A prospective endoscopic study of retropubic vascular anatomy in 121 patients undergoing endoscopic extraperitoneal inguinal hernioplasty

Background: A sound knowledge of retropubic pelvic vascular anatomy is pivotal to the successful performance of endoscopic total extraperitoneal (TEP) inguinal hernioplasty. The objective of the current study was to evaluate the incidence and anatomy of iliopubic and aberrant obturator vessels. Methods: Between July 2001 and March 2002, a prospective endoscopic evaluation of retropubic vascular anatomy was performed on patients who underwent TEP. Endoscopic photographs of the vasculature overlying the superior pubic ramus in the recruited patients were captured on a computer. Results: The retropubic vascular anatomy of 121 patients, who underwent either unilateral (n = 100) or bilateral (n = 21) TEP was examined. The iliopubic artery and vein were invariably present in every patient, and traversed along the iliopubic tract toward the pubic symphysis. The aberrant obturator artery was present in 31 pelvic halves, giving an overall incidence of 22%. The aberrant obturator vein existed between the external iliac and obturator venous system in 27% (n = 38) of the 141 pelvic halves examined. The overall incidence of corona mortis, in the form of either an aberrant obturator vein or artery, was 40% (n = 56). Conclusions: Iliopubic vein and artery are universal findings in every patient. Both aberrant obturator artery and vein cross the superior pubic rami, and are therefore susceptible to injuries during dissection of the Bogros space and stapling of the mesh onto Cooper's ligament. Awareness of these aberrant vessels will help to reduce bleeding and subsequent morbidity. Tracing along the aberrant vessel can easily identify the obturator foramen, which is an anatomic landmark that indicates an adequate inferior dissection of the preperitoneal space.