Research on the presence, origin and anatomical surface of superficial inferior epigastric artery – Cao Ngoc Bich

Journal of military pharmaco-medicine n o 3-2018 108 RESEARCH ON THE PRESENCE, ORIGIN AND ANATOMICAL SURFACE OF SUPERFICIAL INFERIOR EPIGASTRIC ARTERY Cao Ngoc Bich*; Pham Dang Dieu** Tran Ngoc Anh***; Tran Dang Khoa*** SUMMARY Objectives: To describe the presence and origin of superficial inferior epigastric artery (SIEA) of Vietnameses in formalined cadavers, and to describe the anatomical surface of SIEA on abdominal wall. Method: A cross-sectional study was carried out in 30 cadavers. Results: The presence of SIEA is about 85% and eighty five percents of SIEA which originate from the femoral artery. The artery runs outward from middle column to lateral column and we can find the SIEA in the circle with 4 cm diameter at the middle inguinal ligament (90.0%). Conclusion: The presence of SIEA have a high proportion highly and we can find the SIEA in the circle with 4 cm diameter at the middle inguinal ligament. * Keywords: Superficial inferior epigastric artery; Femoral artery; Inguinal ligament. INTRODUCTION The principal blood supply to the abdominal wall are superficial epigastric artery, inferior epigastric artery and superior epigastric artery. These blood supplies have a correlation in presence and vascular diameter. Since that in using the abdominal tissue flaps for plastic surgery, the SIEA flap is first choice. However, the inconsistent anatomy and small dimension of SIEA is problematic. According to many studies by authors in the world, the presence of SIEA varies from 10% to 90%. In Vietnam, this research has not been informed yet. Therefore we carried out the research “Research on the presence, origin and anatomical surface of SIEA” with two targets: To describe the presence and origin of SIEA of Vietnamese in formalized cadavers, and to describe the anatomical surface of SIEA on abdominal wall. SUBJECTS AND METHODS 1. Subjects. - 30 adult Vietnamese cadavers. - Place of implement: the Department of Anatomy at Pham Ngoc Thach Medical University in Hochiminh City. - Inclusion criteria: Adult Vietnamese over 18 years old and has not any surgery on the abdominal wall. - Exclusion criteria: Abdominal wall defects by surgery, trauma or inborn and there was any intervention result in structural changes of abdominal wall vasculature. * An Sinh Hospital ** Pham Ngoc Thach Medical University *** Vietnam Military Medical University Corresponding author: Tran Ngoc Anh (anhtngoc@gmail.com) Date received: 07/01/2018 Date accepted: 28/02/2018 Journal of military pharmaco-medicine n o 3-2018 109 2. Method. The cross-sectional descriptive study. * Dissection: Incision is along the inguinal ligament. Fig 1: Skin incision is on superficial layer of abdominal wall. - Make skin incisions: (1) an incision along the inguinal ligament from superior anterior illiac spine to pubic tubercle, (2) an incision at medial one-third of thigh from midpoint of inguinal ligament forward to femoral direction, (3) a transversal incision over pubic tubercle, (4) a vertical incision from midpoint of pubis to xiphoid process via navel, (5) an incision along the costal coast to extend laterally. - Dissected skin follows above incisions to find SIEA for description of its origin and measurement of its dimensions. The presence of SIEA and the distance from its origin to midpoint of inguinal ligament also were investigated. * Data analysis: Codified variables, statistical analysis was performed with descriptive statistics by using SPSS software ver.21.0 (IBM Co.). RESULTS The study was performed on 30 abdominal wall areas and 60 thigh areas both two sides of right and left of 30 cadavers including 11 females (36.7%), 19 males (63.3%) at the age from 47 to 93 (average 70). 1. Description of presence of SIEA. Table 1: Presence of SIEA on cadavers. SIEA Right side Left side p-value Presence 25 (83,3%) 26 (86,7%) Absence 5 (16,7%) 4 (13,3%) 0,337 Total (n) 30 (100,0%) 30 (100,0%) Presence ratio of SIEA on cadavers were fairly high of 83.3% (right side) and 86.7% (left side), which showed that the presence of SIEA on the same cadaver may not different between two sides (p = 0.337). Journal of military pharmaco-medicine n o 3-2018 110 Fig 2: SIEA present in both two sides. The anatomical inconsistence of SIEA was described by Taylor G.I. in 1975. According to that, SIEA was absent or coud not be identified in 35% of dissected cadavers [2, 7]. Some other studies presented the absent ratio of SIEA from 13% to 40%. This ratio in the our study was compared with the other author’s in the following table: Table 2: Compare the present ratio of SIEA with the other authors’. Author Sample size Presence Fukaya E (2011) [3] 17 64.7% Fathi M (2006) [2] 40 95% Rozen W.M (2010) [7] 500 94% Pellergrin A (2010) [6] 37 22% Ours (2017) 30 83.3 - 86.7% The present ratio in our study was high at 85%. In several cadavers, SIEA was presented in one side only. After study by Thoma A et al in 2008 [9], the absence of SIEA was common and was reported by many authors with ratio at 13 - 40% [10]. As Tachi M et al (2005), SIEA was absent in 50%. Whereby, SIEA flap has backward by the inconsistent presence, too small caliber and short trunk of SIEA [8]. As Nahabedian et al (2008), SIEA flap could be used only in 30% of female with average body mass [5]. Previous studies showed that SIEA flap vascular pedicle was not present in 13 - 42% of surgery. A recent study showed only 43% had at least 1 SIEA seen and suitable for elevation a tissue flap on 21% of patients [4]. Chevray P.M (2003) said that the anatomical variation and small size is flaw of SIEA flap. Taylor and Daniel reported that SIEA was absent in 35% of cadavers. Chevray found the absence of SIEA in 51% of patients. Arnez et al also found the absence of SIEA in 40% and too small caliber in 30% [1]. Fukaya et al (2011) found 35% could not see SIEA [3] and SIEA flap was not be a option for surgeons due to the inconsistence of anatomy and the short and the small of dimension of SIEA. Journal of military pharmaco-medicine n o 3-2018 111 2. Description of origin of SIEA. Table 3: Origin of SIEA. Origin Right side (n = 25) Left side (n = 26) p-values Femoral artery 21 (84.0%) 22 (84.6%) Common trunk of superficial circumflex illiac artery 0 (0%) 1 (3.8%) Common trunk of pudendal artery 2 (8.0%) 1 (3.8%) Common trunk of external circumflex femoral artery 1 (4.0%) 1 (3.8%) External iliac artery 1 (4.0%) 1 (3.8%) 0.0001 Origin of SIEA from femoral artery was majority in both two sides, with 84% in right and 84.6% in left. The minority originated from common trunk with the superficial circumflex illiac artery, pudendal artery, external femoral artery. Fig 3: SIEA arose from common trunk with pudendal artery. Fig 4: SIEA arose from external femoral artery above the inguinal ligament. Journal of military pharmaco-medicine n o 3-2018 112 Fig 5: SIEA arose from common trunk with external circumflex femoral artery. The superficial epigastric artery located right under the inguinal ligament, arising from femoral artery (17%) or from common trunk with superficial circumflex illiac artery (48%) [11]. In cases of clearly presented, 36% from a common trunk and 64.8% arose directly from femoral artery [3]. Heaster et al supposed that in cases of could not see SIEA at level of femoral artery, it could arise from superficial circumflex illiac artery or could be replaced by branches of superficial circumflex illiac artery [3]. 3. Site of SIEA in 3 columns. To investigate the site of SIEA in 3 columns of abdominal wall for each side. Table 4: Location of SIEA as 3 abdominal wall skin colums on cadavers. Location Column Location Right side Left side p values Interior 0 (0.0%) 0 (0.0%) Medial 24 (96.0%) 23 (88.5%) Exterior 1 (4.0%) 3 (11.5%) Level of the inguinal ligament 25 26 0.012 Interior 0 (0.0%) 1 (3.8%) Medial 17 (68.0%) 11 (42.3%) Exterior 8 (32.0%) 14 (53.8%) Level of superior anterior iliac spine 25 26 0.011 Interior 0 (0.0%) 0 (0.0%) Medial 4 (33.3%) 1 (14.3%) Exterior 8 (66.7%) 6 (85.7%) Level of the umbilicus 12 7 0.248 On the cadavers, the site of SIEA at the level of inguinal ligament got high ratio at 96.0% in right side and 88.5% in left side, remaining ratio was in exterior column and not any in the interior column. Journal of military pharmaco-medicine n o 3-2018 113 Ratio in exterior column increased at the level of superior anterior illiac spine up to 32,0% in right side and 50% in left side and up to 66.7% in right side and 85.7% in left side at the level of umbilicus. That means the course of SIEA forward from medial column to exterior column. The presence of SIEA at this level decreased one half in right side and one quarter in left side. Fig 6: Location of SIEA in the left side following 3 columns on cadaver. At the level of inguinal ligament, the site of SIEA in medial column, at the level of anterior superior illiac spine it was still in medial column, but at the level of imbilicus, it was in exterior column. These results were appropriate to the report by Fukaya et al (2011), the ability to see clearly a SIEA in medial column at level of inguinal ligament was 54.4%, at the ASIS was 68.7% in exterior column and at the umbilicus the they came back to medial column up to 60% [3]. 4 Relation between SIEA and midpoint of inguinal ligament. Table 6: Relation between origin of SIEA and midpoint of inguinal ligamenton the cadavers. Relation Right side (n = 25) Left side (n = 26) p-values Interior-Inferior 9 (36.0%) 6 (23.1%) Exterior-inferior 15 (60.0%) 19 (73.1%) Superior 1 (4.0%) 1 (3.8%) 0.040 On the cadavers, SIEA located to exteriorly - and inferiorly was 60% in right side and the next was interiorly-inferiorly area. There was only one case of arising directly from external illiac artery and located right over inguinal ligament. Whereby, we classified radius of circle at midpoint of inguinal ligament to determine the probability of presence of SIEA’s origin. Journal of military pharmaco-medicine n o 3-2018 114 Table 7: Site of origin of SIEA in the classified circle at midpoint of inguinal ligament. Ratio Radius Right side (n = 25) Left side (n = 26) 0 - 1 cm / / 1 - 2 cm 4 (16.0%) 9 (34.6%) 2 - 3 cm 12 (48.0%) 5 (19.2%) 3 - 4 cm 6 (24.0%) 10 (38.5%) 4 - 5 cm 3 (12.0%) 2 (7.7%) Total 25 (100%) 26 (100%) On the cadavers, draw a circle with radius of 40 mm at the midpoint of inguinal ligament to find origin of SIEA. The probability of seeking the origin of SIEA was 88% (right) and 92.3% (left). The circle of radius 40 mm also accorded with “Rule of interval 40” on the abdominal wall. Fig 7: Circle with radius 5 cm to determine the origin of SIEA was beneath the inguinal ligament. The result of the study realized that in the circle with radius 4 cm could find SIEA at 90%, different from result of Fukaya et al (2011). SIEA arose from femoral artery at 2 - 3 cm inferiorly to inguinal ligament [3] and with Fathi M [2] in circle with radius of 1 cm might got the probability to find SIEA was 86.8%. CONCLUSION Present rate of superficial epigastric artery was rather high up to 85%. At the same indvidual, the presence of SIEA might not be simultaneous in both two sides. Origin of SIEA from femoral artery was approximate by 85%. The other minority arising from common trunk with superficial circumflex illiac artery, pudendal artery, external circumflex femoral artery and external illiac artery. The course of SIEA ran gradually from medial column to exterior column. The rate of presence of SIEA at this level decreased one - half in right side and nearly one - quarter in left side. At the site laterally - inferiorly to the midpoint of inguinal ligament SIEA was present more than 60.0% and in the circle with radius 4 cm and the center was the midloint of inguinal ligament, the probability to find out SIEA was 90%. This circle was suitable to the “rule of intervals of 40” in the abdominal wall. REFERENCES 1. Chevray P.M. Breast reconstruction with superficial inferior epigastric artery flaps: A prospective comprarison with TRAM and DIEP flaps. 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