Bilateral indirect inguinal hernia with bilateral corona mortis : A case study from a laparoscopic perspective

The corona mortis is defined as the vascular connection between the obturator and external iliac systems [1]. Usually, the obturator vessels originate from the internal iliac vessels and traverse the lateral pelvic wall along with the obturator nerve. There are marked variations of these vessels in relation to their origin, course and the distance from the pubic symphysis [2]. The name “corona mortis” or crown of death implies the importance of this feature, as significant hemorrhage may occur if accidentally cut and it is difficult to achieve subsequent homeostasis [3]. Laparoscopic inguinal hernioplasty has been performed by many surgeons for patients with bilateral inguinal hernia, recurrent inguinal hernia or in patients with unilateral inguinal hernia who strongly prefer this kind of operation. In such cases, if the laparoscopic repair is indicated, the surgeon must be aware of the potential presence of aberrant obturator arteries. Their unexpected presence can become a matter of great concern not only during laparoscopic repair of inguinal hernia but for anybody who may perform surgical procedures related to the superior pubic ramus. Here we present a case of bilateral indirect inguinal hernia with a rare variant of the corona mortis to signify its vulnerability to injury during surgical repair. Case Report A bilateral indirect inguinal hernia was observed in a 65-year-old male cadaver during routine dissections of the inguinal region. The pelvis was separated at the level of L4-L5 articulation. Pelvic contents were carefully removed including the bowel content of the hernial sacs keeping the hernial openings intact. The external iliac vessels, psoas major muscle, lateral pelvic wall, obturator vessels and nerve were carefully dissected and the vascular elements on the superior pubic rami were evidenced (Figure 1). On the left side, the obturator artery was arising from the anterior division of the internal iliac artery and an arterial corona mortis was found arising from the external iliac artery (Figure 2). The two arteries were anastomosing at the upper margin of the obturator foramen and passing through the foramen as a single vessel. The vein was as usual. Distance from the arch of the lacunar ligament and the pubic symphysis to the anastomosing vessel was 13.2 mm and 3.9 mm, respectively. On the right side, the arterial component was as usual while the vein was draining to the external iliac vein crossing the superior ramus of the pubic bone as the venous corona mortis (Figure 3). The distance from the lacunar ligament and the pubic symphysis to the anastomosing vessel was 13.5 mm and 4.1mm, respectively. Vipula Rasanga BATADUWAARACHCHI Sharmila THILLAINATHAN