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The retroperitoneum is rich in vascular structures and can harbor large hematomas, traumatic or spontaneous. The management of retroperitoneal hematomas depends on the mechanism of injury and whether they are pulsatile/expanding. Rectus sheath hematomas are uncommon abdominal wall hematomas secondary to trauma to the epigastric arteries of the rectus muscle. The common risk factors include anticoagulation, strenuous exercise, coughing, coagulation disorders, and invasive procedures on/through the abdominal wall. The management is largely supportive, with the reversal of anticoagulation and transfusions; angioembolization may be necessary.

The management of sternal wound infections often requires pedicled flaps. In recent years, the emergence of perforator flaps has changed our management of wounds involving tissue loss. For sternal wounds, the superior epigastric artery perforator (SEAP) flap can be used with the propeller procedure with minimal donor site morbidity. In our practice, this flap has replaced the traditional latissimus dorsi and pectoralis major flaps in the treatment of many sternal wounds. We report our experience with 4 patients with large sternal wound infection after cardiothoracic operations. The SEAP flap appears a safe alternative for low-morbidity coverage of sternal infections. Moreover, muscle flaps remain available in case the SEAP flap fails.

Resume Introduction L’absence de code de classification commune des actes medicaux (CCAM) specifique au DIEP ( deep inferior epigastric perforator ) est l’une des raisons expliquant la faible diffusion de cette technique en France. Afin de fournir des elements de reflexion a l’HAS, nous avons cherche en premier lieu a determiner le cout de cette intervention par rapport a une methode de reference. Nous avons realise une etude de cout-identification en comparant les couts d’une reconstruction mammaire secondaire apres radiotherapie par lambeau de DIEP ainsi que par lambeau de latissimus dorsi avec implant (LD + I). Patientes et methodes Sur une periode de 12 mois, les couts directs medicaux et non medicaux ainsi que les couts indirects ont ete releves en milieu hospitalo-universitaire chez les patientes ayant beneficiees d’un DIEP et chez les patientes ayant beneficiees d’un LD + I. Resultats Le cout total d’une reconstruction mammaire secondaire unilaterale par lambeau libre de DIEP etait de 10 671 ± 3005 € ( n = 57), alors que le cout total d’une reconstruction mammaire secondaire par LD + I etait de 8218 ± 2049 € ( n = 18) ( p 0,05). La duree d’occupation de salle etait de 390 ± 64 minutes pour le DIEP et de 283 ± 44 minutes pour LD + I ( p 0,05) . La duree d’hospitalisation etait de 6 ± 2 jours pour le DIEP et de 5 ± 2 jours pour le LD + I ( p > 0,05). Conclusion Le DIEP permet d’obtenir une reconstruction du sein durable pour un cout immediat proche de celui du LD + I (+ 22 %). De plus, en milieu hospitalo-universitaire, la collaboration entre deux microchirurgiens permet de realiser le DIEP dans des temps proches de ceux du LD + I.

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

The origins of the inferior epigastric and obturator arteries and the relationship between these arteries have been determined macroscopically in examinations of 706 body-halves of Japanese subjects. Three very rare inferior epigastric arteries were found to arise from the obturator artery leaving the internal iliac artery. The intimate relationship between these arteries has been documented by the obturator artery arising from the inferior epigastric artery and the anastomosis between them. It is generally interpreted that such anomalies occur as remnant or partial disappearance of the connection between the pubic branches of the inferior epigastric and obturator arteries. The inferior epigastric artery arising from the obturator artery is also thought to be a similar anomaly. Since the obturator artery from the inferior epigastric artery represents one form of extreme anomaly, and the inferior epigastric artery from the obturator artery represents another form, it would seem that these two forms of extreme anomaly should occur at similar frequencies. However, in our research, the incidence of the former was 10.5% while that of the latter was a very low 0.4%. During normal development, the inferior epigastric artery is established at an earlier stage than the obturator artery as a channel for blood supply. We suppose that the difference of blood flow resulting from this time lag is one of the reasons why the inferior epigastric artery from the obturator artery is very rare in comparison to the obturator artery from the inferior epigastric artery.

Background Laparoscopic techniques are responsible for a new set of complications. Their causes, incidence and outcome must be evaluated. New complications of laparoscopic technique in biliary surgery are generally due to lack of training and experience, over-confidence, and errors in technique. Method The records of 2000 successive elective laparoscopic cholecystectomies (LC) were reviewed to evaluate the incidence of complications due to the laparoscopic technique. Results Haemorrhage at the trocar insertion site was recorded in 14 patients. In one patient the epigastric artery was severed and the operation was converted to an open cholecystectomy (OC). In one patient who had undergone a previous laparoscopy, the small bowel was injured and sutured during open laparoscopic access. In 25 patients stones were lost in the peritoneal cavity. Three of them developed intra-abdominal or abdominal-wall abscess due to the stones. Monopolar diathermy was responsible for one colonic perforation and one bile-duct perforation. Discussion Blind introduction of pneumoperitoneum needles and trocars, poor visualisation, excessive use of diathermy, errors in surgical technique and over-confidence are causes of serious complications.

A model of angiogenesis has been developed in the rat. The epigastric vascular pedicle was exposed in the groin, a 7 mm segment of epigastric artery was excised leaving the vein intact and, after a variable period of time for angiogenesis to occur between the ends of the artery, a skin flap was elevated on the epigastric vascular pedicle so that it depended completely for its blood supply on bridging angiogenesis across the created gap. Skin flap survival and vessel counts were measured as indices of the angiogenic response. In this model we observed a spontaneous increase in vessel counts between the ends of the artery, and a corresponding increase in skin flap tissue survival until day 10 after which time vessel counts plateaued whilst tissue survival continued to increase until day 14. In the angiogenic pedicle, a time-dependent development of granulation tissue containing numerous macrophages and mast cells, and capillary sprouting were documented. When flap elevation was performed 7 days after arterial excision skin flap survival was 42%. Thus, in this model, 7 days is a suitable interval for the future evaluation of the effects of either pro- or anti-angiogenic agents.

Based on earlier observations that the thickness of the intima and structure of the media may have an impact on the long-term patency of arterial conduits and the lack of detailed histologic studies of the right gastroepiploic and inferior epigastric arteries, we subjected both vessels to morphometric analysis with emphasis on their suitability as conduits in myocardial revascularization.The right gastroepiploic and inferior epigastric arteries were harvested from 28 unselected individuals (mean age, 73.2 years) at autopsy, and the luminal diameter and the width of the intima and media were measured.At all levels of measurement (origin, 10 cm, and 15 cm), the luminal diameter of the inferior epigastric artery was significantly smaller than that of the right gastroepiploic artery (p0.05). The right gastroepiploic artery demonstrated only mild intimal hyperplasia. In contrast, the inferior epigastric artery showed substantial intimal hyperplasia within the first 1-cm segment (mean, 134 +/- 131 microns versus 50 +/- 49 microns for the corresponding segment of the right gastroepiploic artery; p = 0.01). Intimal hyperplasia was only mild in the remainder of the inferior epigastric artery. In both vessels, the media was muscular with rare dispersed elastic fibers. The mean thickness of the media ranged from 380 +/- 116 microns proximally to 155 +/- 70 microns distally for the right gastroepiploic artery, and from 316 +/- 86 to 165 +/- 70 microns, respectively, for the inferior epigastric artery.In myocardial revascularization, use of the right gastroepiploic artery may generally be preferable to use of the inferior epigastric artery. This recommendation is based on the larger luminal diameter of the right gastroepiploic artery as compared with the inferior epigastric artery, the significantly greater intimal hyperplasia in the first segment of the inferior epigastric artery, and the limitation that the inferior epigastric artery can be used only as a free graft. The rate of development of intimal hyperplasia in the right gastroepiploic artery, if used as an in situ coronary artery bypass graft, may be slow, approximating that of the right gastroepiploic artery in its natural environment.

In order to test methods of predicting skin flap viability, a skin flap model in Sprague-Dawley rats was established. As criteria for studying skin flap survival, we compared measurement of skin pH, temperature, as well as fluorescence photography and computer aided digital morphometry (CADM). Ninety male Sprague-Dawley rats were divided into three groups in which pedicles were clamped for 10, 15, or 20 h. A standardized bipedicled skin flap was prepared, maintained by the epigastric artery, vein and nerve. All flaps were sutured back in place immediately after clamping. We found that postoperative prediction of flap survival based solely upon external appearance was impossible until the 2nd postoperative day. Changes in pH were not statistically significant in the prediction of vital or necrotic flaps. The temperature measurements showed, that in the event of viability the decrease in flap temperature versus the reference temperature (rectal temperature) was significant (P < 0.0094 in Group II, 15 h of ischaemia) or at least a tendency to significance (P < 0.059 in Group III, 10 h of ischaemia) bigger than in the event of partial or total flap necrosis. The photographic documentation using fluorescein showed that all coloured areas survived. Group I (20 h) showed predominantly total flap necrosis. Most flaps in Group III (10 h) exhibited a small necrotic area at the tip. In Group II (15 h) no typical staining pattern could be observed. Furthermore, computer aided digital morphometry demonstrated a decrease of the necrotic area by 7% between the 2nd and 4th postoperative day in Groups II and III. The method which gave the most exact prediction about viability was the fluorescein staining of the flaps via the tail vein.

From March 1990 through January 1991, 47 patients undergoing myocardial revascularization had one (37) or both (10) inferior epigastric arteries (IEA) used as a conduit for bypass with 62 distal anastomoses. The internal thoracic artery (ITA) was used bilaterally in 41 patients and unilaterally in 6 with 100 distal anastomoses. Five patients had a single saphenous vein graft. In total, 167 anastomoses (3.55 per patient) were performed. Single IEA grafts were harvested through a paramedian incision and bilateral grafts, a midline incision. Harvest time was 36.5 minutes for IEA grafts and 29.6 minutes for ITA grafts (p less than 0.0001). Graft length was 11.9 cm for IEA grafts and 16.5 cm for ITA grafts (p less than 0.0001). Distal graft diameter was 2.0 mm for IEA grafts and 2.1 mm for ITA grafts (p less than 0.01). Graft flow was 49.7 mL/min for IEA grafts and 48.7 mL/min for ITA grafts. Microscopic assessment of segments of both the IEA and ITA from 14 patients revealed similar internal elastic laminae and an equal number of fenestrations. Combined intimal and medial thickness was comparable in both conduits. Medial elastic tissue was more prominent in ITA grafts and lacking in eight of the 14 IEA grafts. Gross plaque formation was noted in the proximal 1 to 3 cm of 50% of IEA grafts, but the lumen was not compromised and microscopic thickening was minimal. An unexpected finding was medial calcifications (Mönckeberg's disease) in two of the 14 IEAs without associated atherosclerosis. There was one hospital death, one abdominal wound infection, and one instance of fat necrosis superficial to the sternum.(ABSTRACT TRUNCATED AT 250 WORDS)

We present the case of a 62-year-old lady who was in shock due to continuous bleeding into a rectus sheath haematoma. She was treated by ligation of the inferior and superior epigastric arteries via incisions over the inguinal ligament and the upper rectus abdominis muscle. No attempt was made to evacuate the retroperitoneal component of the haematoma in order to maintain the tamponade.

A patient having undergone triple coronary artery bypass grafting with the left internal mammary artery and both shorter saphenous veins was reoperated on because of occlusion of the venous grafts. As there was no other vascular substitute available, the right internal mammary artery and both inferior epigastric arteries were used to achieve myocardial revascularization. This case demonstrates that bilateral internal mammary arteries and inferior epigastric arteries can be used safely.

We are currently evaluating the inferior epigastric artery as an alternative arterial conduit for coronary bypass grafting. Fifty-seven inferior epigastric arteries were harvested from 47 adults. There were no differences in size between the right and left inferior epigastric arteries. Diameter was 2.5 to 3.5 mm proximally and 2 to 3 mm distally. Usable length was 6 to 16 cm (mean 11.2 ± 0.25 cm). Grade I/IV atherosclerosis was found in one patient (2.1 %). Duplex scanning was used for preoperative evaluation of the inferior epigastric arteries in 51 patients. In 21 patients the arteries were not harvested, in part because of duplex scan findings of small caliber or early bifurcation. In 30 patients the duplex findings could be compared with the surgical findings. The average length at operation was twice the length detected on duplex scan (11.2 cm versus 5.8 cm, p horac C ardiovasc S urg 1992;103:463-5)

The inferior epigastric artery has been used as an alternative arterial conduit in coronary artery bypass graft surgery. Its harvesting requires a single or double, long abdominal paramedian incision that is technically difficult and does not yield a good cosmetic result. We describe an alternative new approach to one or both inferior epigastric arteries through a transverse suprapubic cosmetic incision.

The inferior epigastric arteries are currently being evaluated as alternative autologous arterial conduits for coronary artery bypass operations. The inferior epigastric arteries are Variable in diameter and length and require harvesting through separate abdominal incisions. There is a need, therefore, for a method to preoperatively assess the diameter and length of the inferior epigastric arteries to determine their suitability as a coronary artery bypass graft. We have found that the duplex scan is a valuable noninvasive preoperative imaging modality to evaluate the inferior epigastric arteries.

The free epigastric rabbit flap was used to observe morphological alterations in the microvasculature following prolonged hypothermic ischemic intervals. Free flaps were raised, cooled 1-6 days, and reanastomosed. The epigastric artery, vein, and dermal vessels were examined by electron microscopy. Efforts to keep flap tissues in the cold less than or equal to 5 days were successful (85% of flaps survived following reanastomosis N = 15). Flap failures were accompanied by extensive disruption to the endothelial cells of the epigastric vein. The findings support the efficacy of a cooling period less than or equal to 5 days for free flaps. The morphological alterations in the venous endothelium of the flap also suggest a plausible explanation for flap failures which occur in spite of patent anastomotic sites.

1. 1. Because they are infrequently encountered, ruptures of the rectus abdominis muscle and the deep epigastric arteries have posed a diagnostic problem. Of the 101 cases reported in the last seven years, only twenty-two were correctly diagnosed. 2. 2. It is only by coincidence that almost 50 per cent of the cases in this series have occurred in pregnant women. Nevertheless, the five maternal and twelve fetal deaths emphasize the seriousness of these lesions and the importance of a prompt diagnosis. 3. 3. A correct diagnosis will lead to the intelligent management of these accidents and will depend upon: (1) an awareness of the occurrence of these lesions; (2) careful attention to the patient's history of even the most trivial incident of trauma; (3) the presence of a hard, tender mass fixed in the abdominal wall, confined to the limits of the rectus sheath, and in late cases the presence of ecchymosis about the umbilicus.

The syndrome of the rectus abdominis muscle is a disorder of unknown etiology that produces rupture or tear of the epigastric artery, and stretches the rectus cutaneous medialis nerve, producing excruciating pain. The disorder is misdiagnosed in 60% to 93% of cases. We report two cases that presented as acute abdomen. One helpful diagnostic test was the lidocaine test, accomplished by subcutaneous injection of lidocaine into the sheath of the rectus abdominis muscle near the rectus cutaneous medialis nerve; the procedure provided immediate pain relief and the patients remained asymptomatic. In addition to helping establish a diagnosis quickly the lidocaine test may spare the patient the unnecessary morbidity or mortality of more invasive procedures.