Introduction: Looking to the applied significance of lumbar plexus in the form of its involvement in various injuries, direct or iatrogenic and entrapment, it is imperative to have a thorough knowledge about its formation, branching pattern, and variations. Tubbs et al referred to the lumbar plexus as a ‘no man's land’ because of relative inaccessibility of this region and there is infrequency in operating on retroperitoneal structures by neurosurgeons. However, a recent increase in retroperitoneal laparoscopic surgeries inspired us to revisit the anatomy of lumbar plexus. Material and methods: The study was conducted on 30 formalin embalmed cadavers available in the Department of Anatomy, RMC, PIMS, Loni, Maharashtra. Thorough dissection was performed to observe the formation of branches of lumbar plexus and measurements were taken from the adjacent bony landmarks. Result: Bilateral prefixation of the lumbar plexus was found in one cadaver bilaterally. Ilioinguinal and iliohypogastric nerves were arising by a common stem in 11.66% of cases; in the remaining ones, they were having separate origins. In majority, 81.6% of the genitofemoral nerve pierced the medial third of the anterior surface of the psoas major muscle. Accessory obturator nerve was observed in 3 cases (5%) of 60 plexuses. The site of formation of femoral nerve was 5 cm inferior to the iliac crest in 71.6% of instances. The formation of obturator nerve was found to vary from the level of supracristal plane to 3.5 cm inferior to the plane; in 58.3%, it was 3 cm below the plane. Conclusion: The measurements given in this study will help the surgeon to avoid iatrogenic nerve injury as well as to assess them during lumbar plexus block.

Lumbar plexus and its variations

Introduction Conjoined twins are identical twins joined in utero. It's a rare phenomenon and present a unique challenge to obstetricians and pediatric surgeons. Conjoined twins are complex complication of monozygotic twinning, which is associated with high perinatal mortality. Case report At our clinic complete anomaly scan was done, the patients was found to have monozygotic twins of 15 weeks gestation and carrying a conjoint twin. Our ultrasound revealed fully developed heads facing each other, joint at the thorax and sharing a common abdomen. These twins share a single heart with two atrium and two ventricle. They decide for termination of pregnancy after taken the opinion of religious people. Termination of pregnancy was performed by many methods and we chose to use cytotec tablets which inserted vaginally and the outcome was conjoint twin with two bodies fused from the upper thorax to lower belly. Both fetuses are female and died immediately after termination of pregnancy.

/pdf/early-prenatal-diagnosis-of-thoracopagus-twins-by-ultrasound-3stiuvup33.pdf

Early prenatal diagnosis of thoracopagus twins by ultrasound.

Early prenatal diagnosis of conjoined twins, an extreme form of monozygotic twinning, is very important for the further management and counselling of parents because they are associated with high perinatal mortality. We present a case of thoraco-omphalopagus twins diagnosed at ten weeks and four days of gestation by two-dimensional Doppler ultrasound, which was then terminated.

/pdf/early-prenatal-diagnosis-of-thoraco-omphalopagus-twins-at-1pf511z9bw.pdf

Early prenatal diagnosis of thoraco-omphalopagus twins at ten weeks of gestation by ultrasound.

Purpose Accidental femoral nerve injury is a well-known iatrogenic complication of orthopaedic, abdominal, and pelvic surgery. Because of the largely transitory nature of the symptoms associated with nerve damage, its true incidence is in all likelihood underestimated. This work aims to illustrate the surgical contexts within which this nerve injury is reported, based on the evidence obtained from a Scoping Review of the literature of the last 20 years, with specific reference to the underlying etiopathogenetic mechanisms and prognostic outcomes, to highlight the evaluation issues of medico-legal interest related to this pathology. Methods We conducted a Scoping Review of iatrogenic femoral nerve injuries reported between 2000 and 2021 by searching the electronic databases Pubmed, Scopus, Ovid Medline, Ovid Emcare, and Web of Science. We conducted the review according to the five-step methodology outlined by Arksey and O'Malley. Results The literature search identified 104 papers, including case reports, case series, and retrospective studies. Surgical contexts within which iatrogenic femoral nerve injuries were reported include orthopaedic, abdominal, gynaecological, urological, vascular, and plastic surgery, as well as locoregional anaesthesiological procedures. The long-term prognosis was generally favourable. Conclusions Because of its frequent iatrogenic genesis, femoral nerve injury is a topic of intense medico-legal interest. From the perspective of estimating the patient's disability, the mostly favourable nature of the prognosis makes the medico-legal assessment, in some respects, complex, thus requiring a precise evaluation methodology.

Iatrogenic femoral nerve injuries: Analysis of medico-legal issues through a scoping review approach.

Conjoined twins with monoamniotic placenta result from the incomplete splitting of the embryonic disc at 13th to 15th day of gestation. Conjoined twins represent a unique structural defect of monozygotic monoamniotic twins. Earliest described conjoined twins (the Maids of Biddenden in England) date back to 1100 AD.1 Conjoined twins are inappropriately named as “Siamese twins” in relation to twin brothers Chang and Eng, born in Siam (Thailand) in 1811.2 We report a rare case of Cranio-thoraco-omphalopagus twins born to a primigravida mother at thirty weeks period of gestation.

Cranio-thoraco-omphalopagus.

Vaginal hysterectomy is one of the common surgeries performed by the gynaecologist. Standard textbooks of gynaecology mention about stretch injury of the sciatic nerve and its peroneal branch as complications following vaginal hysterectomy, but not about femoral neuropathy. Hopper et al [1], described this rare entity by stating that this condition is not mentioned in reviews cataloguing complications of more than 1800 vaginal hysterectomies. Three cases of femoral neuropathy following vaginal hysterectomy are presented.

Case 1
A 36 year old patient of abnormal uterine bleeding with first degree uterovaginal prolapse was taken up for vaginal hysterectomy under epidural anaesthesia and the surgery lasted for 2 hours 15 minutes. She was kept on bed rest and continuous bladder catheter for 48 hours. On second postoperative day catheter was removed and the patient collapsed to the ground the moment she got up from the bed. Her vitals were within normal limits. Neurological examination revealed gross weakness of the quadriceps femoris muscles (more on right side), absent knee jerks and blunted sensation over anterior aspect of both thighs. The neurophysician opinion was “Postoperative bilateral femoral neuropathy”. She was managed with graded physiotherapy. The patient responsed to treatment and by third week she was walking with support and sensations had completely recovered. She was advised to continue physiotherapy at discharge and she was symptom free by six weeks.

Femoral Neuropathy following Vaginal Hysterectomy.

Conjoined twins are the most extreme form of twinning, occurring in about 1% of monozygotic twins with incidence of about 1 in 50,000 to 1 in 100,000 births. However 60% are still born or die shortly after, the true incidence is around 1 in 200,000 live births.1 The antenatal diagnosis is difficult clinically but extremely important. The prenatal diagnosis of conjoined twins is usually suggested at prenatal sonography, which has the advantage of offering a safe, accurate, and reliable method of detecting anomalies of foetal growth and structure.2,3 However, because of the intrinsic limitation of sonography with regard to tissue contrast, MRI has been explored as a safe alternative. We present a case of conjoined twin (Craniopagus and Thoraco-omphalopagus) diagnosed by ultrasound and MRI at 15 weeks of gestation.

Early prenatal diagnosis in a case of conjoined twin with Craniopagus and Thoraco-omphalopagus

The Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and the upper part (2/3) of the vagina. The first sign of MRKH syndrome is primary amenorrhea in young women presenting otherwise with normal development of secondary sexual characteristics and normal external genitalia, with normal and functional ovaries and karyotype 46, XX [1].

The vaginal agenesis in this syndrome can be treated by various methods, both surgical and nonsurgical. We present a case treated by creating a neovagina using amnion as a graft for the vaginoplasty.

Vaginal Agenesis in Mayer Rokitansky Kuster Hauser Syndrome

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Femoral Neuropathy following Vaginal Hysterectomy.

Early prenatal diagnosis in a case of conjoined twin with Craniopagus and Thoraco-omphalopagus

Vaginal Agenesis in Mayer Rokitansky Kuster Hauser Syndrome