Int J Anat Res 2015, 3(4):1704-09. ISSN 2321-4287
Original Research Article
VARIABILITY OF ORIGIN OF OBTURATOR ARTERY AND ITS CLINICAL
SIGNIFICANCE
Sakthivel * , Sw athi Priyadarshini.
ABSTRACT
Address for Correspondence: Dr. Sakt hivel, Tut or, Depart ment of Anat omy, B. K. L. Walawaker Rural M edical College, Kasarw ade, Saw arde, Chiplun (t k), Rat nagiri (dt ) 415606, M aharast ra, India. E-M ail: dr.sakt [email protected]
Background: Obt urat or ar t er y is a branch of ant er ior division of int er nal i liac ar t er y. It nor m ally r uns ant eroinferiorly on t he lat eral w all of pelvis t o t he upper part of t he obt ur at or foram en and leaves t he pelvis by passing t hrough t he obt urat or canal. On it s course, t he art ery is accom panied by t he obt urat or ner ve and vein. It supplies t he m uscles of t he m edial com part m ent of t he t high. A sever e and pot ent ially let hal com plicat ion in pelvic injur ies is art erial bleeding com m only involving t he branches of t he int ernal iliac art ery, nam ely t he lat eral sacral, i liolum bar, obt urat or, vesical and inferior glut eal art eries. A sound know ledge of ret ro-pubic pelvic vascular anat om y is pivot al for successful perfor m ance of endoscopic procedures such as t ot al ext ra-perit oneal inguinal hernioplast y or laparoscopic hernior raphy.
The context and purpose of the study: This st udy is an at t em pt t o analyse t he origin, course, dist ribut ion of obt urat or ar t ery in pelvis and t heir clinical im plicat ion.
Result: out of 60 form alin fixed pelvic halves 36.6% of t he specim ens, (26.67% in m ales and 10% in fem ales) t he origin of obt urat or ar t ery w as found t o be nor m al f rom ant er ior division of int ernal iliac art ery. About 63.63% from var ious ot her sources.
Conclusion: This know ledge of var iat ion in t he origin of obt ur at or art er y is im por t ant w hile doing pelvic and groin surgeries r equir ing appropriat e ligat ion. Such aberrant origins m ay be a signif icant sour ce f or persist ent bleeding in t he set t ing of acut e t raum a. Know ledge regar ding t he variat ions of obt urat or art ery is useful dur ing sur geries of fract ure and direct or indirect inguinal, fem oral and obt urat or hernias.
KEY W ORDS: Int ernal Iliac Ar t ery, Obt urat or Art ery, Superior Glut eal Art ery, Iliolum bar Art er y, Ext ernal Li lac Art ery, Infer ior Epigast ric Art ery.
INTRODUCTION
Int ernat ional Journal of Anatomy and Research, Int J Anat Res 2015, Vol 3(4):1704-09. ISSN 2321- 4287 DOI: ht t p:/ / dx.doi.org/10.16965/ ijar.2015.321
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Received: 24 Nov 2015 Accept ed: 14 Dec 2015 Peer Review : 24 Nov 2015 Published (O): 31 Dec 2015 Revised: None Published (P): 31 Dec 2015
Int ernat ional Journal of Anat omy and Research ISSN 2321-4287
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DOI: 10.16965/ ijar.2015.321
Tut or, Depart ment of Anat omy, B. K. L. Walawaker Rural M edical College, Rat nagiri, M aharast ra, India.
deferens in male. In t he obt urat or foramen it divides in t o ant erior and post erior branches. It is accompanied by t he obt urat or nerve above and vein below. In pelvis, it gives branches t o urinary bladder, nut rient branch t o ilium and pubis. Behind t he pubis it anast omoses w it h inferior epigast ric artery.
Origin of obt urat or art ery from ot her art erial Obt urat or art ery, a branch from t he ant erior
M ATERIALS AND M ETHODS
RESULTS
source have been report ed in some st udied [1, 2, 3]. The presence of vit al organs and ot her anat omical st ruct ures w it hin t he closely packed con f ines of t he pel vis m akes t h e st udy of vascular pat t erns and t heir variat ions significant [4]. Due t o t he rapid development of surgical p r oced ur es an d i n v est i gat o r y t ech n i qu es involved in obst et ric procedures or urogenit al int ervent ions, it is essent ial t o underst and t he vascular t ree in t he abdomen especially in t he pelvis [5].
The st udy w as conduct ed on sixt y adult pelvic halves of know n sex w hich w ere being used for d issect io n p u r p o ses f o r t eachi n g m ed i cal student in the department of Anatomy, Chettinad hosp it al and r esear ch inst it ut e, TN, Ind ia. Dissect ion w as carried out according t o t he dissect ion steps given in Cunningham’s manual of pract ical anat omy [6].
In each half of t he pelvis t he com m on iliac art eries w as first locat ed. Then t he int ernal iliac branch of t he common iliac art ery and its ant erior division was ident ified in t he pelvic cavit y. The obt urat or art ery w as t raced from it s origin t ill obt urat or foramen. The origin of t he obt urat or art ery relat ionship of t he art ery t o it s adjacent st ruct ures and branching pat t ern w as recorded and adequat ely phot ographed.
The source of origin of obt urat or art ery w as st udied in 60 formalin fixed pelvic halves. In 36.67% of t he specimens, (26.67% in males and 10% in females) t he obt urator art ery arises from ant erior division of int ernal iliac art ery pass ant ero-inferiorly on t he lat eral w all t o t he upper part of obt urat or foramen in t he pelvis (Figure 1). It w as relat ed lat erally t o obt urat or fascia separ at ing it fr om obt ur at or int er nus w it h obturator nerve above and obt urator vein below.
In 63.63% of specimens t he origin of obt urat or art ery w as from various sources i.e., post erior division of internal iliac artery, superior gluteal artery, combined w it h iliolumbar artery and di-rect branch from ext ernal iliac or inferior epi-gast ric artery. A detailed descript ion regarding t he variat ions in t he origin of obt urat or art ery is described as follow s.
Fig.1: Dissected specim en of right pelvic region of a m ale cadaver.
ext er nal iliac ar t er y (EIA) ant er ior ly and post er ior ly int ernal iliac art ery (IIA) along w it h it s ant erior division (AD) post erior division (PD), t he obt urat or art ery (OA) ar i se s f r o m t h e an t e r i o r d i vi si o n an d r u n s ant eroinferiorly just below t he obt urat or nerve (ON) t ow ar ds o bt u r at o r f o r am en d isap pear s b y passin g undercover of obt urat or int ernus m uscle (IM )
Variation 1: The origin of obt urat or artery from
t he t runk of ext ernal iliac art ery w as found in a t ot al of 5 specimens (male 4 and female 1). The obt urat or art ery passed ant er iorly over t he superior ramus of pubis and t urned inw ards t o enter int o t he obt urat or canal (Fig. 2). In t he present st udy, t he incidence of obt urat or artery from direct branch of ext ernal iliac art ery w as found t o be 8.33%.
Fig. 2: Dissect ed specim en of right pelvic region of a m ale cadaver.
Int J Anat Res 2015, 3(4):1704-09. ISSN 2321-4287
Var iat io n 2 : In t h i s t y p e o f var i at i o n t h e obt urat or ar t er y f rom post er ior division of internal iliac artery (Fig.3) instead of t he usual ant er ior division of int ernal iliac art ery. The incidence percent age of t his part icular t ype of variat ion in t he present st udy w as found t o be 11.67%.
Fig. 3: Dissect ed specim en of right pelvic region of a m ale cadaver.
Int ernal iliac ar t ery (IIA) and ext er nal iliac art ery (EIA) from com m on iliac art ey (CIA), Obt urat or art ery (OA) ar ising f r om post er ior division (PD) of int er nal iliac art ery (IIA). Here obt urat or art ery runs ant erioinferiorly alone w it h obt ur at or ner ve (ON) t ow ar ds obt ur at or foram en (OF).
com m o n t r un k f r o m p ost er i or di v isio n o f internaliliac artery (Fig. 4). This t ype of variat ion w as observed in 2 specimens.
Variation 4: The origin of obt urat or artery from
t he superior glut eal art ery w as observed in a t ot al of 9 specimens (male 7 and female 2). The art ery from it s origin w as found t o pass beneat h t he branches of ant erior division t o ent er t he obt urat or foram en (Fig. 5). The art ery w as relat ed t o obt urat or nerve above.
Fig. 4: A dissect ed specim en of left pelvic region of a m ale cadaver.
Int ernal iliac ar t ery (IIA) and ext er nal iliac art ery (EIA) from com m on iliac art ey (CIA), here Obt urat or art ery (OA) arising from t runk of post erior division (PD) of in-t er nal iliac arin-t er y (IIA) has a com m on in-t runk (CT) along w it h ilio-lum bar art ery (ILA) runs ant eroinf erior t ow ard obturat or foram en (OF) below t he obt urat or art ery (OA).
Fig. 5: Dissect ed specim en of lef t pelvic region of a m ale cadaver.
Int ernal iliac ar t ery (IIA) and ext er nal iliac art ery (EIA) from com m on iliac art ery (CIA), here Obt urat or art ery (OA) arises from Superior glut eal art ery (SGA) that int urn branch f rom int ernal iliac art er y (IIA).
Fig. 6: Dissect ed specim en of lef t pelvic region of a m ale cadaver.
Int ernal iliac ar t ery (IIA) and ext er nal iliac art ery (EIA) from com m on iliac art ey (CIA), Obt urat or art ery (OA) arising from infer ior epigast r ic art ery (IEA) w hich in t urn branch f rom ext ernal iliac art er y (EIA).
Table 1: Incidence of origin of obt urat or art ery f rom var ious branches of int ernal and ext ernal iliac ar t eries.
Anterior division (Normal) 16 6 22 36.67
Superior gluteal artery 7 2 9 15
Posterior division 5 2 7 11.67
With ilio-lumbar artery 2 0 2 3.33
Directly from external Iliac
artery 4 1 5 8.33
Inferior epigastric artery 12 3 15 25
External iliac artery n=20
Origin M ale Female Total
Internal iliac artery n=40
Incidence %
As a w hole t he incidence percent age of usual origin of obt urator art ery was found to be 36.67% and variable origin of t he obt urat or art ery w as found t o be 63.33%.
DISCUSSION
The obt urat or art ery runs ant eroinferiorly from t he ant erior t runk of int ernal illac art ery on t he lat er al pelvic w all t o t he upper part of t he obt urat or foramen. It leaves t he pelvic via t he obt urat or canal and divides int o ant erior and post erior division. In t he pelvic it is relat ed laterally t o t he fascia over obturator int ernus and is crossed on it s medial aspect by the uret er and, i n t h e m ale, by t he v as d ef er en s. In t h e nulliparous female t he ovary lies medial t o it . The obt urat or nerve is above t he art ery, t he obt urat or vein below it [7].
The anat omical know ledge pert aining t o diverse variat ions about t he origin of obt urat or art ery from int ernal and ext ernal iliac art ery or from it s branches.Obt urat orart ery courses in pelvic and leave it by passing t hr ough obt ur at or foramen alone wit h obturat or nerve is of ut most i m po r t an ce d u r in g n um er ou s su r gical manipulat ion. Accidental hemorrhage is common during erroneous int erpret at ion of anomalous blood vessels. Alarmingly, hemorrhage has been consider ed t he leading cause of obst et rical mort alit y in t he Unit ed St at es of America and t he leading cause of mat ernal deat hs in all t he developing count ries [8] . Thus, a t horough know ledge of t he norm al and t he abnorm al anat omy of t he branches of t he int ernal iliac art ery are essent ial for obst et ric surgeons.
Origin of obt urat or art ery has been report ed by various aut hor ’s out of w hich M angala M Pai [10] and Sharmist aBisw as [11] st udy has been compared in below t able.
Table 2: Incidence percen t ages of var ious or i gin of obt urat or ar t ery.Present st udy Vs M angala M Pai and Sharm istaBis w as st udy.
Posterior division of Internal iliac
artery 11.67% 7.20% 12.50% With ilio-lumbar artery 3.33% 1% 0%
Superior gluteal artery 15% 10.20% 16%
Inferior epigastric artery 25% 14.30% 3.50%
Dual origin from internal &
external iliac artery’s. - 2.20% -Inferior gluteal artery - -
-Internal pudendalartery - -
-Common trunk of inferior gluteal
& internal pudendal - - -M ode of Origin M angala M Pai
(2009) [10]
36.67% 60.20%
Anterior division of Internal iliac artery
External Iliac artery(Direct) 8.33% 5.20%
-Present study (2013)
Sharmishta Biswas 2010 [11]
44.60%
Obturator artery from anterior division of Internal iliac artery (Fig.1):
Origin of obt urat or art ery from int ernal iliac art ery is t hree t imes more frequent t han t hose arising from inferior epigast ric or ext ernal iliac art ery Bergman [9]. The most common source of origin of the obt urator art ery is a single branch arising from t he ant erior division of t he int ernal iliac art ery. This t ype of variat ion w as m ore frequent ly observed by M angala M Pai [10] (60%) and Shar m ist aBisw as [ 11] (40.2%) as com pared t o t hat of present st udy (36.67%) [Table 2].Whereas Pick [2] reported only a 21% incidence in t his t ype of variat ion
Obturator artery from posterior division of Internal iliac artery and its branches (Fig. 3):
The origin of obt urat or art ery arising from t he post er ior division of int er nal iliac ar t er y is consider ed as a r are obser vat ion in Indian populat ion. Therefore an at t em pt has been m ade t o highlight it s clinical im plicat ions in r elat ion t o t he anom alous or igin f r om t he internal iliac artery [12].The obturator artery may originat e direct ly from post erior division or in combination with iliolumbar and superior glut eal artery.
Int J Anat Res 2015, 3(4):1704-09. ISSN 2321-4287
CONCLUSION
Origin of Obt urator art ery in com bination
w ith ilio-lum bar artery (Fig. 4): The origin of
obt urat or art ery along w it h ilio-lumbar art ery w as found in 3.33% of specimens in t he present st udy. This t ype of variat ion is rarely reported (1%) by M angala M Pai [10] [Table2].
Obturator artery from superior gluteal artery
(Fig. 5): Our result s show ed an incidence of 15%
for t his t ype of variat ion (Table 2) coincidence (16%)[11] and low er incidence rat e (10%)[ 9].
Origin of obturator artery from external iliac artery (Fig. 2)
This t ype of variat ion w as m ore fr equent ly observed by M issankov [13] (25%) and M angala M Pai [10] (5.2%) as compared t o t hat of present st ud y (8.33%), w h er eas Br ai t h w ait e [ 16] report ed only 1.1% and Jakubow icz et .al., [14] report ed only 1.3% incidence in t his t ype of variat ion.
Obt urat o r art ery f rom inferior ep igast ric
artery (Fig. 6): The comm on origin of inferior
epigast ric and obt urat or art eries is a relat ively frequent variation that occurs in 20–30% of cases [9].The first t o report about origin of obt urat or from inferior epigast ric art ery [15]. Our result s show ed an incidence of 25% for t his t ype of variat ion w hich w as sim ilar t o Poynt er [15], Bergman [9], and low er incidence of 14.3% [10].
The or igin of obt urat or ar t ery from inferior glut eal, int ernal pudendal, common t runk for inferior glut eal and int ernal pudendal art eries or from t he lumbar art ery w as not observed in any of t he specimens in t he present st udy. This w as in cont rast t o previous st udies [9, 16]. In t he same way, dual origin of t he obt urat or artery from bot h internal iliac and ext ernal iliac art eries w as not observed in t he present st udy. Such v ar i at i o n w er e m axi m all y r ep o r t ed b y Brait hw ait e [16], w ho found in 6.5%, Bergman [9] found in 1% and M angala M Pai [10] found in 2.2%.
Obt urat or art ery in ret ropubic fat may obscure visualizat ion of t hese sm all vessels dur ing ilioinguinal incision, m aking t hem prone t o iat rogenic injury dur ing operat ions such as inguinal hernioplast y and prost at ect omy [17]. The obt urat or veins are also prone t o injury. In addit ion t o iat rogenic injury, t he proximit y of t hese vessels t o t he superior pubic ramus may
result in persist ent hemorrhage associat ed w it h pelvic fract ures.
Aberrant anat omy of t he obt urat or art ery can increase t he risk of iat rogenic or traumat ic injury. The obt urat or art ery may have an anomalous origin from t he inferior epigast ric artery, t he posterior t runk of t he internal iliac artery, or t he superior or inferior glut eal art eries. Branches of t he obt urat or and inferior epigast ric vessels lie in close proxim it y, on opposit e sides of t he superior pubic ramus. Occasional anast omoses crossing t he t op of t he superior pubic ramus t o connect t hese t w o vascular dist ribut ions w as t er m ed “ corona m or t i s” by Let ou r nel [ 18] because it forms a vascular “ crow n” prone t o life-t hreat ening hemorrhage w hen injured.
In t he present st udy various source of origin of obt urat or ar t er y w er e observed. The m ost common t ype of origin observed in t he present st udy is from ant erior division of obt urat or artery. Among the variable source of origin, t here is an increased incidence percent age of t he art ery arising from inferior epigast ric art ery. Origin of obt urat or art ery in combinat ion w it h ilio-lumbar art ery is a rare t ype of origin reported in t he present st udy. During surgical repair of hernia and fract ure of superior ramus of pubis, t he obt urat or ar t ery m ay be injured due t o anomalous origin from t he ext ernal iliac art ery w hich might lead t o profuse bleeding. Surgeons m ust be conscious of unexpect ed sources of hem or rhage, such as an aberrant obt ur at or ar t er y o r v ei n, an d u nexp ect ed il io -pu bi c vessels and t ake appropriat e precaut ions t o avoid injury t o t hese st ruct ures. The hum an cadaver is probably an ideal model t o explore t he nuances of pelvic surgeries.
LIST OF ABBREVIATIONS
EIA - Ext ernal Iliac Art ery IIA - Int ernal Iliac Art ery AD - Ant er ior Division PD - Post erior Division OA - Obt urat or Art ery ON - Obt urat or Nerve
ACKNOW LEDGEM ENTS
We are sincerely t hankful t o Dr. T.K. Balaj i, Professor, Depart ment of Anat omy, Chett inad Universit y for his valuable suggest ions required in t his w ork.
Conflicts of Interests: None
REFERENCES
[9]. Ber gm an R A. Illust r at ed Encylopedia of hum an Anat om c Variat ion: Opus II: Cardiovascular syst em : Art eries: Pelvis. 2008.
[ 10] . M angala M Pai. Var iabi lit y in t he or igin of t he Obt urat or art ery. Clinics, 2009;64(9):897-901. [11]. Sharm ishta Bisw as. Variat ion of origin of Obt urat or
ar t er y in east er n Indian populat ion – A st udy. Jo u r n al o f An at o m i cal So ci e t y o f I n d i a, 2010;59(2):168-72.
[ 12] .Di nesh Kum ar and Rat h . An om al ou s or igin o f Obt urat or ar t ery f rom t he int er nal i liac ar t er y. I n t e r n at i o n al j o u r n al o f M o r p h o l o gy, 2007;25(3):639-641.
[13]. M issankov A A. Variat ions of t he pubic vascular anast om oses in black Sout h Af r icans. Act aAnat (Basel), 1996;155:212-214.
[14] . Jakubow icz, Czernoaw ska-Gr zesinska: Var iabi lit y in origin and t opography of t he inf erior epigast ric and obt ur at or ar t er ies. Folia M or phol (W ar sz), 1996;55:121-126.
[ 15] . Po yn t er, C.W.M . Con geni t al an om al ies of t he ar t e r i es an d vei n s o f t h e h u m an b o d y w i t h bibliography. Universit y St udies of t he Universit y of Nebraska, 1922;22:1-106.
[16]. Brat hw ait e J L. Variat ions in origin of t he parietal b r an ch es o f t h e In t er n al i l i ac ar t er y. J.An at . 1952;86:423-30.
[17]. Negura A. Anat om o-sur gical st udy of hem orrhagic risks in uret hro-vesical Burch-t ype suspension. Rev FrGynecolObst et , 1989;84:941–943.
[18]. Let ournel E. Acet abulum fr act ur es: classificat ion and m anagem ent . Clin Or t hop Relat Res, 1980; 151:81-106.
[1] . Parson F G and Keit h A. Sixt h annual r eport of t he co m m i t t ee o f co l l ect i ve i n vest i gat i o n o f t h e anat om ical societ y of Great Brit ain and Ireland, 1895-96. J.Anat .Physiol. 1897;31:31-44.
[2] . Pick. The origin of t he obt urat or ar t ery - a st udy of 640 body-halves. Am erican Jour nal of Anat omy, 1942;70:317-343.
[3] . Arey L B. The vascular syst em in Developm ent al Anat omy. W B Saunders Com pany. 1954;6:364-377. [4]. Prabhu L V. Observat ions on t he Variat ions in origins of t he Principal Branches of t he Int ernal Iliac Artery. Anat . Karnat aka, 2001;1:1-10.
[5] . Chand ler F A, Seidler F. Int rapelvicExt raperit oneal Resect ion of t he Obt ur at or Nerve. Surg. Gyn Obs. 1939;69:100-102.
[ 6] . Rom anes GJ. cunningham ’s m anual of pract ical anat omy, 15t h ed, unit ed st at es, oxford universit y press. 2010;
[7] . Standring S: Gray’s Anat omy. The anat om ical basis of clinical pract ice, 40t h edit ion. New york: Elsevier
Churchill Livingst one. 2008:1088.
[8] . Cunningham F G, Leveno K J, Bloom S L, Haut h J C, Gilst rap L C. 3RD, W enst rom KD (eds): W illiam s Ob st et r i cs, 22n d Ed . New Yo r k; M cGr aw –Hi l l Pr ofessional,2005:p. 7–8.
