Obturator Artery

This artery has received much attention due to its surgical interest connected with its origin from the epigastric artery. Poynter suggested that the first report of the origin of the obturator from the epigastric was that of Haller, 1745, note 9, who says ,"Non tamen perpetuum est cam arteriam a pelves truncis nasci, eam novies ex epigastrica ortam." Further that the surgical significance of the epigastric source seems to have been recognized by Monro in 1806. These early observations were followed by many others, which Poynter tabulated as follows:

Percentage Frequency of Origin of the Obturator from the Epigastric Artery.

Name

Date

No. Obs.

%

Female

Male

Right

Left

Cloquet

1817

500

30.4

31.4

24.4

-

-

Breschet

1819

63

19

-

-

-

-

Hesselbach

1819

64

43.3

-

-

37.5

46.8

Quain

1844

360

31.4

33.9

29.8

-

-

Schlöbig

1844

112

21

34.2

28.4

-

-

Isaacs

1855

706

18.3

-

-

-

-

Wyeth

1878

52

34

-

-

-

-

Hoffmann

1878

400

32.5

-

-

-

-

Hartmann

1881

180

19

-

-

-

-

Krusche

1885

80

20

-

-

-

-

Pfitzner

1889

226

37.6

-

-

33.3

34.2

Jastschenski

1891

404

24

26.3

34.6

33.2

26.8

Dwight

1895

500

25

23.2

28.3

23.8

26

Levi

1902

200

25.2

-

-

-

-

Poynter

1922

400

26.2

-

-

-

-

Dubreuil-Chambardel

1925

440

29.5

Total No. Observations = 4,484 Frequency = 25.1%

Anson's group has reported that one might expect an unusual obturator artery from the epigastric or external iliac in about 48% of individuals.

The obturator artery is very variable in origin and no embryological explanation has been found. Poynter suggests that the study of embryos of about the 33 mm stage should settle the question.

The obturator may arise from the common iliac, the anterior division of the internal iliac (41.4%), Ansons group found this origin in about 70% of individuals), inferior epigastric (25%), based on the Poynter table given above), superior gluteal (10%), inferior gluteal/internal pudendal trunk (10%), inferior gluteal (4.7%), internal pudendal (3.8%) or external iliac (1.1%).

The obturator artery may arise from both the hypogastric (internal iliac) and from the epigastric; this is commonly found (numerous 19th century authors including the present authors.).

The obturator has been found arising from the femoral artery adjacent to its profunda branch.

In only 23% of cases is a similar origin found on both sides of the body.

Anson says that one may expect an unusual obturator artery in about 48% of individuals.

The obturator artery gives rise to the ligamentun teres femoris artery in about 54% of subjects.

The obturator may have two roots, one arising as usual and the other from the external iliac.

Accessory obturators may be found.

Unusual branches of the obturator include: an iliolumbar, inferior vesical, uterine, vaginal, dorsal penis, ureteric, perineal, external pudendal, and inferior epigastric.

Its acetabular branch may be absent.

The epigastric artery may itself be absent and its distribution replaced by branches from the the profunda femoris. A condition where there is no connection between the intra and extra pelvic portions of the artery has been reported by several authors.

The obturator artery was reported 55 times in a review of the Committee of Collective Investigation of the Anatomical Society of Great Britian and Ireland (Parsons, F.G. and A. Keith). In 20 cases (36.4%) it arose as a separate trunk from the anterior division; in 10 (18.1%) from the inferior epigastric (deep epigastric); in 9 (16.4%) separately from the hypogastric trunk; in 8 (14.5%) from the posterior division, in 5 (9.1%) from the internal iliac before its division; while in 3 (5.4%) it arose in common with the middle rectal (middle hemorrhoidal), 2 of these coming from the anterior division, and one from the hypogastric trunk (Internal Iliac). Parsons and Keith reported that the origin of the obturator from the inferior epigastric; of 138 subjects examined at Guy's Hospital the obturator was seen to arise from the inferior epigastric only 11 times (8%); Quain's Anatomy, 10th ed. gives a value of nearly 30%. Parsons and Keith state in their report that the percentage was 18.1%. Although we do not have any statistics, the authors of this present book believe that a value closer to that of Quain's Anatomy may be closer to the true value based on our observations over 40 years. Additional observations are obviously needed.

In 1836, Reid reported that, "the obturator artery runs a greater risk of being wounded during the operation for strangulated femoral hernia, than surgeons are inclined to admit; and if this be the case, the varieties in the origin and course of this artery deserve a fuller consideration than what is usually allotted...." The most common origin of the obturator artery is from the internal iliac or some of its branches; but in a great number of cases it is found to arise either directley, or much more commonly indirectly from the internal iliac, by a trunk common to it with the epigastric. When it arises from the internal iliac, it is evident that it can in no way be implicated in the operation for femoral hernia, in whatever manner it may be performed. Even when it arises from the external iliac, it is but very rarely endangered in the ordinary methods of performing this operation, as it generally proceeds downwards and inwards, first passing along the outer or iliac side of the femoral ring, and then along part of its posterior margin, to reach the upper portion of the obturator foramen. In rarer cases, which seem to be principally those in which the common trunk of the obturator and epigastric is longer than usual, the obturator takes a more circuitous course, passing along the upper margin of the femoral ring, and then along its inner or pubic margin. It must be evident that when a femoral hernia descends, the relative position of the artery to the neck of the sac, in these two cases, is very different, and, in a practical point of view, involves very important considerations.

Reid points out, that the most common, or what is considered the normal origin of this artery, is from the internal iliac, or one of its branches. The origin next in frequency is by a common trunk with the epigastric from the external iliac. More rarely it springs directly from the external iliac, and still more rarely from the femoral. Though the artery may thus arise from points placed at a considerable distance from each other, it invariably makes its way out of the pelvis by the same opening, viz. the upper part of the obturator foramen. When it is a branch of the femoral it passes upwards along that artery, passes below Pouparts's ligament (injuinal) and places itself in the same position as if it had arisen within the abdomen.

Reid cites Cloquet who examined 250 subjects; 125 females and 125 males, for the purpose of ascertaining the relative frequency of the origin of the obturator, from the hypogastric (internal iliac), external iliac, and the epigastric. In these the obturator arose from the hypogastric (internal iliac) in both sides in 160; from the epigastric on both sides in 56; from the epigastric on one side, and the hypogastric (internal iliac) on the othere, in 28; from the external iliac in 6. Including both sides of the body, thus increasing the number of arteries examined to 500, and taking all the obturator arteries which arose from the hypogastric (internal iliac) arteries, and all those which arose from the epigastric arteries, or directly from the external iliac, he found that the obturator arose from the hypogastric in 348; from the epigastric or external iliac in 152. According to these results, the frequency of the origin of the obturator artery from the hypogastric (internal iliac) are to those from the epigastric and external iliac as 3 to 1. The obturator was found to arise rather more frequently from the hypogastric (internal iliac) in males than in females. Monro, cited by Reid, thought the relative proportion between the origin of the obturator artery from the internal iliac and its branches, and from the epigastric and the external iliac, to be as 20 to1. Velpeau, also cited by Reid, stated that his observations, drawn from the examination of nearly a thousand cases, led him to coincide in Monro's opinion. According to Reid, Hesslbach thought that the origin of the obturator from from the external iliac and epigastric is not very common, and strangely asserts, that it rarely occurs except in females. Further, Manec stated the proportion to be 1 in 6; Scarpa and Lawrence as 1 in 15. Citing other research, the obturator was found to arise in common with the epigastric in 12 out of 63 subjects, affected with crural hernia, and in all passed behind the neck of the sac. Meckel was of the opinion that the obturator arises nearly as frequently from the the epigastric and external iliac, as from the internal iliac and its branches. Reid concluded his paper by stating that his conclusions from his dissections coincide most closely with those of Cloquet.

Origins of Obturator Artery, from Braithwaite.

Origin

Female # / %

Male # / %

Total # / %

A. From Interal Iliac Artery:

Direct branch from anterior division

24 / 39.3

46 / 46.2

70 / 41.4.

Inferior gluteal-internal pudendal trunk

5 / 8.2

12 / 11.1

17 / 10.0.

Inferior gluteal artery

2 / 3.2

6 / 5.5

8 / 4.7.

Internal pudendal artery

2 / 3.2

4 / 3.7

6 / 3.8.

Superior gluteal artery

10 / 16.4

7 / 6.4

17 / 10.0.

Iliolumbar artery

3 / 4.9

2 / 1.8

5 / 3.5.

B. From External Iliac Artery

Direct branch

1 / 1.6

1 / 0.9

2 / 1.1.

Inferior epigastric artery

10 / 16. 4

23 / 21.3

33 / 19.5.

C. From Internal and External Iliac Arteries:

By double origin

4 / 6.4

7 / 6.4

11 / 6.5.

Totals:

61 / 99.6

108 / 99.7

169 / 99.5.

See also inferior epigastric artery below.

The Variation of the Obturator Artery Arising from the External Iliac Artery; Frequency According to Gender Males Females # Cases % # Cases %

Quain

181

29.8

180

33.9

Cloquet

250

24.4

250

31.4

Schlobig

74

28.4

38

34.2

Krusche

63

25.9

16

37.5

Jastschinski

572

26.3

462

34.6

Pfitzner

163

38.3

39

35.6

Totals

1,303

26.9

985

35.3

From Dubreuil-Chambardel, 1925

The Variation of the Obturator Artery Arising from the External Iliac Artery; Frequency According to Side Bilateral Unilateral # Cases Studied Right Left

Meckel ? 1 10

Cloquet 250 62 28

Quain 159 25 18 38 20

Hesselbach 32 12 15

Pfitzner 105 35 36

Schlobig ? 22 12

Dubreuil-Chambardel 130 41 27 49 22

---------------------------------------------------------------------------------------------------------------------------

Uni-/Bilateral Side Totals 539 128 115

---------------------------------------------------------------------------------------------------------------------------

Unilateral Side, (R/L) Totals 426 92 93

From Dubreuil-Chambardel

Sources of the Obturator Artery

Author(s) # cases Obturator from Internal Iliac Obturator from External Iliac # cases % # cases %

Cloquet (Paris)

500

348

69.6

152

30.4

Hoffmann (Bale)

400

270

67.5

130

32.5

Quain (London)

361

246

68.6

115

31.4

Pfitzner (Strasbourg)

226

141

62.4

85

37

Hartmann (Berlin)

180

146

81

34

19

Schlöbig (Leipzig)

112

78

69.6

34

21

Krusche (Dorpat)

80

63

78.8

17

20

Hesselbach (Wurzburg)

64

37

57.7

27

43.3

Breschet (Paris)

63

51

81

12

19

Wyeth/Warwell (London)

52

34

66

18

34

Dwight (America)

500

371

74.2

129

25.8

Jastschinski (Varsovic)

1034

723

70

311

30

Levi (Florence)

110

82

74.8

28

25.2

Dubreuil-Chambardel (Paris)

440

310

70.5

130

29.5

Totals %

4122

2900

70.84%

1222

28.4

From Dubreuil-Chambardel, 1925.

Riferimenti dell’opera originale

Elenco riportato come compare nella fonte, senza normalizzazione dei formati bibliografici.

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