Is corona mortis a historical myth? A perspective from a gynecologic oncologist

Abstract

To the Editor;Corona mortis is the vascular anastomosis between theobturator and external iliac or inferior epigastric vessels. It isalso known as the ‘crown or circle of death’ because massivebleeding may occur due to an injury.The obturator artery arises from the internal iliac artery andlies longitudinally to the obturator foramen on the medial partof obturator internus muscle. Anatomically, the corona mortisis on the retro-pubic part of the superior pubic rami lateral tothe symphysis pubis, where a pubic artery or vein in this fieldmay arise from the inferior epigastric or external iliac vessels,lie to the obturator foramen, and be damaged during surgicalprocedures. The incidence of venous corona mortis is between27% (1) and 100% (2). On the other hand, the incidence ofarterial corona mortis is between 14.8% (3) and 36% (4).The corona mortis may have several anatomic variations.The vascular supply of the pelvis has many connections andvariations, as such, the clinical role of the corona mortis insurgical practice is a matter of importance to prevent significant,uncontrolled bleeding for general surgeons, gynecologists,urologists and orthopedic surgeons during femoral herniaoperations, urogynecologic operations such as transvaginaltape procedures, pelvic lymphadenectomies or pelvic fractureoperations (5).During procedures with an anterior approach to the pelvissuch as hernioplasty, femoral hernia repair or sometimestransvaginal tape operations, the surgeon may not recognizeor see the vascular connections on the retro-pubic area,which is on the posterior parts of the surgically exposed field.However, during operations where the surgeon opens theretroperitoneal area such as in pelvic lymph node dissection,the retro-pubic vascular anastomoses are easily seen after acareful and tiny dissection over the external iliac artery belowthe inguinal ligament. The corona mortis will be noted overthe superior pubic ramus, on the medial part of ligamentum teres uteri, where it enters the inguinal canal. The Figure 1shows the pubic vein below the inguinal ligament on theposterior part of superior pubic rami. This large area ofexposure will maintain quick maneuvers during abnormalbleeding to control the hemorrhage. Our clinical practiceof 96 pelvic lymphadenectomies showed an incidence of2.01% (2/96) arterial anastomoses and we had a total of 4hemorrhages (4.1%) from the pubic vein (venous coronamortis), which were easily controlled. In that manner, theterm corona mortis is questionable in gynecologic oncologypractice. Nevertheless, the amount of bleeding and the abilityto control hemorrhage from an arterial corona mortis couldnot be foreseen.