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Corona Mortis

- Discussion:
     - refers to retropubic vascular communication between either the external iliac (or deep epigastric vessels) and the obturator artery; 
     - medial window (of ilioinguinal approach) is used to identify any possible communication between obturator system and external
            iliac or inferior epigastric system (instead of the internal iliac artery); 
             - inferior epigastic artery:
                     - arises from the external iliac artery (arising from the ventral side, proximal and deep to the inguinal ligament)
                     - ascends obliquely toward the umbilicus along the medial margin of the deep inguinal ring;
                     - IEA pierces transversalis fascia below  arcuate line and enters rectus sheath to reach deep surface of the rectus
                             abdominis muscle;
                     - it both serves as a surgical landmark and constitutes a potential target for injury during inguinal hernia repair;
                     - IEA divides deep to the rectus sheath into 2 branches:
                            - ascending branch that anastomoses at the umbilicus, medial to the rectus sheath, with the abdominal branch (or
                                      superior epigastric artery) of the internal thoracic artery;
                            - descending branch:
                                      - obturator branches: courses along the ischium and anastomose with the obturator artery;
                                      - pubic branches: courses along the pubic rami and reach the pubic symphysis;

     - these anomalous vessels occur in about 10-30 % of patients; 
     - it is typically located about 3 cm from the symphysis pubis; 
     - carefully dissect both lateral and posterior to the external iliac vessels to look for any anomolous vessels prior to medial vessel
               retraction (which might avulse any anomalous vessels between these systems); 
               - if anamalous branch is present, then it needs to be ligated to prevent bleeding from this vessel, which is difficult to control
                        if it retracts into pelvis

- references: 
     - Corona mortis: incidence and location 
     - Retropubic vascular hazards of the ilioinguinal exposure: a cadaveric and clinical study. 
     - The incidence and location of corona mortis: a study on 75 cadavers. 
     - Retropubic Vascular Hazards of the Ilioinguinal Exposure: A Cadaveric and Clinical Study.
     - Corona mortis. An anatomic study in seven cadavers and an endoscopic study in 28 patients
     - Inferior epigastric artery arising from the obturator artery as a terminal branch of the internal iliac artery and consideration of its rare occurrence.
     - Vascular anatomy over the superior pubic rami in female cadavers.
     - Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum