P. Chaynes

Vulvar necrosis after surgical treatment of femoral neck fracture: a case report and investigation of the mechanism of injury

We report the case of a young patient, presenting with total bilateral vulvar necrosis after reduction of a femoral neck fracture. This report describes the management of this complication, its mechanism of injury and the associated means of prevention. We present an investigation of the vulvar vasculature in order to understand the mechanism of injury. The study of the vulvar vasculature rejects the anatomical hypothesis of selective damage to the internal and external arteries. Instead, it suggests intraoperative impingement of the terminal blood vessels caused by compression against the perineal post prompting discussion on the use of moulded countertraction posts during orthopaedic surgery.

Anatomical description of the umbilical arteries and impact of their ligation on pelvic and perineal vascular supply after cystectomy in women

ObjectiveIn radical cystectomy, the surgeon generally ligates the umbilical artery at its origin. This artery may give rise to several arteries that supply the sexual organs. Our aim was to evaluate pelvic and perineal devascularisation in women after total cystectomy.Patients and methodsWe carried out a prospective anatomical and radiological study. We performed bilateral pelvic dissections of fresh adult female cadavers to identify the dividing branches of the umbilical artery. In parallel, we examined and compared the pre- and postoperative imaging investigations [magnetic resonance imaging (MRI) angiography] in patients undergoing cystectomy for benign disease to quantify the loss of pelvic vascularisation on the postoperative images by identifying the occluded arteries.ResultsThe anatomical study together with the radiological study visualised 35 umbilical arteries (n = 70) with their branching patterns and collateral arteries. The uterine artery originated from the umbilical artery in more than 75% of cases (n = 54) of the internal pudendal artery in 34% (n = 24) and the vaginal artery in 43% (n = 30). The postoperative MRI angiograms showed pelvic devascularisation in four patients. Devascularisation was dependent on the level of surgical ligation. In the four patients with loss of pelvic vascular supply, the umbilical artery had been ligated at its origin.ConclusionThe umbilical artery gives rise to various branches that supply the pelvis and perineum. If the surgeon ligates the umbilical artery at its origin during total cystectomy, there is a significant risk of pelvic and perineal devascularisation.

Anatomical study of the inferior vesical artery: is it specific to the male sex?

PurposeThe aim of our study was to clarify the origin of the inferior vesical artery and determine its existence in women.MethodsThis descriptive study is based on 25 dissections (6 male and 19 female cadavers). We dissected the internal iliac artery and its branches from the iliac bifurcation, bilaterally and comparatively. Each arterial branch supplying the bladder was identified and dissected as far as the bladder.ResultsIn total, 50 topographies of the bladder vascularization were visualised. The inferior vesical artery was observed in 92% of the male subjects and in 47.4% of the female subjects. In the male cadavers, it arose from the internal iliac artery in 72.7% of cases and from the umbilical artery in 27.3% of cases. In the female cadavers, it arose from a common trunk with the umbilical artery and the uterine artery in 33.3% of cases and directly from the umbilical artery in 33.3% with one terminal branch supplying the upper part of the vagina. In two female subjects, the inferior vesical artery arose from the first segment of the uterine artery (22.2%), and in one subject from the obturator artery (11.1%).ConclusionsThe inferior vesical artery is not specific to the male sex. The contradictions found in the literature of this artery are due to the variations observed in pelvic vascularization and to the close connections between vaginal and bladder vascularisation in women. However, surgeons should consider these variations, to prevent bladder devascularization by non-selective ligation.

Les muscles élévateurs de l’anus en IRM avec reconstruction tridimensionnelle

Introduction Les techniques d’imagerie permettent une « dissection »du Muscle Elevateur de l’Anus (MEA) sur le vivant. L’innocuite de l’Imagerie par Resonance Magnetique (I.R.M.) avec reconstruction tridimensionnelle (3D) autorise cette « dissection » a tous les âges. Materiel et methode Cinq sujets (un de sexe masculin et quatre de sexe feminin) âges de 5 a 71 ans ont beneficie d’une IRM (1,5 TESLA) du pelvis avec etude statique et sequences ponderees T1 et T2 dans les 3 plans de l’espace. L’analyse anatomique des MEA est effectuee sur les sequences natives ainsi que sur les reconstructions 3D (logiciel IN SPACE – Siemens). Resultats L’analyse anatomique des M.E.A. est possible chez tous les sujets. Les reconstructions 3D restent d’interpretation delicate chez les enfants. 1) La portion laterale presente au repos un aspect en dome surtout marque dans la partie posterieure ; 2) La portion mediale poursuit en dedans et vers le bas la portion laterale. Les deux portions mediales s’unissent sur la ligne mediane en avant et en arriere du canal anal. Les reconstructions 3D montrent la continuite des portions laterale et mediale et le caractere tenu de la portion laterale. Discussion : L’importance du M.E.A. en clinique et les donnees encore limitees dont on dispose aujourd’hui justifient la poursuite d’un travail de « dissection » sur le vivant. Les connaissances de ce muscle dans le domaine pediatrique ne reposent souvent que sur des extrapolations a partir des donnees obtenues chez l’adulte. Conclusion L’IRM et notamment grâce aux reconstructions 3D permet une approche plus globale et « in vivo » du MEA.