anterior superior (SIAS) and pubic tubercle were connected with a line. The same amount of local anesthetic was administered to the external 1/3 portion of this line with the double pop technique. Procedure duration and NRS scores were recorded. There was no statistically significant difference between the two groups in terms of NRS scores (p: 0.073). There was a statistically significant difference in duration of FICB administration between the two groups (p < 0.001). Both USG-guided and landmark approach FICB methods provide adequate and similar analgesia for positioning in spinal anesthesia. However, in cases where there is no problem with access to the ultrasound device or time, safer blockage can be provided by imaging neurovascular structures with ultrasound.

Association of low-lying pubic tubercle with inguinal hernia

Association of low-lying pubic tubercle with inguinal hernia

3D pelvimetry and biometric measurements: a surgical perspective for colorectal resections

PurposeMale sex, high BMI, narrow pelvis, and bulky mesorectum were acknowledged as clinical variables correlated with a difficult pelvic dissection in colorectal surgery. This paper aimed at comparing pelvic biometric measurements in female and male patients and at providing a perspective on how pelvimetry segmentation may help in visualizing mesorectal distribution.MethodsA 3D software was used for segmentation of DICOM data of consecutive patients aged 60 years, who underwent elective abdominal CT scan. The following measurements were estimated: pelvic inlet, outlet, and depth; pubic tubercle height; distances from the promontory to the coccyx and to S3/S4; distance from S3/S4 to coccyx’s tip; ischial spines distance; pelvic tilt; offset angle; pelvic inlet angle; angle between the inlet/sacral promontory/coccyx; angle between the promontory/coccyx/pelvic outlet; S3 angle; and pelvic inlet to pelvic depth ratio. The measurements were compared in males and females using statistical analyses.ResultsTwo-hundred patients (M/F 1:1) were analyzed. Out of 21 pelvimetry measurements, 19 of them documented a significant mean difference between groups. Specifically, female patients had a significantly wider pelvic inlet and outlet but a shorter pelvic depth, and promontory/sacral/coccyx distances, resulting in an augmented inlet/depth ratio when comparing with males (p < 0.0001). The sole exceptions were the straight conjugate (p = 0.06) and S3 angle (p = 0.17). 3D segmentation provided a perspective of the mesorectum distribution according to the pelvic shape.ConclusionSignificant differences in the structure of pelvis exist in males and females. Surgeons must be aware of the pelvic shape when approaching the rectum.

REFLECTED INGUINAL LIGAMENT: A POTENTIAL ANATOMICAL LANDMARK FOR MESH FIXATION IN INGUINAL HERNIA REPAIR.

Introduction Recurrence of inguinal hernia after surgery secondary to mesh fixation techniques still remains a complication of inguinal hernioplasty. This study focuses on evaluating the reflected inguinal ligament and its potential in surgical application. Method A total of 181 patients undergoing inguinal hernia repair at Travancore Medical College, Kollam, Kerala between 2015 to 2020 were included in the study. The reflected inguinal ligament was identified by tracing fibres passing upwards and medially from the pubic tubercle to the rectus sheath. The incidence of the ligament and its shape were documented. Results Of the 181 patients, the male to female ratio was 7.6:1. The average age of the study population was 55.1 ± 14.3. 37% had right sided inguinal hernia, 19% had left sided inguinal hernia and 44% had bilateral inguinal hernia. Intraoperatively, the reflected inguinal ligament was identified in all patients with 60% having a triangular shape and rest had rectangular shape. Rectangular shape is more common as age increases. Discussion Current literature rarely examines the reflected inguinal ligament in depth. Further ambiguity is caused by various authors using different nomenclature for the ligament. Accepting the limitations such as constrained geographical variation in our study population, the findings of our study in combination with those of existing literature warrants further studies specifically evaluating the reflected inguinal ligament. Conclusion The reflected ligament was identified in all of our patients. This study recommends that further studies evaluate the reflected inguinal ligament as a potential landmark to fix the medial end of the mesh during inguinal hernioplasty.

Characteristics of the Superficial Circumflex Iliac Artery Perforator Flap in a Western Population and a Practice Approach for Free Flap Reconstruction.

There has been increasing interest in the superficial circumflex iliac artery perforator (SCIP) flap as a source of thin, pliable soft tissue combined with a favorable donor site. Despite several clinical series from Asia, barriers to adoption include reluctance to perform submillimeter "supermicrosurgery" and the effect of body habitus on flap feasibility. The purpose of this study is to distinguish vascular anatomic characteristics of the SCIP flap in a North American population. Computed tomography angiography was examined in 84 flaps in healthy prospective renal donor patients from a radiographic database. Descriptive statistics as well as linear regression comparing variables to body mass index (BMI) were performed. Mean BMI was 27.1 ± 3.5 kg/m2, while the mean patient age was 47.8 ± 11.4 years. The superficial circumflex iliac artery (SCIA) originated from the common femoral artery in 92% cases, with remainder originating from the profunda femoris. The mean vessel diameter was 1.85 mm at source vessel origin. Distance from skin to source vessel averaged 30.7 mm. Suprascarpal subcutaneous thickness averaged 16.5 mm. The mean distance from Scarpa's fascia to vessel origin was 14.1 mm. Direct three-dimensional distance from vessel origin to pubic tubercle was 50.2 mm. A medial and lateral perforator split off of the SCIA was observed in 38 cases (45%). Significant differences were shown when comparing BMI to skin to source vessel distance (p < 0.001), suprascarpal subcutaneous fat thickness (p < 0.001), and fascial distance to vessel origin (p < 0.001). BMI did not significantly affect vessel diameter. Despite a significantly higher BMI than many previously published cohorts, the SCIP remains an excellent source of thin and pliable tissue. When dissected closer to the source vessel, a vessel caliber of nearly 2 mm can be achieved, which may obviate the need for "supermicrosurgery" in this population.

Perforator Mapping of the Profunda Artery Perforator Flap: Anatomy and Clinical Experience.

Discovering alternatives to workhorse flaps that have more consistent anatomy and lower donor-site morbidity has become a focus of reconstructive surgery research. This study provides a simplified approach to profunda artery perforator flap design and harvest based on reliable anatomical landmarks. A retrospective review was conducted of 70 patients who underwent 83 profunda artery perforator flap reconstructions for postoncologic defects from 2016 to 2018. The authors recorded and analyzed the profunda artery perforator flap sizes and clinical applications, the numbers and locations of the perforators, and the patient outcomes. Most of the profunda artery perforator flaps were for head and neck [46 patients (65.7 percent)] and breast [21 patients (30 percent)] reconstructions. Flaps were most commonly based on perforator A (33.7 percent) and perforator B (33.7 percent), followed by perforators B and C combined (18.1 percent). Perforators were located a mean of 7.5 cm (perforator A), 12.7 cm (B), and 17.6 cm (C) distal to the pubic tubercle parallel to the axis between the pubic tubercle and the medial femoral condyle and 7.9 cm (A), 7.3 cm (B), and 6.1 cm (C) posterior from the axis. There was no flap loss. One patient underwent successful salvage surgery after arterial flap thrombosis. Eight patients (9.6 percent) developed superficial wound dehiscence that was managed conservatively. Perforator mapping demonstrated consistent anatomical locations of sizeable profunda artery perforators in the inner thigh. Along with its consistent and robust vascular anatomy and minimal donor-site morbidity, the profunda artery perforator flap's volume and pliability make it a reliable option for soft-tissue reconstruction. Therapeutic, IV.

Association of Low-lying Pubic Tubercle in Patients with Inguinal Hernia

A low-lying pubic tubercle is one of the commonly implicated anatomical factors associated with indirect inguinal hernias. Even though many studies have addressed this topic, we found that they had major lacunae that are addressed in this article. The purpose of this study was to compare the incidence of low-lying pubic tubercle in a direct and indirect inguinal hernia, the accuracy of radiological measurement with clinical measurement for low-lying pubic tubercle, and to establish a mean cutoff value for low-lying pubic tubercle in our patient population. This was a case series analysis conducted at a tertiary care hospital. Forty Indian men patients with uncomplicated inguinal hernia between the age group of 22 and 60 years and the same number of matched healthy individuals (age, height, and body mass index–matched) without inguinal hernia as controls were studied. Three measurements, namely, distance between two anterior superior iliac spines (SS), the vertical distance from the pubic tubercle to the interspinal line (ST), and mid-inguinal point to pubic tubercle (MIP to PT) were taken clinically and radiologically by X-ray pelvis. The mean cutoff value for the ST segment measured clinically and radiologically was 8.10 and 8.15 cm, respectively. In our study, the ST line which measures the length of pubic tubercle was significantly longer in patients with indirect inguinal hernia, clinically and radiologically (9.56 SD 0.84 and 9.45 SD 1.02, respectively). The mean SS, MIP to PT was also significantly longer (p 25) individuals. Based on the results of our study, it can be concluded that low-lying pubic tubercle is associated with the development of an indirect inguinal hernia.

Single-dermatome single-incision laparoscopic right hemicolectomy.

We describe a novel single-incision laparoscopy right hemicolectomy technique using a single-dermatomal, muscle-splitting approach through a 4-cm incision located between the right anterior superior iliac spine and pubic tubercle. This new technique may be superior to traditional single-incision laparoscopy colectomy with the potential benefits of less post-operative pain, lower opioid requirements, lower risk of incisional hernia and better cosmesis but requires further validation.

Variations of the Anatomy and Bony Landmarks of Deep Circumflex Iliac Artery in a Select Kenyan Population.

The deep circumflex iliac artery (DCIA) is a large caliber artery which branches laterally from the external iliac artery (EIA), directly opposite the origin of the inferior epigastric artery (IEA). Population variations have been reported in its origin, length, and branching patterns. These may alter its relationship to palpable surgical landmarks such as the anterior superior iliac spine (ASIS) and the pubic tubercle (PT) which are used to locate the artery preoperatively, thus predisposing it iatrogenic injury. Despite this, there is paucity of data from the Kenyan setting. Cross-sectional study design. To determine the variations of the anatomy and bony landmarks of the Deep circumflex iliac artery in a select Kenyan population. A total of 104 DCIA from 52 formalin fixed adult cadavers were dissected to expose the DCIA, following which its vessel of origin and distance from the ASIS and PT, relation to the inguinal ligament (IL), length and branching patterns were noted. The average of the measurements were calculated. All data were collected and analyzed using Microsoft Excel 2007 (Microsoft Corporation, Redmond, WA). Representative photos of the vessel and its variations were taken. The DCIA was found to be present and bilaterally symmetrical in all cadavers. In all cases observed, it originated as a lateral branch from the EIA (100%), opposite the IEA and directly behind the IL in 98% of the cases. Its average distance from the ASIS along the IL was 7.28 ± 0.99, while it was 5.91 ± 1.03 from the pubic tubercle to its origin. Its length ranged from 3.7 cm to 9.5 cm, with an average length of 3.86 cm in the right limb and 3.67 cm in the left limb. As regards its branching patterns, in 78% of the cases, it bifurcated into the horizontal and ascending branches, in 6%, it trifurcated and in 4%, it divided into more than 3, exhibiting a fine tree-like branching (arborization). The DCIA in our setting exhibited variations from other settings and an increase in awareness of these variations will probably reduce future iatrogenic lesions of the DCIA and its major branches in Kenya.

Automatic Characterization of Pelvic and Sacral Measures from 200 Subjects.

An understanding of pelvic and acetabular morphology and orientation is required for accurate surgical reconstruction of the hip and spine, as well for component placement in a total hip arthroplasty. Our objectives were to develop an automated system for measuring pelvic and sacral orientations utilizing computed tomographic (CT) scans and to characterize these measures across 200 asymptomatic subjects. An automated feature recognition algorithm was created to identify acetabular and pelvic orientation across 200 scans generated for non-musculoskeletal conditions. Three-dimensional models were generated from CT data to serve as inputs to the algorithm. Acetabular orientation was defined by comparing a plane fit to the acetabular rim with the anterior pelvic plane. Pelvic inclination, pelvic tilt, and sacral slope were defined as the angles between landmarks identified across the pelvis: pubic tubercles, acetabular center, left and right anterior superior iliac spines, and sacral plate. The mean sacral slope was 36.49°, the mean pelvic tilt was 15.60°, and the mean pelvic incidence was 52.05°. The mean sacropubic angle was 32.48° and the mean pelvic-Lewinnek angle was 8.93°. Significant differences between male and female subjects were observed in the sacral slope (mean difference, 4.72°; p < 0.05), pelvic tilt α (mean difference, 4.17°; p < 0.05), pelvic tilt γ (mean difference, 3.06°; p < 0.05), and the pelvic-Lewinnek angle (mean difference, 1.76°; p < 0.05). The comparison of acetabular orientation measures with those in a prior study of the same cohort yielded intraclass correlation coefficients (ICCs) all above 0.97. The validation of sacral orientation via manual measurement also yielded ICC values all at or above 0.97. Our algorithm showed a high degree of consistency in acetabular orientation measures with respect to a prior study of the same cohort. The measures of pelvic orientation were found to be accurate and reliable when compared with manual measurements of the same data set. All measurements of pelvic orientation were consistent with the means reported in the literature. An accurate and reproducible, automated technique for determining pelvic and acetabular orientation provides a way to characterize these measures as an aid in clinical diagnosis and preoperative planning.