Search

SUMMARY Surgical exposure of the anterior column, anterior wall, pelvic brim, and sacroiliac joint is accessible through the lateral window of the ilioinguinal approach. Residual attachment of the abdominal muscles and inguinal ligament to the anterior superior iliac spine (ASIS) is often a limiting factor to expanded distal and medial exposure, especially in patients with a large abdomen that hangs over the pelvis. An ASIS osteotomy has been described to improve exposure, particularly of the distal anterior wall and joint capsule, pubic ramus, and anterior quadrilateral plate. However, an ASIS osteotomy can be troublesome to reattach. In this study, we introduce a soft tissue release technique to mobilize the abdominal muscles and inguinal ligament to allow expanded surgical access to the distal anterior column/wall and sacroiliac joint and to create a working space for fracture reduction and fixation.

Objective To describe in detail the variability of the attachments of the iliopectineal fascia (IPF) and its relation to the external iliac vessels to inform surgical approaches and help prevent injury to the adjacent vascular structures. Methods A cadaveric study was performed on 16 specimens. The IPF was identified from the lateral and medial perspectives of the II and anterior intrapelvic approaches, respectively, and its anatomic characteristics were described. Results The IPF originates in the fascia of the psoas muscle, it has variable attachments in the pelvic brim, and it inserts in the medial surface of the iliac bone where it is continuous with the obturator internus fascia. Two variants were found in relation to the external iliac vessels. In one variant found in 4 cadavers, the IPF formed a sail-like structure that surrounds the external iliac vessels. In the other variant observed in 4 cadavers, the IPF overlaid the iliac fossa, under the external iliac vessels which laid free in the iliac fossa. Conclusions The anatomic variants of the attachment of the IPF to the pelvic brim and its variants in relation to the external iliac vessels must be accounted for when performing acetabular surgery to prevent vascular injury and attain adequate exposure.

While laparoscopic heminephrectomy is performed for poorly functioning moieties, laparoscopic reconstruction with renal preservation is feasible when the affected moiety is functioning. Laparoscopic pyelopyelostomy at the level of pelvic brim can offer an alternative solution. We retrospectively reviewed the records of patients treated between 2017 and 2019 with renal duplication anomalies, and a preserved function. Five patients were identified, who underwent laparoscopic high internal diversion after placing a retrograde double J stenting in the receiving moiety. Stents were removed 8 weeks after surgery. All patients had uneventful post-operative recovery and showed clinical and radiological improvement at 1-year follow-up with no further episodes of urinary tract infection (UTI). The mean operative time was 155 min (range 130–170) and mean time to discharge was 4 days (range 2–5). The management of the duplex renal systems should be individualized for every patient. In the presence of a functioning moiety, laparoscopic reconstruction can be accomplished by pyelopyelostomy. This approach gives wider anastomosis, is easier to perform and gives better drainage than laparoscopic uretero-ureterostomy where the receiving ureter is often narrow potentially risking the normal moiety.

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.

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

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.

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

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.

The role of the stomach in the digestive system is that of a food blender and a reservoir. Inside the stomach mechanical and chemical breakdown into a liquid mass, the chyme, takes place. Food particles have to be as small as 1–2 mm in diameter before they pass to the duodenum. The reservoir function is reflected by the fact that an empty stomach contains approximately 100 ml, while a full stomach may contain more than 2 l and may even extend as low as the pelvic brim. The reflux of gastric content is prevented by, among others, the lower esophageal sphincter and emptying into the duodenum is regulated by the pyloric sphincter. The functional aspects make the stomach a highly mobile and distensible sac.

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.

OBJECTIVES The iliopectineal fascia (IPF) serves as an important anatomical compass during the ilioinguinal and anterior intrapelvic approaches. The purpose of this investigation is to qualitatively and quantitatively describe the IPF by cadaveric dissection. METHODS Dissections were performed on 7 paired fresh-frozen cadaveric pelvic specimens. Measurements were made with surgical rulers to determine attachments of the IPF relative to surrounding anatomy. RESULTS The IPF is the thickened anterior portion of the iliopsoas fascia, attached superolaterally at the iliac crest for a mean insertion distance of 2.5 cm (range, 2.0-3.0 cm), immediately posterior to the origin of the inguinal ligament. Inferomedially, the IPF attaches to a bony ridge along the apex of the iliopectineal eminence, between the pelvic brim posteriorly and the anterior wall of the acetabulum anteriorly (mean distance, 4.3 cm; range, 3.1-5.6 cm). The attachment at the iliopectineal eminence is 7.8 cm (range, 6.0-10.0 cm) from the pubic symphysis, measured curvilinearly along the brim. The mean length of the IPF between its superolateral and inferomedial attachments is 9.2 cm (range, 8.0-11.8 cm). Anterolaterally, the IPF is the site of attachment of the internal oblique and transversus abdominis. Posteriorly, the IPF continues as the iliopsoas fascia. CONCLUSIONS The authors have sought clarity and reconciliation of the myriad terms and descriptions of the IPF and its surrounding anatomy. We recommend a thorough understanding of this anatomy to enable safe and effective surgery via the ilioinguinal and anterior intrapelvic approaches to the acetabulum.

SUMMARY Percutaneous screw fixation in the treatment of a variety of pelvic fractures may involve placement of a pelvic brim or "LC-2" screw. The technique requires the use of the combined obturator oblique inlet view to define the medial and lateral cortical borders of the corridor and an iliac oblique view to define the cranial aspect of the sciatic notch. No technique has been reported on how to safely avoid placement of such percutaneous fixation beyond the posterior cortex of the ilium. A simple technique using the blunt end of a guidewire and a true lateral of the posterior ilium is reported.

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 incidence of secondary perineal hernia (SPH) has increased since the introduction of extralevator abdominoperineal resection and laparoscopic abdominoperineal resection. Currently, laparoscopic mesh repair is the usual procedure. Here, we demonstrate a repair of SPH without mesh that uses the mobilized cecum to cover the pelvic hernial orifice. An 83-year-old man complained of discomfort when sitting for long periods. He was status post laparoscopic abdominoperineal resection and was diagnosed with SPH. Hernia repair was performed. After transperitoneal adhesiolysis in the inferior pelvis, the right colon was laparoscopically mobilized, and the pelvic orifice was covered by suturing the cecum to the pelvic brim. The perineal skin was managed with negative pressure wound therapy. The postoperative course was uneventful. There has been no sign of recurrent herniation for 12 months. This method of SPH repair is simple to perform and avoids mesh-related complications.

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.

Flank and lumbar hernias are challenging because of their rarity and anatomic location. Several challenges exist when approaching these specific abdominal wall defects, including location, innervation of the lateral abdominal wall musculature, and their proximity to bony landmarks. These hernias are confined by the costal margin, spine, and pelvic brim, which makes closure of the defect, including mesh placement, difficult. This article discusses the anatomy of lumbar and flank hernias, the various etiologies for these hernias, and the procedural steps for open and robotic preperitoneal approaches. The available clinical evidence regarding outcomes for various repair techniques is also reviewed.

This review article will focus on the classification and treatment options for pelvic ring fractures. The pelvic ring can be split into anterior and posterior supporting structures. Injury can result in mechanical pelvic instability, the significance of which is determined by the magnitude and direction of forces applied during injury. The typical fracture patterns of anteroposterior compression, lateral compression and vertical shear form the basis of the Young and Burgess classification. However, the logic of the Tile classification system is useful in determining the degree of pelvic instability and the optimal surgical stabilization options. Posterior pelvic ring stabilization is often performed percutaneous after closed fracture reduction with sacro-iliac screws. This avoids the soft tissue complications often associated with open posterior approaches. Alternative reduction techniques can be performed through an open anterior approach using the first ilio-inguinal window to approach sacro-iliac joint disruptions as well as crescent fractures of the posterior iliac wing. The anterior pelvic ring, traditionally stabilized with external fixation, can be well accessed with the open ‘STOPPA’ approach. This allows access to an area extending from the pubic symphysis around the pelvic brim to the anterior aspect of the sacro-iliac joint where plates can be applied. Other options for anterior ring stabilization include column screws and the use of the ‘In-fix’ (Internal Fixator).