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Introduction The management of acetabulum fractures in osteoporotic elderly, as well as comminuted fractures in younger patients is likely to be difficult. These fractures need specific fixation techniques especially when the quadrilateral plate is involved. Standard implants may not be able to adequately support the fixation, so newer pre-shaped fixation plates have been proposed with some of these already in use. The concept of anatomic plates has come up for many fracture locations for providing a better buttress effect to the comminuted fragments. There has been a need to look for an anatomic buttress plates being developed for acetabulum fractures involving the quadrilateral surface. Materials and methods The literature has been reviewed to find the various newer designs that have been used for buttressing the quadrilateral surface in comminuted acetabular fractures. An attempt has been made to study their design characteristics and clinical outcomes. The review also includes the analysis of Anatomic Quadrilateral plate (AQP) used in fixation of acetabulum fracture involving quadrilateral surface in a series of 33 patients. Results There has been few anatomical plates developed for the stabilization of acetabular quadrilateral surface fractures. Some of these plates have been successfully used in management of acetabular fractures primarily in young patients. Issues however remain in their application and outcomes in osteoporotic fractures of the acetabulum, as these plates support the pelvic brim fragments either from superior or medial surface. The newer development i.e. ‘Anatomical Quadrilateral Plate’ is optimized to counter the displacement forces due to its positioning on the pelvic brim rather than its superior or medial surface. Other special features include the possibility of longer screws across bone due to oblique position of holes, the typical location of a locking hole on the plate beam which permits dual cortical compression fixation either by using a bigger screw or a specially designed screw in screw construct across the supra-acetabular corridor. The option of using hybrid fixation of both locking and unlocked screws in AQP allows proper stress distribution on the underlying bone, aiding both primary as well as secondary stability. The minimum of one year post surgery outcome of patients having acetabular fixation using this Anatomic quadrilateral plate has been analyzed in 33 patients. Twenty three of these were aged more than 50 years and 28 out of total 33 were males. Associated injuries included Ipsilateral lower limb injury in 2 patients and distal radius fracture in 5 patients. The fracture pattern included ‘Anterior column posterior hemi-transverse’ in 10 patients,’ Associated Both Column’ injury in 9 and ‘T type’ acetabular fractures in 8 patients. Isolated ‘Anterior column’ was fractured in 6 patients. The surgical approach was ‘Anterior Intra-pelvic’ (AIP) in 23 patients and ‘Modified Ileo-femoral’ in other 10 patients. One patient had additional K L approach. Among the implants, the AQP plate was used without its pubic arm in 6 patients. The post-operative x rays showed anatomical reduction in 28 patients, while other 5 had gaps and/or steps up to 2 mm size. In subsequent car, one of these patients needed hip arthroplasty for problem arising due to collapse in fixation within six months. EQ 5D 5L telephonic score was used to know the outcome at minimum of one year follow up in 33 patients. As per this score, only 3 patients had an issue with mobility, with only one having problem in self-care activity. Six patients complained of minor limitations in carrying out their usual activities and only one patient had anxiety affecting him. In their self-assessment of overall health status, 22 patients marked it 100, 7 made it 90, 3 as 80 and 1 had marked it as 70 in a score range of 0–100. Considering the predominant elderly profile in this series of patients, the acetabular reconstruction using ‘Anatomic quadrilateral plate’ has shown encouraging results. Conclusion For stabilization of acetabular fractures involving quadrilateral surface area and pelvic brim, various new implants have been used. The Anatomic quadrilateral plate due to its anatomical shape, the various options in fracture fixation is best optimized for management of comminuted acetabulum fractures especially in poor quality bones. It has been successful in achieving good outcome in elderly group of patients having these complex injuries.

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, and permits stable internal fixation for the acetabular fracture patterns with main anterior displacement and the anterior and lateral parts of the pelvis. The present study was a prospective clinical study including 10 patients with acetabular fractures who were treated operatively using modified Stoppa approach . The classification of acetabular fractures described by Letournel and Judet. All operative data was recorded Patients were followed-up for 12 months after the operation. The maximum displacement of the bony fragment was measured in the unit of mm by using PACS, Marosis mview ver. 5.4 Our result shows the incidence of perioperative complication. Two patients developed DVT and two patients developed obturator nerve palsy. Our result shows the radiological outcomes of the included patients. The mean CT gap was 1.685 ±0.27mm. Eighty percent of the patients had anatomical Matta class. Our result shows the Merle D‟Aubigne-Postel score of the included patients. Eighty percent of the patients had excellent score. The incidence of MVO after PPCI may be lowered by the addition of manual TA (6,24). The results of the present study show that the additional intracoronary administration of a high dose of adenosine may further improve STR up to 70%. Future larger studies with clinical endpoints are warranted to confirm the benefit of intracoronary administration of a high dose of adenosine in addition to glycoprotein IIb/ IIIa antagonist administration and TA in the setting of PPCI or rescue PCI.

Introduction/Background* Laparoscopic Ovarian Transposition (OT) has already been proven to be a safe and effective procedure to preserve ovarian function in patients receiving pelvic radiotherapy for a variety of gynaecological malignancies. Different techniques have been described. Aim This video demonstrates our PS technique for OT in a 32-year-old patient with stage 1B3 poorly differentiated squamous cell carcinoma of the cervix who subsequently underwent radical chemoradiation. Methodology/Technique Laparoscopy was performed as usual, using a 10mm umbilical optic port and four 5mm ports placed in both iliac fossae and high in both flanks. Thorough inspection of the peritoneal cavity revealed no evidence of disseminated disease. Approximately 100mls of free blood was seen in the pelvis. Both ovaries were slightly enlarged and the right ovary had a ruptured haemorrhagic cyst. She had previously developed OHSS after ovarian stimulation and egg retrieval. The uterus was bulky and retroverted. Both tubes were normal. All the upper abdominal organs looked normal and there was no evidence of disease on the ovaries or peritoneal surfaces therefore we decided to proceed to bilateral ovarian transposition. Result(s)* Bilateral retrograde salpingectomy was performed using a Harmonic scalpel and specimens were sent for histology. Both pelvic side walls were opened and both ureters were identified. Both utero-ovarian ligaments were transected along with 2cm of round ligament on both sides and ovarian flaps were created. The ovarian flaps were mobilised and the infundibulopelvic ligaments were skeletonised. The para-colic gutters were incised approximately 10cm above the pelvic brim and were tunnelled. Both ovarian flaps were pulled through and stapled outside the irradiation fields to prevent them from falling back into the pelvis following the procedure. Titanium staples were used for easy identification of ovaries on imaging. At the end of the procedure both ovarian pedicles were tension-free with good mobility and no risk of necrosis or torsion. There were no intraoperative complications and the patient experienced a good recovery. Conclusion* We consider that the ovarian flap allows the ovaries to have a degree of natural movement, while at the same time preventing torsion and minimising ovarian damage associated with the use of transfixed stitches.

Objective 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. Methods 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). Results 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. Conclusion 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.

Introduction In fragility fractures of the pelvis (FFP), fractures of the posterior pelvic ring are nearly always combined with fractures of the anterior pelvic ring. When a surgical stabilization of the posterior pelvis is performed, a stabilization of the anterior pelvis is recommended as well. In this study, we aim at finding out whether conventional plate osteosynthesis is a valid option in patients with osteoporotic bone. Materials and methods We retrospectively reviewed medical charts and radiographs of all patients with a FFP, who underwent a plate osteosynthesis of the anterior pelvic ring between 2009 and 2019. Patient demographics, fracture characteristics, properties of the osteosynthesis, complications and revision surgeries were documented. Single plate osteosynthesis (SPO) at the pelvic brim was compared with double plate osteosynthesis (DPO) with one plate at the pelvic brim and one plate anteriorly. We hypothesized that the number and severity of screw loosening (SL) or plate breakage in DPO are lower than in SPO. Results 48 patients with a mean age of 76.8 years were reviewed. In 37 cases, SPO was performed, in 11 cases DPO. Eight out of 11 DPO were performed in patients with FFP type III or FFP type IV. We performed significantly more DPO when the instability was located at the level of the pubic symphysis (p = 0.025). More patients with a chronic FFP (surgery more than one month after diagnosis) were treated with DPO (p = 0.07). Infra-acetabular screws were more often inserted in DPO (p = 0.056). Screw loosening (SL) was seen in the superior plate in 45% of patients. There was no SL in the anterior plate. There was SL in 19 of 37 patients with SPO and in 3 of 11 patients with DPO (p = 0.16). SL was localized near to the pubic symphysis in 19 of 22 patients after SPO and in all three patients after DPO. There was no SL in DPO within the first month postoperatively. We performed revision osteosynthesis in six patients (6/48), all belonged to the SPO group (6/37). The presence of a bone defect, unilateral or bilateral anterior pelvic ring fracture, post-operative weight-bearing restrictions, osteosynthesis of the posterior pelvic ring, and the presence of infra- or supra-acetabular screws did not significantly influence screw loosening in SPO or DPO. Conclusion There is a high rate of SL in plate fixation of the anterior pelvic ring in FFP. In the vast majority, SL is located near to the pubic symphysis. DPO is associated with a lower rate of SL, less severe SL and a later onset of SL. Revision surgery is less likely in DPO. In FFP, we recommend DPO instead of SPO for fixation of fractures of the anterior pelvic ring, which are located in or near to the pubic symphysis.

The human pelvis is a complex anatomical structure that consists of the innominate bones, sacrum and coccyx to form the pelvic ring. Even though considered to be a symmetric entity, asymmetry of the pelvic ring (APR) might occur to alter its anatomy, function, or biomechanics or to impact assessment and treatment of clinical cases. APR and its assessment is complicated by the intricate anatomy of the pelvic ring. There is only limited information and understanding about APR with no established evaluation methods existing. The objective of the present study was to adopt CT‐based 3D statistical modeling and analysis to assess APR within the complex anatomy of the pelvic ring. We were interested to establish a better understanding of APR with knowledge and applications transferred to human anatomy, related research, and development subjects and to clinical settings. A series of 150 routine, clinical, pelvic CT protocols of European and Asian males and females (64 ± 15 (20–90) years old) were post‐processed to compute gender‐ and ancestry‐specific 3D statistical models of the pelvic ring. Evaluations comprised principal component analysis (PCA) that included size, shape, and asymmetry patterns and their variations to be assessed. Four different CT‐based 3D statistical models of the entire pelvic ring were computed according to the gender and ancestry specific groups. PCA mainly displayed size and shape variations. Examination of additional PCA modes permitted six distinct asymmetry patterns to be identified. They were located at the sacrum, iliac crest, pelvic brim, pubic symphysis, inferior pubic ramus, and near to the acetabulum. Accordingly, the pelvic ring demonstrated not to be entirely symmetric. Assessment of its asymmetry proved to be a challenging task. Using CT‐based 3D statistical modeling and PCA, we identified six distinct APRs that were located at different anatomical regions. These regions are more prone to APRs than other sites. Minor asymmetry patterns have to be distinguished from the distinct APRs. Side differences with regard to size, shape, and/or position require to be taken into account. APRs may be due different load mechanisms applied via spine or lower extremity or locally. There is a need for simpler and efficient, yet reliable methods to be routinely transferred to human anatomy, related research, and development subjects and to clinical settings., Using CT‐based 3D statistical modeling and principal component analysis we were able to identify six distinct regions of the pelvic ring, which can exhibit asymmetries. PC 7 of the European females is an example showing all of the six asymmetries of the pelvic ring located at the sacrum, the iliac crest, the pelvic brim, the acetabulum, the pubic symphysis and the inferior pubic ramus.

A 31-year-old woman, who is a known case of polycystic ovary syndrome, underwent modified radical hysterectomy and right ovarian transposition to the anterior abdominal wall for endometrioid adenocarcinoma Grade II. She then visited our facility for in vitro fertilization (IVF) and surrogacy in the year 2016. Three cycles of IVF were performed using gonadotropin-releasing hormone (GnRH) antagonist in the first two attempts and GnRH agonist in the third attempt, with percutaneous technique of oocyte retrieval from the transpositioned right ovary. In the third attempt in July 2017, we were able to retrieve five oocytes and subsequently froze three embryos and one blastocyst. The surrogate underwent sequential transfer in June 2018 which resulted in a positive clinical singleton pregnancy. The outcome of IVF following percutaneous oocyte retrieval led to a successful pregnancy and subsequent delivery by emergency cesarean by a healthy female baby on February 16, 2019. This is the first reported case of ovarian hyperstimulation and percutaneous aspiration of oocytes from a transpositioned right ovary (subcutaneous plane) in our country. Global literature survey revealed publications only of transabdominal retrieval of ovaries moved above the pelvic brim.

Background: The purpose of this study was to clarify the anatomy of the superior hypogastric plexus, which would contribute to advancement of nerve-sparing paraaortic lymphadenectomy. Materials and methods: Eighteen cadavers were dissected and morphometrically analysed based on photographic images. Anatomical landmarks such as aortic bifurcation, transitional points of abdominal aorta to bilateral common iliac arteries, and cross point of the right ureter and pelvic brim, and cross point of sigmoid mesentery and pelvic brim were selected as reference points. Results: The left lowest lumbar splanchnic nerve was located more laterally to transitional point of abdominal aorta to in 11/18 specimens, whereas the right lowest lumbar splanchnic nerve passed onto the right transitional point in only one specimen. The lowest lumbar splanchnic nerves or the superior hypogastric plexus covered the aortic bifurcation in 11/18 specimens. The superior hypogastric plexus was separate from the cross point of right ureter and pelvic brim as well as cross point of sigmoid mesentery and pelvic brim. Conclusions: The superior hypogastric plexus is at risk of injury during paraaortic lymphadenectomy because of its topography. Preservation of the superior hypogastric plexus regarding its anatomic basis during paraaortic lymphadenectomy is required.

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.

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 74.9 years, standard deviation (SD) 16.9 years] 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.

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

Musculoskeletal injuries such as dislocation of the shoulder and hip joints and fractures of the femoral neck are known complications of seizures. Bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture is a rare entity and is prone to delayed diagnosis, even more so in patients who experience post-seizure disorientation. The authors report the case of a 74-year-old male patient with bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture due to seizure activity. Bilateral open reconstruction and fixation of the quadrilateral plate with a 3.5-mm pre-bent reconstruction plate reinforced with 3.5-mm pelvic brim reconstruction plate was performed. In conclusion, this case is an example of rare bilateral quadrilateral plate fracture caused due to seizure activity, a fracture for which a high level of suspicion should be kept in mind while evaluating the patient post-seizure episode.

Dislodgment of trial femoral heads and migration into the pelvis during total hip arthroplasty is a rarely reported complication with limited published cases. There are three primary mechanisms of femoral head separation: dislodgement during reduction attempt, disassociation from anterior dislocation while assessing anterior stability, and during dislocation after implant trialing. If the trial femoral migrates beyond the pelvic brim, it is safer to finish the total hip arthroplasty and address the retained object after repositioning or in a planned second procedure with a general surgeon. We recommend operative retrieval since long-term complications from retention or clinical results are lacking. Keywords: Total hip arthroplasty, THA, Complications, Femoral head dislodgement

Study Objective To demonstrate a surgical video wherein deep infiltrating endometriosis (DIE) was resected off the left pelvic sidewall. Design Step-by-step video demonstration of DIE resection from the external iliac vessels and the ureter. Setting Academic tertiary referral center. Patients or Participants 41-year-old female with history of endometriosis, presented with pelvic pain and left lower extremity swelling. Abdominal and pelvic imaging revealed extensive left pelvic sidewall fibrosis, resulting in compression of the external iliac vein, hydroureter and renal atrophy. Further urologic workup showed minimal to no residual function of the left kidney. Interventions Patient was taken to the operating room for resection of sidewall endometriosis and concomitant nephrectomy. Exploration of the peritoneal cavity showed that endometriosis was confined to the pelvis, heavily involving the left pelvic sidewall. The left retroperitoneum was entered and avascular spaces were elaborated. The left hydroureter and IP ligament were identified above the pelvic brim, as well as the common iliac vessels. Once proximal and distal access to the external iliac vessels were obtained, the majority of DIE was resected off the vessels. Complete resection of sidewall DIE would have led to vascular injury; therefore, the decision was made to proceed with debulking of fibrosis off the vessel surface and the remainder of the lesions inferior to the external iliac vessels. Given inability to salvage distal left ureter and non-functional kidney, concomitant left nephrectomy was performed. Measurements and Main Results The procedure and post-operative course were uncomplicated. There was significant improvement in patient's pelvic pain and lower extremity swelling. One month after surgery, she underwent balloon angioplasty and stenting of left external iliac vein to attain complete patency of the vein. Conclusion Long-standing DIE can lead to vascular compression and unsalvageable renal obstruction, which requires a multidisciplinary team approach in order to address this multisystem disease.

Objective To illustrate the surgical management of advanced endometriosis causing extrinsic ureteral compression. Design Video description of the case, demonstration of the surgical technique, reevaluation at 14-year follow-up, and review of urogenital endometriosis. Patient provided consent for the video recording and publication. This surgical report with no identifying patient data was exempt from Institutional Review Board approval. Setting Tertiary referral center. Patient(s) A 42-year-old nulligravida with a known history of endometriosis presented with persistent pelvic pain and no other specific symptoms. She had previously undergone a diagnostic laparoscopy demonstrating advanced endometriosis involving multiple organs, including the urinary tract. She was referred to us for further surgical management. Preoperative intravenous pyelogram showed partial obstruction and constriction of a long portion of the midpelvic and distal left ureter with proximal hydroureter, consistent with extrinsic ureteral compression. Intervention(s) The patient underwent operative video laparoscopy using a multipuncture technique, with enterolysis, extensive left ureterolysis, shaving of periureteral constrictive fibrosis and endometriosis, cystoscopy, and placement of left ureteral stent. Main Outcome Measure(s) There was extensive endometriosis and fibrotic adhesions involving the left pelvic sidewall. Proximal hydroureter was noted to the pelvic inlet secondary to severe periureteral fibrosis from the pelvic brim to the bladder meatus, with significant narrowing of the pelvic ureter. The endometriosis was resected using hydrodissection and shaving with a carbon dioxide laser. Histopathologic evaluation of the resection specimens confirmed endometriosis. Result(s) An intravenous pyelogram performed 4 weeks postoperatively revealed ureteral patency and resolving hydroureter, and her ureteral stent was removed. Annual renal ultrasounds for the subsequent 2 years were normal. Fourteen years later, she remained asymptomatic on no suppressive treatment. A follow-up intravenous pyelogram was performed and showed a normal urinary tract with bilateral ureteral patency and no recurrent strictures or hydroureter. Conclusion(s) In selected cases, conservative shaving of periureteral fibrotic endometriosis avoids ureteral resection and has acceptable outcomes.

Objective Excisional 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 , 2 , 3 , 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. Design Using 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. Setting Tertiary care academic hospitals: Mount Sinai Hospital in Toronto, Ontario, Canada, and S. Orsola Hospital in Bologna, Italy. Interventions Radical 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. Conclusion The 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.

Deep infiltrating endometriosis of the urinary tract is rare but can result in ureteric obstruction, hydroureteronephrosis and renal failure. Ureteric endometriosis usually affects the distal third of the left ureter among women of reproductive age. Greater awareness of ureteric endometriosis and a multidisciplinary approach in the management is essential to achieve optimal outcomes. We present an atypical case of right ureteric obstruction due to endometriosis at the pelvic brim resulting in complete loss of renal function and necessitating nephroureterectomy.

Ovarian cancer is characteristic of superficial implantation and peritoneal carcinomatosis. Hudson introduced a novel technique 50 years ago, which removed the entire Douglas pouch as a false capsule of the tumor (Hudson, 1968 [1]). Angeles et al. standardized the procedure in 10 steps in a previous publication (Angeles et al., 2019 [2]). We made small modifications of the Hudson procedure in this video. Ovarian cancer is characteristic of superficial implantation and peritoneal carcinomatosis. Hudson introduced a novel technique 50 years ago, which removed the entire Douglas pouch as a false capsule of the tumor (Hudson, 1968 [1]). Angeles et al. standardized the procedure in 10 steps in a previous publication (Angeles et al., 2019 [2]). We made small modifications of the Hudson procedure in this video.The key points of the procedure were summarized as follows. Firstly, dissecting off the pelvic parietal peritoneum very superficially. Secondly, the round ligament, infundibulo-pelvic ligament, medial umbilical ligament, and umbilical artery are divided and ligated in the extraperitoneal space. Thirdly, the bladder is mobilized caudally and the vesico-vaginal space is exposed after completely dissecting off the vesical peritoneum. Fourthly, the ureter is isolated and mobilized laterally. Then, uterine vessels and parametria are divided and ligated, which is followed by colpotomy to access the recto-vaginal septum. By retracting the total specimen cranially, the Douglas pouch is dissected retrogradely according to Hudson procedure. Lastly, the peritoneum of the mesorectum and mesosigmoid is shaved at the pelvic brim. Therefore, using this method, almost all the pelvic visceral peritoneum was dissected (). In addition, we didn't intentionally expose the anatomical spaces (pre-vesical, para-vesical, para-rectal, and pre-sacral) completely, which was effective and time-saving.Complete removal of the disseminated tumors in both parietal and visceral peritoneum was achieved by the method introduced in our video.Our method, modified from Hudson procedure, is effective for complete cytoreduction in selected ovarian cancer patients with extensive peritoneal carcinomatosis sparing rectosigmoid resection.

Aim: Breech is the most common form of malpresentation. It is defined as when foetus occupies a longitudinal lie with the pelvic extremity at the pelvic brim and head at the fundus of the uterus. The present study was conducted on 100 cases of breech presentation to find out the labour outcome in breech deliveries and various factors affecting it. Materials and Methods: The present study was conducted in the Department of Obstetrics and Gynaecology, Umaid Hospital, attached to Dr. S.N. Medical College, Jodhpur. A total of 100 cases of breech presentation including single as well as plural pregnancies in which one or more foetuses were presenting as breech were taken. Both booked and unbooked cases in primigravidae and multigravidae were studied. The cases were selected at random among those who got admitted in labour room. Results: In the present series, incidence of breech deliveries came to be 4.1094%. Incidence of breech presentation was maximum (45%) in the age group of 21–25 years. In this study, out of 100 cases, 62 were multigravidae and 38 were primigravidae, and 43 cases (43%) were associated with factors which endanger of life of the foetus, among which twin pregnancy and pre-eclamptic toxaemia were the most commonly associated factors. In the present series, among 100 cases studied, 14 were breech babies and congenital malformation, of which hydrocephalus was the most common malformation found. Conclusion: The study concludes that prematurity is associated with high incidence of breech presentation. The most common variety of breech presentation is flexed breech, which is found more in multigravidae. Caesarean section is the mode of delivery of choice as it carries minimal foetal loss. Extended variety of breech is safest for the baby and carries minimal foetal loss.

Purpose The triradiate cartilage transiently projects medially within the pelvic brim around the time of triradiate closure, mimicking the ischial spine sign. The purpose of this study was to characterize this newly identified radiographic sign using a longitudinal radiographic study. Methods We identified 72 subjects from a longitudinal radiographic study of healthy adolescents, each with at least four consecutive, annual anterior−posterior radiographs of the left hip, including physeal closure. Images were reviewed to identify the presence of the triradiate bump, the year it was most prominent, and the number of years relative to triradiate closure after which it had completely remodeled. Results The transient medial projection of the triradiate cartilage (triradiate bump) was identified in 26/40 (65 %) females and 22/32 (69 %) males ( p = 0.74). The medial projection of the triradiate cartilage was most prominent at 10.8 ± 0.8 years of age in females and 12.6 ± 0.7 years of age in males ( p < 0.001). The triradiate cartilage projected medially a mean of 4.7 ± 0.8 or 5.1 ± 1.4 mm for females and males, respectively ( p = 0.29), but remodeled completely in all cases around triradiate closure. Conclusions The transient medial projection of the triradiate cartilage within the pelvic brim, the ‘triradiate bump sign’, is a common radiographic finding in healthy adolescents around the time of closure of the triradiate cartilage that may mimic the ischial spine sign. These two signs can be distinguished as the projection of the ischial spine is located more inferiorly within the pelvic brim and the triradiate bump has a horizontal limb of radiolucency extending to its medial border.

Purpose The internal iliac artery displays variations that may predispose it to inadvertent injury during pelvic surgeries. This study aimed to describe variations of the internal iliac artery among Kenyans. Basic procedures Fifty-seven pairs of right and left-sided hemi-pelvises, 48 from males and 9 from females, were used in this study. We collected data on the internal iliac artery origin, relations, termination, branching, length and course of parietal branches. Data were then coded and entered into SPSS (version 21, Chicago, IL), where we performed descriptive statistics and analyses. Findings In all cases, the internal iliac artery originated singly from the common iliac artery. The IIA originated above the vertebral level of the L5/S1 disk (pelvic brim) in 30/57 (52.6%) cases, with the highest observed at L4. In most cases (32/57 [56.8%]), the IIA terminated at S1 vertebral level. The internal iliac artery lay medial, anterior and lateral to the sacroiliac joint in 37/57 (64.9%), 18/57 (30.6%) and 2/57 (5%) cases, respectively. Regarding parietal branching, 39/57 (64.8%) cases had a type 1 pattern as per the Adachi classification. The mean diameter and length of the internal iliac artery were 7.32 ± 1.69 mm and 36.97 ± 14.12 mm, respectively. The differences in dimensions of the IIA between the left and the right sides were not significant. Principal conclusions A considerable proportion of the Kenyan population demonstrates an origin of the internal iliac artery above the pelvic brim. Unique termination via trifurcation and ramification may also be observed in the Kenyan population. Surgeons and radiologists performing vascular interventions in the pelvis should be mindful of these variations.

Renal migration anomalies are rare and often under-reported. Kidneys that fail to ascend to their normal location in the renal fossa are usually termed 'ectopic' kidneys, which can be unilateral or bilateral. Those that fail to ascend above the pelvic brim are commonly termed pelvic kidneys. We present a case of a 41-year-old male haemophiliac on routine investigation with a previous history of anaemia and bone pains, currently asymptomatic. He was found to have malrotated pelvic kidneys with vascular anomalies. Even though most patients with pelvic kidneys are asymptomatic, they are usually discovered in childhood or as young adults. This case is important because, in addition to the late discovery of the bilateral pelvic kidneys, there is coexistence of a bleeding disorder which may pose a challenge in patients' management. This is to also make the patient aware of his condition and avoid taken unnecessary risk which might make his condition worse.

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.

Overview Introduction The periacetabular osteotomy procedure reorients a retroverted acetabulum into a more anatomically appropriate position. Step 1: Evaluation of Acetabular Retroversion Evaluate acetabular retroversion on the basis of a combination of radiographic signs. Step 2: Patient Positioning and Skin Incision After draping and sterile preparation with the patient in a supine position, make an incision following the skin lines of the inguinal fold. Step 3: Exposure of the Deep Muscle Layers and the Pelvic Brim Detach the abdominal wall muscles from the anterior iliac crest and detach the sartorius muscle and the inguinal ligament to expose the iliac fossa and the pelvic brim. Step 4: Surgical Dissection for Preparation of the Ischial Osteotomy Detach the iliocapsularis muscle and mobilize it medially to allow access to the infra-articular space and palpation of the ischial bone. Step 5: Incomplete, Partial Ischial Osteotomy Introduce a curved chisel with a crescent-shaped tip into the infra-articular space in order to perform the osteotomy of the ischial bone. Step 6: Osteotomy of the Superior Pubic Ramus Place subperiosteal blunt retractors around the superior pubic ramus to ensure safe and complete pubic bone osteotomy. Step 7: Supra-Acetabular and Retroacetabular Osteotomy Start the supra-acetabular horizontal osteotomy at the anterior superior iliac spine and end it 2 cm lateral to the pelvic brim, where the osteotomy is angled 100° distally. Step 8: Mobilization of the Acetabular Fragment With the help of a spreader and a 4.5-mm threaded Schanz pin, free and mobilize the acetabular fragment. Step 9: Reorientation of the Acetabular Fragment Perform internal rotation of the acetabular fragment with the help of the threaded Schanz pin. Step 10: Improvement of Anterior Head-Neck Offset (Femoral Neck Osteoplasty) Anterior capsulotomy and improvement of anterior head-neck offset is recommended when internal rotation is Step 11: Anteroposterior Pelvic Radiograph Following Periacetabular Osteotomy Ideally, a postoperative radiograph should show negative crossover and posterior wall signs while the ischial spine sign typically remains positive. Results The long-term results of the periacetabular osteotomy in a series of twenty-two patients (twenty-nine hips) with symptomatic acetabular retroversion were evaluated after a mean duration of follow-up of eleven years (range, nine to twelve years). Indications Contraindications Pitfalls & Challenges

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°, P0.05), 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.

Study Objective To demonstrate techniques of ureterolysis during complex laparoscopic hysterectomy. Design Technical video demonstrating different approaches to ureterolysis for complex benign pathology during laparoscopic hysterectomy (Canadian Task Force classification III). Setting Benign gynecology department at a university hospital. Intervention Performance of ureterolysis during laparoscopic hysterectomy for benign pathology. Conclusion Ureteric injury has significant morbidity and is the most common reason for litigation following hysterectomy, with an estimated risk of 0.02% to 0.4%. 1 , 2 . Ureterolysis is infrequently practiced by benign gynecologists; however, it may be necessary during complex surgery. Benign pathology requiring hysterectomy, such as endometriosis, myomas, large uteri, and adnexal masses, are recognized risk factors for ureteric injury [3] . Most injuries occur during division of the uterine artery at the level of the internal cervical os. The average distance between the ureter and cervix is 2 cm, but it is only 0.5 cm in 3.2% of the population with a normal pelvis [4] . Preventive strategies, such as the use of a uterine manipulator, may increase this distance, although it still might not be sufficient to prevent injury in women with normal anatomic variants and complex pathology. Visualizing the ureter at the pelvic brim and side wall without retroperitoneal dissection may be inadequate because the segment of ureter between the intersection of the uterine artery and the bladder is not visible. The ureter can be safely dissected up to 15 cm without compromising its viability. In this educational video, we demonstrate various simple, quick, and reproducible techniques to perform ureterolysis for complex benign pathology. These techniques can be used by both expert and novice surgeons to perform and teach ureterolysis. Our method determines the course of the ureter throughout the pelvis and relation to the uterine artery to reduce intraoperative injury. We have performed more than 350 cases with no injuries.

Aim: Ipsilateral ureteroureterostomy is an established method for the treatment of duplication anomalies in children. With the advent of pediatric laparoscopy, many urologic procedures in children are being performed using minimal access techniques. We present our experience with laparoscopic ipsilateral ureteroureterostomy (LIUU) for duplex anomalies. Patients and Methods: The data of children who underwent LIUU was reviewed for demographic parameters, clinical and operative details, follow-up and results. Results: Over 3 years period, LIUU was performed in eight children (age 6-60 months). Five children had complete ipsilateral duplication with ectopic upper moiety ureter, one child each had ipsilateral incomplete duplication and bilateral duplex systems (with ipsilateral ectopic upper moiety ureter). One child had ipsilateral complete duplex with Grade V vesicoureteric reflux into the lower moiety ureter. Four children had antenatal diagnosis of hydronephrosis; three children had a urinary infection and two children presented with urinary incontinence. The surgical procedure consisted of cystoscopy, retrograde studies and cannulation of the recipient ureter. Then, LIUU was performed using three ports. The ectopic (donor) ureter was divided at the pelvic brim; the recipient ureter was opened and end-to-side LIUU was performed with 5/0 vicryl stitches over a double J (DJ) stent placed in the recipient ureter. Bladder catheter was removed after 2 days, and DJ stent was removed after 4 weeks. At a mean follow-up of 19 months (3-36), all children are asymptomatic and continent, with a significant reduction in hydroureteronephrosis on ultrasound. The cosmetic results were excellent. Conclusion: LIUU is a safe and effective technique in the management of duplication anomalies in children. It could be performed with minimal blood loss, minimal postoperative pain, excellent cosmesis and good success.

The ilioinguinal approach for psoas recession over the pelvic brim allows for direct visualization and protection of the femoral nerve while preserving hip flexion strength. Hip flexion contracture is a common problem in patients with spastic paresis such as cerebral palsy and may also affect patients who have sustained trauma about the hip. These contractures may impair gait and the ability to carry out activities of daily living. The iliopsoas muscle is the main deforming force; however, contraction of the hip capsule and surrounding soft tissue may also contribute1. Iliopsoas tenotomy at the level of the lesser trochanter treats the contracture at the cost of hip flexor strength, making it difficult for ambulatory patients to climb stairs or even walk on a level surface2,3. Intramuscular psoas recession over the pelvic brim is an alternative that preserves hip flexor strength while correcting the flexion contracture4-8. In this procedure, the psoas tendon is lengthened as it traverses the pelvic brim while the iliacus is preserved (Video 1). Thus, the iliopsoas unit is fractionally lengthened, preserving its ability to flex the hip. Previous studies have shown that hip flexion strength against gravity and manual resistance is maintained while improving dynamic pelvic tilt and step length during gait after this procedure4,8. Video 1 Introduction to psoas recession over the pelvic brim. An image in the video is copyrighted by, and reproduced with permission of, the AO Foundation, Switzerland.

A 30 year old nulligravida female reported to the fertility centre of AHD with the complaints of primary infertility for three and half years and spasmodic dysmenorrhoea. There is also history of progressively increasing right lower abdominal pain as well as discomfort which was cyclically associated with the onset of menses. Transabdominal sonography showed-‘Endometrial splitting into two at the fundus–suggesting bicornuate uterus. Echogenic soft tissue in the cervical canal due to blood clots. Non visualized right kidney. Mildly enlarged left kidney’. HSG done outside AHD suggestive of unicornuate uterus with single fallopian tube. IVU showed non visualized right kidney. Normally excreting left kidney. TVS showed normal sized septated nulliparus uterus with homogeneous myometrium and thick endometrium with proliferative phase echo. Mildly enlarged right ovary with mildly distended right tube. Mild collection adjacent to the vagina. Then the patient came to the gynaecology dept of AHD from where she was sent to our Radiology department to undergo MRI of pelvis. The MRI showed uterine didelphys. Obstructed hemivagina (right) with hematocolpos extended upto pelvic brim along right and posterior aspect of uterus through anomalous dilated remnant of right lower ureter with ipsilateral renal agenesis. Patient was diagnosed as OHVIRA syndrome radiologically. DOI: http://dx.doi.org/10.3329/pulse.v6i1-2.20358 Pulse Vol.6 January-December 2013 p.66-69

The management for ovarian dysgerminoma is different from those of other ovarian tumors, making accurate diagnosis crucial for patient care. We report a case of 9 year old girl who presented with abdominal distension. Examination revealed a huge palpable intra-abdominal mass. Plain X ray abdomen showed a large homogenous mass filling the mid part of the abdomen and causing displacement of bowel loops laterally. Abdominal sonography showed a large heterogenous lobulated abdominal mass reaching up to the pelvic brim. CECT abdomen showed a large well defined lobulated heterogeneously enhancing mass of 59-61 HU occupying most of the mid part of abdomen and reaching up to the pelvic brim. It showed multiple areas of necrosis with few small specks of calcification. The mass was removed after laparotomy under general anesthesia. Finally, after histopathological examination with raised β-human chorionic gonadotropin (β-hCG) levels, the diagnosis of ovarian germ cell tumor (Dysgerminoma) was made.

Objective: To evaluate the safety and efficacy of semi-rigid ureteroscopy in proximal and distal ureteral stones, and to compare the operative and perioperative characteristics between the two stone groups. Materials and Methods: We retrospectively reviewed the medical records of patients who underwent semi-rigid ureteroscopy for management of ureteral stones at the International Medical Center between June 2007 and September 2012. All stones were fragmented using Holmium: yttrium-aluminum-garnet (YAG) laser lithotripter. Stones located above the pelvic brim are considered proximal and below it are distal. Results: One hundred and ninety-one patients were included. One hundred and three patients (54%) underwent ureteroscopy for proximal stones and 88 (46%) for distal stones. The stone size in the proximal group was 10 mm (±5.5) versus 8.6 mm (±5) in the distal group. The initial stone-free rate for proximal and distal calculi were 89–98.2%, respectively. The perioperative complication rate was higher in the proximal group 10% compared to the distal group which is 1.5% (P = 0.06). Both groups have the same average of hospital stay 1.2 days. Conclusion: Although there is a clinical difference between proximal and distal calculi groups in terms of complication and stone-free rates, this difference remained statistically insignificant (P = 0.06). Using a smaller caliber semi-rigid ureteroscopy combined with Holmium-YAG laser can be carried out as a day care procedure and showed a slightly higher risk in patients with proximal ureteral calculi which should be explained to the patient

Case Description—A 7-year-old 573-kg (1,261 -lb) Swiss Warmblood gelding was evaluated because of signs of acute abdominal pain. Clinical Findings—Physical examination revealed a markedly distended abdomen with subjectively reduced borborygmi in all abdominal quadrants. A large, gas-distended viscus was present at the pelvic brim preventing complete palpation of the abdomen per rectum. Ultrasonographic evaluation could not be safely performed in the initial evaluation because of severe signs of abdominal pain. Treatment and Outcome—Ventral midline celiotomy was performed, and right dorsal displacement of the ascending colon was corrected. Progressive signs of abdominal pain after surgery prompted repeat ventral midline celiotomy, and small intestinal incarceration in a large, radial mesojejunal rent was detected. The incarceration was reduced, but the defect was not fully accessible for repair via the celiotomy. Repair of the mesenteric defect was not attempted, and conservative management was planned after surgery; however, signs of colic returned. A standard laparoscopic approach was attempted from both flanks in the standing patient, but the small intestine could not be adequately mobilized for full evaluation of the rent. Hand-assisted laparoscopic surgery (HALS) allowed identification and reduction of jejunal incarceration and repair of the mesenteric rent. Although minor ventral midline incisional complications were encountered, the horse recovered fully. Clinical Relevance—HALS techniques should be considered for repair of mesenteric rents in horses. In the horse of this report, HALS facilitated identification, evaluation, and repair of a large radial mesenteric rent that was not accessible from a ventral median celiotomy.

A 50-year-old man with intractable anal pain attributed to proctalgia fugax underwent insertion of a sacral nerve stimulator via the right S3 vertebral foramen for pain control with good symptomatic relief. Thirteen months later, he presented with signs of sepsis. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a large presacral abscess. MRI demonstrated increased enhancement along the pathway of the stimulator electrode, indicating that the abscess was caused by infection introduced at the time of sacral nerve stimulator placement. The patient was treated with broad spectrum antibiotics, and the sacral nerve stimulator and electrode were removed. Attempts were made to drain the abscess transrectally using minimally invasive techniques but these were unsuccessful and CT guided transperineal drainage was then performed. Despite this, the presacral abscess progressed, developing enlarging gas locules and extending to the pelvic brim to involve the aortic bifurcation, causing hydronephrosis and radiological signs of impending sacral osteomyelitis. MRI showed communication between the rectum and abscess resulting from transrectal drainage. In view of the progressive presacral sepsis, a laparotomy was performed with drainage of the abscess, closure of the upper rectum and formation of a defunctioning end sigmoid colostomy. Following this, the presacral infection resolved. Presacral abscess formation secondary to an infected sacral nerve stimulator electrode has not been reported previously. Our experience suggests that in a similar situation, the optimal management is to perform laparotomy with drainage of the presacral abscess together with simultaneous removal of the sacral nerve stimulator and electrode.

The surgical goal for unstable pelvic injuries is to reduce and stabilize the anterior and posterior pelvic rings. Anatomical reduction and stable internal fixation of both the anterior and posterior rings can result in good radiologic and clinical outcomes. The surgical approach and fixation method used are based on the fracture classification, the amount of displacement, soft tissue condition, associated injuries, and overall hemodynamic status of the patient. Surgical fixation was focused on the posterior pelvic ring, which contributes about 60% of the overall pelvic ring stability, and then the anterior ring lesion is assessed for its need of fixation, if required. Matta and Tornetta1) have emphasized the importance of an accurate reduction and stable fixation for posterior ring injuries. Posterior pelvic ring fixation is traditionally associated with vertically unstable fractures. These injuries are associated with a substantial risk of retroperitoneal hemorrhage, presence of the Morel-Lavallee lesion, and 25% incidence of skin breakdown following internal fixation of these fractures. However, the visualization necessary for the reduction often requires significant soft tissue dissection and long operative times, which are problematic in unstable patients. There are various surgical options for anterior ring fixation, including external fixator, retrograde intrapubic screw, and plate. The most commonly used surgical approach is a Pfannenstiel-type incision for the symphyseal disruption and medial ramus fracture. For the plate fixation of a displaced lateral ramus fracture and anterior column, an ilioinguinal approach, described by Letournel,2) is widely used as the exposure of choice, which may require a long operation time, meticulous handling around the neurovascular bundle, and significant blood loss. Based on the current concept of minimally invasive surgery that emphasizes less tissue dissection, the modified Stoppa approach has gained in popularity. The Stoppa approach has been introduced for the treatment of pelvic-acetabular fractures, allowing the easy exposure of the pelvic brim, where bone quality is optimal for screw fixation.3,4,5,6) The purpose of our study was to investigate the surgical outcomes of unstable pelvic ring injuries treated using the Stoppa approach for stable anterior ring fixation.

One year and nine month old baby girl brought to the hospital with swelling in the left gluteal region noticed by the parents since three months of age. They consulted a local practitioner who suggested aspiration by needle, which was done multiple times. The size of the swelling used to decrease immediately after aspiration but returned to its usual size within 1-2 months. On examination, the child was alert, active with normal growth and development. Left gluteal region was more prominent with skin over the region showing multiple puncture marks (Fig. 1), palpation revealed an illdefined, immobile, and non-tender mass with variable consistency. Per rectal examination showed mass extending up to the presacral region. Bimanual palpation revealed extension of the mass up to the level of the pelvic brim. Ultrasound revealed a well-defined anechoic cystic lesion near coccyx. MRI of the left gluteal region showed two peripherally enhancing lesions near the anterior-inferior part of the coccyx confirming the diagnosis of SCT (Fig. 1). Serum alpha fetoprotein level was normal. At operation, a large dumb-bell shaped mass with both solid and cystic (mainly) components, arising from the coccyx, was completely excised along with coccygectomy. Postoperative recovery was uneventful. Biopsy report showed it to be mature teratoma (Fig. 1) with margins free of tumor. The parents were counseled for regular follow-up.

The purpose of the study was to assess the stability provided by an ilio-iliac dorsal plate fixation technique using an AO narrow DCP on the pelvic brim in vertically and rotationally unstable type-C pelvic ring injuries.We examined 12 fresh cadaver pelvises in a single limb stance load. A type-C pelvic ring injury (a type I lateral sacral fracture in the classification of Denis with symphysis pubis rupture) was performed on the cadaver specimen and fixed with a four-hole narrow dynamic compression plate to stabilize the symphysis pubis rupture; the sacrum fracture was stabilized either anteriorly with two 3-hole reconstruction plates ("anterior plate osteosynthesis") or with a posterior fixation using a 12-hole narrow DCP. A cyclic load of between 100 and 250 N was applied to the fifth lumbar vertebra of the specimen. An extensometer was attached to both sides of the sacrum fracture to detect movements at the fracture site.We were able to achieve usable measurements in nine specimens. Three measurements were performed on each specimen, and the movements recorded at the fracture gap in trans-sacral plate fixation were higher than or similar to those observed for anterior plate synthesis in 23 out of 27 cases.Dorsal ilio-iliac bridge plate fixation provides somewhat reduced stability compared to anterior plate fixation, but the difference is not significant.

Variations in the disposition of colon are developmental in origin. Interruption of typical locations may lead to a variety of acute and chronic pathological conditions. Here we report an unusual case of abnormal position of descending colon with right-sided sigmoid colon observed in a 70-year old male cadaver during the routine dissections for undergraduate medical students. In the present case, the descending colon crossed the vertebral column at L4 level to reach the right pelvic brim to continue as right sided sigmoid colon. Awareness of this finding is of crucial significance when performing procedures like percutaneous gastrotomy and radiologically guided entrostomy as it can lead to fatal sepsis in patients who undergo minimally invasive procedures.

A 69-year-old obese man was involved in a high-speed head-on motor vehicle collision. He was tachycardic and normotensive on arrival. He subsequently developed hemodynamic instability requiring blood transfusion. On examination he had bilateral pneumothoraces, an anterior-posterior compression (APC) pelvic fracture, an open wound at the left groin, and gross hematuria after Foley catheter placement. CT imaging revealed hemoperitoneum, right hepatic lobe grade II lacerations, splenic laceration, mesenteric root injury with extravasated contrast, intraperitoneal and extraperitoneal bladder rupture, bilateral ureteral injuries at the level of the pelvic inlet (see figure 1), APC pelvic fracture, bilateral rib fractures, pneumothoraces, and pulmonary contusions. Figure 1 CT of the abdomen and pelvis with cystogram. Delayed images demonstrating accumulation of contrast in the retroperitoneum arising from the right and left ureter at the level of the pelvic brim. Extraluminal contrast from the intraperitoneal bladder injury is also identified. He underwent emergent exploratory laparotomy. Exploration confirmed the injuries noted on the CT scan. Hepatorrhaphy with abdominal and preperitoneal pelvic packing was performed. A large anterior bladder wall injury was visualized. Neither ureteral orifice was seen. The right ureter was completely transected at the level of the pelvic brim. The left ureter was decompressed and the full extent of its injury was not determined; however, the bladder injury left concern for a distal avulsion. The patient continued to be in shock. What would you do? Reconstruct the urinary bladder and reimplant bilateral ureters. Ligate the ureter and prepare for pelvic embolization and nephrostomy tubes. Continue to explore looking for the full extent of the left ureter. Externalize the ureters to the abdominal wall with the open abdomen.

Shoulder dystocia is a condition where there is a difficulty in the delivery of the shoulder of the fetus occurs This is an obstetric emergency It happens when the fetalbiacromial diameter is larger than the biparietal diameter or the maternal pelvic brim is flat rather than gynecoid If this frightening situation is not manage properly in time and by expert hand it can cause severe fetal and maternal outcome All doctors should require proper training and knowledge for the management of this emergency situation Well trained health professionals can improve the outcome of the delivery when shoulder dystocia occurs There is no any strong evidence to prevent shoulder dystocia because it is so unpredictable But good control of blood glucose level of diabetic mother will reduce the incidence of macrosomic baby Elective caesarean section is recommended for suspected fetal macrosomia to prevent brachial plexus injury

Objectives: Alternatively to the modified Stoppa approach, the Pararectus approach is used clinically for treatment of acetabular fractures. This study assessed the surgical exposure and the options for instrumentation using both of these approaches. Methods: Dissections were conducted on five human[for full text, please go to the a.m. URL], Deutscher Kongress für Orthopädie und Unfallchirurgie (DKOU 2016)

Bilateral congenital mid ureteric stenosis is a very rare entity causing hydroureteronephrosis. The pathophysiology and aetiology of this condition is uncertain. Congenital functional obstruction of the mid ureter has only 17 reported cases, that too of unilateral pathology. We report a case of an 11-year-old male child who was presented with left sided lump in abdomen since one year. On bilateral retrograde ureteropyelography (RGP), bilateral mid ureteric stenosis was documented at the level of pelvic brim. Tc99m Diethylene Triamine Pentacaetic Acid (DTPA) scan showed non functioning left kidney and decreased function and retention on right side. We did a left nephroureterectomy and uretero-ureterostomy without tapering over a Double-J stent (DJ), with excision of stenosed segment on right side. Pathological review of the ureteric segments of both sides revealed proximal dilatation with non-specific thickening of the muscular wall of the stenosed segments of ureter. The differential diagnosis must additionally include ureteral valves and fibro epithelial polyps. Important role of intravenous pyelography in such cases must be emphasized to localize the pathology site. In addition, retrograde ureteropyelography is essential in management of this anomaly to delineate the stenosed segment of the ureter preoperatively, so that the surgeon can be well prepared with final plan of management.

Purpose. To define the centre of the hip joint and the bone stock around the hip joint from the supra-acetabular portion or pelvic brim so as to avoid penetration of guidewire into the hip joint when performing internal fixation using the anterior approach. Methods. A total of 42 cadavers were utilised. Measurements were completed before and after cutting the pelvis into 4 pieces. Before cutting the pelvis, the centre of the hip joint was measured on the pelvic brim. After cutting the pelvis, the bone stock around the hip joint was measured in each section. The pelvic brim and the anteroinferior iliac spine were utilised as guide points in the measurements, because these parameters could be determined during an anterior surgical procedure. Results. On the pelvic brim, the reflected centre of the hip joint centre was located approximately 3.2 mm anterior to the distal edge of the anteroinferior iliac spine. The mean minimum bone stock of the pelvic brim was 14.0 mm in the centre of the hip joint section. Conclusion. This study described the anatomical reference points around the hip joint, and the ways in which they can be utilised to increase the safety of the anterior approach for internal fixation. It is important to define the centre of the hip joint from the supra-acetabular portion or pelvic brim, given that it is not visualised during surgery using an anterior approach.

Background Displaced anterior column fractures have increasingly been treated surgically by the ilioinguinal approach and fixation with lag screws and a buttress plate on the pelvic brim. However, a major disadvantage of the ilioinguinal approach is possible damage to the neurovascular bundle and the lymphatic structures in the intermediate part of the approach. This study aims to present a novel surgical technique of the less invasive anterior iliac approach and compression osteosynthesis for high anterior column fractures of the acetabulum. Methods In this retrospective case series, 19 patients treated operatively for isolated high anterior column fractures using the less invasive anterior iliac approach and compression osteosynthesis were included. Patient demographics, the cause of injury, associated injuries, time to surgical reconstruction, and operation time were collected from the medical records. The quality of reduction was assessed by postoperative standard radiographic views and computed tomography scans and graded according to Matta's criteria. Clinical and radiographic grades were assessed according to Matta's criteria at the last follow-up. Results This less invasive surgical technique was successful for reduction and fixation in all high anterior column fractures and provided sufficient stability to allow immediate mobilization of the patients after surgery. Twelve fractures were combined with the quadrilateral plate fracture and seven fractures did not involve the quadrilateral plate. According to Matta's criteria, anatomical reduction was obtained in 17 patients and imperfect reduction in two patients. Clinical results were excellent in 17 patients and good in two patients. Radiographic results were excellent in 17 patients and good in two patients. Ten patients had neurapraxia of the lateral femoral cutaneous nerve related to the approach, which was resolved completely in seven. One patient had deep vein thrombosis. Conclusions Our less invasive surgical technique of the anterior iliac approach and compression osteosynthesis is a useful addition to the existing techniques in the treatment of high anterior column fractures of the acetabulum. Despite being a limited approach and fixation, this technique provides sufficient exposure for reducing and fixing the fracture and adequate stability to allow immediate mobilization of the patient after surgery.

bone was considered as ideal bone for sex determination after skull. Material and Method:- This study was carried out on 120 dried human hip bones and classified them in to three groups according to nine visual criteria Male, female and Unknown group. Out of 120 hip bones 45% were male, 30% were female and remaining 25% were related with unknown group. Pelvic brim chord and pelvic brim depth were measured and index was calculated. These three parameters were statistically analyzed. Results:- Mean values of pelvic brim chord, pelvic brim depth and pelvic brim chord index( PBCX PBD) were higher in female as compared male and unknown sex group hip bones. Difference of the mean of these measurements statistically analyzed and P value >0.133 for pelvic brim chord, P value- 0.001 for prelvic brim depth and pelvic brim chord index was found. Conclusion:- After statistical analysis It was found that there was significant difference in the mean value of pelvic brim depth and pelvic brim chord index. And difference in the mean value of pelvic brim chord was not statistically significant.

Introduction Sigmoid volvulus is a common etiological factor in acute large bowel obstruction. The increased length of sigmoid colon is attributed as one of the causes of sigmoid volvulus. Aim The aim of this study was to find the morphology of sigmoid colon in South Indian population using cadavers. Materials and methods The present study was performed with 31 cadavers used for teaching purpose. The sigmoid colon was classified into classical, long-narrow and long- broad types by their disposition in the abdominal cavity. The sigmoid loop's relation to pelvic brim was also observed and grouped as pelvic and suprapelvic in position. The length of sigmoid colon along the mesenteric and antimesenteric border, height and width of sigmoid mesocolon in relation to the pelvic brim and the root of mesentery were measured in the study. Results The study showed that the majority of the sigmoid colons fell into the classical type (47.6%). The sigmoid colon in pelvic position was significantly more prevalent. The mean length of sigmoid colon was 15.2 ± 4.4cm and 19.2 ± 6cm considering the pelvic brim and root of mesentery as reference points of measurement respectively. The mean length along antimesenteric border was 22.3 ± 7.9cm and 25 ± 8.7cm along the same reference points. The mean length of mesocolon height was 6.5 ± 3cm with reference to pelvic brim and 7.3 ± 3cm with reference to root of Sigmoid mesocolon respectively. The mean width of mesocolon was 7.4 ± 3cm (pelvic brim) and 8 ± 2cm (root of Sigmoid mesocolon) There was a positive correlation of sigmoid colon length with the height of the mesocolon. The gender analysis showed that males had statistically significant longer sigmoid colon and mesocolon. Conclusion This study documents that the South Indian population has a more classical type of sigmoid colon and that the anatomical dimensions of sigmoid colon and its mesocolon is significantly longer in males.

Objective. To investigate the several parameters of femoral neck geometry associated with hip fracture risk in Siberial population. Material anil methods. 51 patients (39 women and 12 men: aged 60-90 years) with hip fractures and 102 persons (78 women, 24 men) without fractures (control group). Bone mineral density (BMD) was measured by dualenergy X-ray absorptiometry (DPX-IQ, Lunar, USA) in lumbar spine and in the hip (femoral neck, trochanter, Ward’s triangle) of the contralateral hip to the fracture. BMD was not significant in both groups. We measured hip axis length (the distance from greater trochanter to inner pelvic brim), the femoral neck axis length (the distance from the trochanter to ihe apex of the femoral head), neck width and the neck/shaft angle on the scan printout. Results. The hip axis length was longer in the women with the hip fractures (56,3±3,9 mm vs.53,7±3,7 mm, p