1944 Letters June 1995 Am J Obstet Gynecol

1. My study does not conclude, or appear to con- clude, that an abnormal cerebral-to-umbilical artery resistance index is a risk factor independent of oligo- hydramnios. The interaction between these two vari- ables was not addressed in my study. However, on the basis of unpublished observations, I agree with Dubin- sky and Parvey that when oligohydramnios is present the outcome is worse than when amniotic fluid volume is normal.

2. The receiver-operator characteristic curve for the umbilical artery resistance index shown in Fig. 2 is not a straight line. However, the area under the curve is 0.61, indicating that umbilical artery resistance alone had a relatively poor predictive value for intrauterine growth retardation in the population under study. The lack of accuracy of umbilical Doppler imaging in pre- dicting poor fetal outcomes in low- and high-risk popu- lations is a fact that has been substantiated by several randomized controlled trials.l-5 I believe, however, that umbilical Doppler velocimetry is an important and beneficial tool in the management of patients in which intrauterine growth retardation is suspected as a result of abnormal fetal biometry studies.

Fernando Arias, MD, PhD Department of Obstetrics and Gynecology, St. Johns Mercy Medical Center, 621 S. New Ballas Road, Ste. 2009, St. Louis, MO 63141

REFERENCES 1. Tyrell SN, Lilford RJ, Macdonald HN, et al. Randomized

comparison of routine vs. highly selective use of Doppler ultrasound and biophysical scoring to investigate high risk pregnancies. Br J Obstet Gynaecol 1990;97:909-16.

2. Newnham JP, O'Dea MRA, Reid KP, Diepeveen DA. Dopp- ler flow velocity waveform analysis in high risk pregnancies: a randomized controlled trial. Br J Obstet Gynaecol 1991; 98:956-63.

3. Davies JA, Gallivan S, SpencerJAD. Randomized controlled trial of Doppler ultrasound screening of placental perfusion during pregnancy. Lancet 1992;340:1299-303.

4. Mason GC, Lilford RJ, Porter J, Nelson E, Tyrell S. Ran- domized comparison of routine versus highly selective use of Doppler ultrasound in low risk pregnancies. Br J Obstet Gynaecol 1993; 100:130-3.

5. Whittle MJ, Hanretty KP, Primrose MH, Neilson JP. Screen- ing for the compromised fetus: a randomized trial of umbilical artery velocimetry in unselected pregnancies. AM J OBSTET GYNECOL 1994;170:555-9.

6/8/64741

Vascular anatomy of the anterlor abdominal wall in gynecology and obstetrics To the Editors: We read with interest the article by Hurd et al. (Hurd WW, Bude RO, DeLancey JOL, NewmanJS. The location of abdominal wall blood vessels in rela- tionship to abdominal landmarks apparent at laparos- copy. AM J OBSTET GVNECOL 1994;171:642-6) on the tomographicaUy followed course of the inferior epigas- tric, superficial epigastric, and superficial circumflex iliac arteries for establishing safer laparoscopic trocar placement. The need of preserving this vasculature is obvious, but previously only one precise article was

published in a less readily available journal. ~ Formally the nomenclature of the two mentioned vessels is deep inferior epigastric artery and superficial inferior epigas- tric artery. ~

Anterior abdominal wall vasculature was studied in much detail during the past decade. 2' s The major contribution in this field was by Taylor et al. The results of their numerous investigations were presented in renowned reconstructive surgery journals and summa- rized in a recent review. 2

The primary blood supply to the lower abdominal segments is provided by the deep inferior epigastric artery. Because the artery does not bifurcate nor trifur- cate on its course from the terminal external iliac artery to the posterior surface of the rectus muscle, it can always be identified as a single trunk from the perito- neal side by transillumination or palpation. The extra- muscular portion is the only constant part of the artery, so it is a good orientation reference.

The superficial inferior epigastric artery supplies the hypogastric integument (skin and subcutaneous tissue), and the vessel or its medial branch is sectioned with the Pfannenstiel incision. Lateral to the rectus muscle the vasculature comes from the intercostal arteries, super- ficial circumflex iliac artery, and the ascending branch of the deep circumflex iliac artery, providing an acces- sory longitudinal pathway. ~ Musculocutaneous anasto- moses form the vertical connection system.

Each artery studied by Hurd et al. may accidentally have laparoscopic trocar or other instrument manipu- lation, particularly in obese patients. The brief ana- tomic description above was necessary to explain that long-term trophic consequences will be minor because of the dense anastomotic network, unless the injury is extensive.

Additionally, both vascular impairment and the arte- rial or venous nature of bleeding should be clearly stated in the patient's records. This information can be crucial for future design of a lower transverse rectus musculocutaneous flap. Other surgeries involving a hy- pogastric vascular history are hernia repair, abdomino- plasty, omphaloplasty, or panniculus morbidus excision.

Congratulations to Hurd et al. for their constructive study, which entirely concurs with previous findings. ~

Maciej J6£wik, PhD, Wiktor Lotocki, PhD, and Marcin J6~wik, MD

Department of Gynecology and Septic Obstetrics, School of Medicine, Bialystok, Warszawska 15, 15-062, Bialystok, Poland

REFERENCES 1. Hunt RB. Avoiding injury to deep epigastric vessels during

laparoscopy. Gynaecol Endosc 1993;2:47. 2. Taylor GI, Watterson PA, Zelt RG. The vascular anatomy of

the anterior abdominal wall: the basis for flap design. Perspect Plast Surg 1991 ;2:1-28.

3. Onishi K, Maruyama Y. Cutaneous and fascial vasculature around the rectus abdominis muscle: anatomic basis of abdominal fasciocutaneous flaps. J Reconstr Microsurg 1986;2:247-53.

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