Showing papers in "Surgical and Radiologic Anatomy in 2008"

Anatomical terminology and nomenclature: past, present and highlights.

Abstract: The anatomical terminology is a base for medical communication. It is elaborated into a nomenclature in Latin. Its history goes back to 1895, when the first Latin anatomical nomenclature was published as Basiliensia Nomina Anatomica. It was followed by seven revisions (Jenaiensia Nomina Anatomica 1935, Parisiensia Nomina Anatomica 1955, Nomina Anatomica 2nd to 6th edition 1960–1989). The last revision, Terminologia Anatomica, (TA) created by the Federative Committee on Anatomical Terminology and approved by the International Federation of Associations of Anatomists, was published in 1998. Apart from the official Latin anatomical terminology, it includes a list of recommended English equivalents. In this article, major changes and pitfalls of the nomenclature are discussed, as well as the clinical anatomy terms. The last revision (TA) is highly recommended to the attention of not only teachers, students and researchers, but also to clinicians, doctors, translators, editors and publishers to be followed in their activities.

Multidetector-row CT angiographic imaging of the celiac trunk: anatomy and normal variants

Abstract: Purpose To evaluate the ability of MDCT reformations in describing the celiac trunk vascular anatomy and variations.

Anatomic considerations and the relationship between the piriformis muscle and the sciatic nerve

Abstract: Stating background The piriformis syndrome is one of the non-discogenics causes of sciatica. It results from the compression of the sciatic nerve (SN) by the piriformis muscle (PM) in the neutral and piriformis stretch test position. The evidence of the increase in pain in the test position requires a detailed anatomical study addressing the changes that occurred in the SN and PM anatomy during the test position. The aim of this study is to examine this relationship morphometrically.

Microanatomical structure of the human sciatic nerve.

Abstract: Sciatic nerve is the largest peripheral nerve of the human body. It gives motor and sensitive innervation for the most of lower limb. The aim of the present investigation was revealing his fascicular pattern in relation to microanatomic morphometric characteristics of its connective tissue sheaths. The material consisted of sciatic nerve slices, excised from 17 cadavers of humans aging 8–93 years. After routine histologic processing and light microscopic examination of the preparations, morphometric analysis was performed at magnifications of 40 and 630×. Sciatic nerve showed to be polyfascicular nerve type, with the group pattern of nerve fascicless distribution. The number of fascicless ranged from 27 to 70, whereas the number of fascicless per square millimeter was 1–4. Morphometric and correlation analysis confirmed the significant increase of whole sciatic nerve cross section area, which was associated with the significant increase of its epi- and perineural connective tissue sheaths. Interfascicular sciatic nerve domains of elderly persons contained more adipose tissue. Moreover, already detected loss and degeneration of the large myelinated nerve fibers within fascicles was accompanied by the significant increase of endoneural connective tissue. In conclusion, our study revealed comparative connective tissue enlargement of human sciatic nerve in the course of aging. These phenomena might influence on result of injured nerve’s surgical reparations. We interpret this finding as non-specific compensatory phenomenon elicited by loss of thickest myelinated nerve fibers, higher vulnerability of remaining ones, and age-dependent decrease of connective tissue elasticity.

An initial qualitative study of dual-energy CT in the knee ligaments.

Abstract: Objective To study the clinical application of dual-energy CT (DECT) in the knee ligaments.

Variations in the intracranial vertebrobasilar system

Abstract: Aim The aim of our study was to demonstrate some possible variations in the vertebrobasilar system (VBS) in the Turkish population and to compare our results with the literature.

Comparison of point counting and planimetry methods for the assessment of cerebellar volume in human using magnetic resonance imaging: a stereological study

Abstract: The cerebellum is involved in motor learning and cognitive function in human. Many studies have been conducted to assess the cerebellar volume. To the best of our knowledge, there is no cerebellar volume study evaluating the efficiency and the accuracy of point-counting and planimetry methods of the Cavalieri principle in the literature. In this study, the volume of cerebellum was estimated in 53 Turkish young volunteers (26 males and 27 females), aged between 20 and 25 who are free of any neurological symptoms and signs, using serial magnetic resonance (MR) images. The cerebellar volumes of subjects were determined on MR images using the point-counting and planimetry methods. The mean results of planimetry method were 116.69 +/- 10.1 and 114.41 +/- 9.3 cm(3 )in males and females, respectively. The mean results of point-counting method were 116.34 +/- 10.6 and 113.48 +/- 8.8 cm(3 )in males and females, respectively. Our results revealed that female subjects had less cerebellar volumes compared with males, although there was no statistical significant difference between genders (P > 0.05). Total cerebellar volumes obtained by two different methods were not statistically different (P = 0.189) and they were correlated well to each other (r = 0.935). We found that the point-counting method takes less time than the planimetric method (mean 8 +/- 3.6 vs. 15 +/- 5.5 min). Thus, while planimetric and stereological approaches yield very similar results, the stereological method has the advantage of greater speed and, therefore, efficiency.

Intracranial arterial fenestrations: frequency on CT angiography and association with other vascular lesions

Abstract: Fenestrations (segmental duplications) of the intracranial arteries are rare anomalies, felt to result from incomplete fusion of primitive embryologic vessels They have been associated with aneurysms and other vascular lesions The rate of fenestrations based on published angiographic series has been much lower than that at cadaveric series The purpose of this study is to determine the frequency of fenestrations and associated vascular lesions at CTA A total of 504 sequential CTA studies from 2005 to 2006 were retrospectively reviewed for the presence of fenestrations, aneurysms and other vascular lesions Fenestrations were present in 53 patients (11%) Their frequency was not significantly different in patients referred for aneurysm indications, when compared to those referred for non-aneurysm indications As expected, there was a much higher frequency of aneurysms in the former group Associated vascular lesions were relatively uncommon Aneurysms were present at the fenestration site in three patients, and remote from the fenestration site in eight One fenestration patient with an associated aneurysm at the fenestration site also had an AVM remote from the fenestration The frequency of fenestrations in this study was higher than in previously published radiologic studies, suggesting that fenestrations are relatively common, and may be more frequently visualized using cross-sectional imaging Association with aneurysms and other vascular lesions was relatively uncommon Our results do not support the theory that fenestrations predispose a patient to aneurysms or vascular malformations remote from the site of the fenestration Although the association of aneurysms at the site of fenestrations is well documented, our results do not show an overall higher rate of aneurysm formation in patients with fenestrations compared to those without

Perineal pain and inferior cluneal nerves: anatomy and surgery

Abstract: Neuropathic perineal pains are generally linked to suffering of the pudendal nerve. But some patients present pains described as a type of burning sensation located more laterally on the anal margin and on areas including the scrotum or the labiae majorae, the caudal and medial parts of the buttock and the upper part of the thigh. These pains extend beyond the territory of the pudendal nerve. It is interesting to note that the inferior cluneal nerves are responsible for the cutaneous sensitivity in the inferior part of the buttock. We wanted to check if these nerves, or some of their branches, could be responsible for such pains. An anatomic study, containing six dissections on corpse, has been conducted. The inferior cluneal nerves, emerging from the posterior femoral cutaneous nerve have some branches joining the perineum, especially by a perineal ramus. However, two conflict areas have been identified on the path of these nerves and on the perineal ramus: one at the level of the sacrotuberal ligament, and the other being the passage under the ischium. Two surgical approaches have been established from these observations with the aim of suppressing the conflicts.

Volumetric evaluation of the relations among the cerebrum, cerebellum and brain stem in young subjects: a combination of stereology and magnetic resonance imaging.

Abstract: The Cavalieri estimator using a point grid is used to estimate the volume of three-dimensional structures based on two-dimensional slices of the object. The size of the components of intracranial neural structures should have proportional relations among them. The volume fraction approach of stereological methods provides information about volumetric relations of the components of structures. The purpose of our study is to estimate the volume and volume fraction data related to the cerebrum, cerebellum and brain stem. In this study, volume of the total brain, cerebrum, cerebellum and brain stem were estimated in 24 young Turkish volunteers (12 males and 12 females) who are free of any neurological symptoms and signs. The volume and volume fraction of the total brain, cerebrum, cerebellum and brain stem were determined on magnetic resonance (MR) images using the point-counting approach of stereological methods. The mean (+/-SD) total brain, cerebrum and cerebellum volumes were 1,202.05 +/- 103.51, 1,143.65 +/- 106.25 cm3 in males and females, 1,060.0 +/- 94.6, 1,008.9 +/- 104.3 cm3 in males and females, 117.75 +/- 10.7, 111.83 +/- 8.0 cm3 in males and females, respectively. The mean brain stem volumes were 24.3 +/- 2.89, 22.9 +/- 4.49 cm3 in males and females, respectively. Our results revealed that female subjects have less cerebral, cerebellar and brain stem volumes compared to males, although there was no statistically significant difference between genders (P > 0.05). The volume ratio of the cerebrum to total brain volume (TBV), cerebellum to TBV and brain stem to TBV were 88.16 and 88.13% in males and females, 9.8 and 9.8% in males and females, 2.03 and 2.03% in males and females, respectively. The volume ratio of the cerebellum to cerebrum, brain stem to cerebrum and brain stem to cerebellum were 11.12 and 11.16% in males and females, 2.30 and 2.31% in males and females, 20.7 and 20.6% in males and females, respectively. The difference between the genders was not statistically significant (P > 0.05). Our results revealed that the volumetric composition of the cerebrum, cerebellum and brain stem does not show sexual dimorphism.

Lumbar hernia: anatomical basis and clinical aspects

Abstract: The purpose of this study was to describe the anatomy of the two orifices of the abdominal posterior wall where lumbar hernias could appear. They may protrude through the superficial lumbar triangle (JL Petit) or the deepest superior orifice (Grynfeltt). The exact limits were precised by dissections in cadavers to explain the main differences of these two locations. We report two cases of spontaneous lumbar hernias discovered in outpatient clinic. Clinical diagnosis was difficult and both the patients were sent for lumbar lipoma but a meticulous examination gave us a clue. MRI was useful to confirm the defect in the posterior abdominal wall under the 12th rib. Only one patient was operated by a direct approach with a reinforcement of an unabsorbable mesh. No recurrence appeared during follow-up. Thanks to clinical and anatomical knowledge, these rare superior lumbar hernias were diagnosed and a correct surgical treatment permitted a quick recovery.

Anatomy and biomechanics of the vertebral aponeurosis part of the posterior layer of the thoracolumbar fascia

Abstract: There is significant paucity in the literature regarding vertebral aponeurosis. We were able to find only a few descriptions of this specific fascia in the extant medical literature. To elucidate further the anatomy of this structure, forty adult human cadavers were dissected. Both quantitation and anatomical observations were made of the vertebral aponeurosis. The vertebral aponeurosis was identified in 100% of specimens. This fascia was identified as a thin fibrous layer consisting of longitudinal and transverse connective tissue fibers blended together deep to the latissimus dorsi muscle. It attached medially to the spinous processes of the of the thoracic vertebrae; laterally to the angles of ribs; inferiorly to the fascia covering the serratus posterior inferior muscle (superficial lamina of the posterior layer of thoracolumbar fascia); superiorly it ran deep to the serratus posterior superior and splenius capitis muscles to blend with the deep fascia of the neck. At the level of the serratus posterior inferior muscle, the vertebral aponeurosis fused to form a continuous layer descending toward the sacrotuberous ligament covering the erector spinae muscle. Morphometrically, the mean length of the vertebral aponeurosis was 38 cm and the mean width was 24 cm. The mean thickness was three mm. There was no significant difference between left and right sides, gender or age with regard to vertebral aponeurosis length, width, or thickness (P > 0.05). During manual tension of the vertebral aponeurosis, the tensile force necessary for failure had a mean of 38.7 N. In all specimens, the vertebral aponeurosis was capable of holding sutures placed through its substance. We hope that these data will be of use for descriptive purposes and may potentially add to our understanding of the biomechanics involved in movements of the back. As back pain is perhaps the most common reason patients visit their physicians, additional knowledge of this anatomical region is important.

Vascular anatomical basis of clavicular non-union

Abstract: The middle third of the clavicle is commonly involved in any injury and account for 5–10% of all fractures in adults. Although non-unions are rare, their treatment has not been well defined yet. This report describes the arterial supply of the clavicle to clarify the pathological mechanism and the surgical procedure of non-unions. This study was based on delineation of the thoraco-acromial and suprascapular arteries with colored latex on 17 specimens (ten cadavers). Observations were made after macroscopic dissection and maceration. The main blood supply to the middle third of the clavicle was the periosteal. This supply came from the two branches of the thoraco-acromial trunk that penetrated the pectoralis major muscle and the deltoid muscle. In 13 cases, these two periosteal branches were anastomosed between these two muscle attachments. Periosteal vascularization was always seen on the superior surface and the anterior border of the bone, but never on the inferior surface or the posterior border. The suprascapular artery contributed to supply the middle third of the clavicle by several periosteal branches and also by an independent branch. This branch was born proximally near the internal, middle thirds union and passed along the posterior face of the subclavius muscle and pierced the bone through the nutria foramina located near the external, middle thirds union. Nevertheless, intraosseous arteries were noted only in four cases. In these cases, they were never more than 2cm long. Our results showed that the periosteal blood supply located between the muscles insertions and the arterial supply from the suprascapular artery could be twice compromised in case of important displacement or severe fracture. If treatments of clavicular fractures or non-unions cannot preserve the periosteal blood supply, bone grafting should be indicated.

Topography of carotid bifurcation: considerations for neck examination.

Abstract: Clinical examination and surgical procedures require the knowledge of anatomical structures of such a complex area as neck, especially the developmental anomalies in vascular drainage may occur. The aim of this study was to describe the common carotid artery bifurcation to its surrounding structures to locate it properly by using external and internal landmarks. Measurements were performed on 43 Thai cadavers by the direct inspection method. Carotid bifurcation level was compared to the level of cervical vertebra, isthmus of thyroid cartilage, angle of mandible and origins of superior thyroid artery, and lingual artery. Most of carotid bifurcations were found at the level of C3, between C3 and C4, and C4 vertebra, as well as the tendency to lower position in men was noted. Measurements to the angle of mandible on the left sides were significantly different in studied groups (P = 0.02), also with lower position of bifurcation in men. The mean level of carotid bifurcation was approximately 6 mm above ITC, which literally is at the level of the superior border of thyroid cartilage. Moreover, in four cases, common carotid artery did not bifurcate bilaterally, and in four cases, no bifurcations were found at the right side of neck. Further, many superior thyroid arteries originated from common carotid artery. To sum up, during the clinical procedures, the level of thyroid cartilage is mostly advised to follow to locate the carotid sinus. Further, the described variations in topography of carotid bifurcation and arteries origins may have important clinical implications.

Quantitative anatomy of vertebral artery groove on the posterior arch of atlas in relation to spinal surgical procedures.

Abstract: Background The location of the vertebral artery on a groove on the superior surface of the posterior arch of atlas makes it vulnerable to injury during surgical procedures in this region. Knowledge of the quantitative anatomy of the vertebral artery groove is therefore necessary.

CT evaluation of cervical pedicle in a Chinese population for surgical application of transpedicular screw placement.

Abstract: The lower cervical pedicle size differs between the Chinese and the non-Chinese population. Knowledge of pedicle dimensions and surface landmarks is crucial for the safe placement of screws, but few quantitative data concerning the lower cervical pedicle using CT scan and multiplanar reformations (MPR) in a Chinese population exist. The aim of this study was to evaluate lower cervical pedicle (C3-C7) dimensions in a Chinese population by computed axial tomography for surgical application. The dimensions of the pedicles (C3-C7) were determined in 60 patients from CT images of cervical spinal lesions. Measurements of pedicle height, width, pedicle axis length, effective length, and two angles of the pedicles, the distances from the projection point of the pedicle axis to the lateral edge of the lateral mass and to the inferior edge of the superior facet were measured. The smallest outer pedicle width was found at C3 among the female and C4 among the male. This measurement was significantly different between male and female patients in the outer pedicle width (P < 0.05; independent samples t test) at C3 and C4. The mean values of the outer pedicle width ranged from 5.4 to 6.7 mm in males, and 4.4 to 6.3 mm in females. The projection point of the pedicle axis in the lateral-superior area of the cervical lateral mass was the most important. There were significant correlations (P < 0.01; Kendall's W test) between the vertebral level and both pedicle angles (PTA and PSA). The smallest pedicle transverse angle was at C7 in males and females. The cervical spinal cord or vertebral artery may be at risk of injury if the angulation of the screw insert is over-medial or over-lateral in the transverse plane. Therefore, preoperative CT evaluation of pedicle transverse angle is very important. Considering the amount of variation among individuals, our data on CT measurements of pedicle in a Chinese population in conjunction with evaluation of the results of preoperative CT may enhance the safety of transpedicular screw fixation in the lower cervical spine.

Measurements of pre- and postpubertal human larynx: a cadaver study

Abstract: This study investigates the differences in proportion and structure of the larynx in both children and adults, as well as changes which the larynx undergoes during puberty and adolescence. Furthermore, we have tried to answer the question on the existence of laryngeal sexual dismorphism in pre-pubertal (or pubertal) children. Larynges of 20 adults (10 men and 10 women) and 34 larynges of children not more than 12 years of age were acquired from the Forensic Medicine Department of the Medical University of Warsaw, Poland. Methods used are based on (1) anatomical preparation, (2) anatomical description and (3) measurements performed with the use of a digital camera and a computer-aided system MULTISCAN. Statistics, the Student's test and Pearson's linear correlation coefficient were calculated. Results show that proportions of the larynx depend on the age of the individual. The younger the individual is the more slender the larynx would be. However, proportion is not gender-related and hence is about the same in both males and females of any given age-group. Nevertheless, basic parameters were larger in males.

Radiological anatomy of the sigmoid colon

Abstract: The variable incidence of sigmoid volvulus, which depends on the presence of an elongated sigmoid colon, suggests the possibility of variations in the length of the sigmoid colon. This study was undertaken among the three major population groups to prove this hypothesis. Radiological films of patients of the three population groups (African, Indian and White) undergoing barium enema were reviewed. The stature was measured by the distance from T12 to L4. The collective length of the rectum and sigmoid colon as well as the entire colon was measured on the barium enema film using an opisometer. Measurement was from the upper border of the symphysis pubis to the upper border of the left iliac crest. The level of the apex of the sigmoid colon loop and its redundancy were also assessed. There were 109 patients (61 females) undergoing barium enema (39 Africans, 49 Indians, and 21 Whites). For the entire group the T12–L4 distance was 16.6 ± 2.2 cm and the entire colon length was 133 cm (range 88–262 cm) and was significantly longer among African patients (P = 0.003). The combined length of the rectum and sigmoid colon was 48.8 ± 15.7 cm (Africans 60.9 ± 14.4 cm, Indians 41.3 ± 12.2 cm and Whites 44 ± 11.6 cm). The sigmoid colon was significantly more redundant in Africans (90%), compared to Indians (25%) and Whites (24%) (P = 0.003 for Indians and P = 0.048 for whites). The apex of the sigmoid colon reached L1–L3 in 54% among Africans, 6% among Indians and in 10% among Whites (10%). African patients had the longest combined length of the rectum and sigmoid colon translating into a long sigmoid colon. They also had the highest number of redundant sigmoid colon. This may explain the high incidence of sigmoid volvulus in African patients.

Surgical anatomy of the sphenopalatine foramen and its arterial content

Abstract: The sphenopalatine artery is the end artery of the maxillary artery located within the pterygopalatine fossa and passes through the sphenopalatine foramen (SPF) on lateral nasal wall. Nasal bleeding from this artery is potentially life threatening and may urgently require endonasal endoscopic occlusion. The aims of the present study have been first to investigate the location of the SPF, secondly the pattern of the main branches of the sphenopalatine artery at the foramen. 12 adult dry skulls and 6 adult cadaver heads injected within Indian Ink have been analyzed under an operating microscope Leica. All measurements were assessed using a digital calliper. The inferior border of the SPF has been situated 18.27 mm (15.09–20.87 mm) above the horizontal plate of the palatine bone and 13.04 mm (9.01–14.85 mm) above the horizontal lamina of the nasal inferior turbinate. Endoscopically, the posterior wall of the maxillary sinus is located at the level or anteriorly within 10 mm to the anterior border of the SPF. In all cases, the anterior border of the SPF is characterized by an easy recognizable sharp bony crest at the narrow middle part of the hourglass shape foramen. The SPF is 6.13 mm high (5.24–6.84 mm), with deep grooves extended superiorly and inferiorly from the foramen in eight skulls (8/12). The posterior lateral nasal artery which courses inferiorly and vertically (diameter 1.80 ± 0.20 mm) and the nasal septal artery which courses superiorly and vertically (diameter 1.30 ± 0.30 mm) have been the two major branches just leaving the SPF. One or two smaller collateral branches (diameter less than 1 mm) to the superior and/or the middle turbinate can get out coming from the stem of the main branches or directly from the SPF. So, the success rate of sphenopalatine artery ligation during endoscopic surgical procedure needs selective dissection of the two main branches of the sphenopalatine artery close to the SPF.

Large patent median arteries and their relation to the superficial palmar arch with respect to history, size consideration and clinic consequences.

Abstract: Background A large patent median artery can be involved in several clinical disorders like carpal tunnel syndrome, anterior interosseous nerve syndrome and pronator syndrome.

The clinical anatomy of the communications between the radial and ulnar nerves on the dorsal surface of the hand.

Abstract: Sensations of the dorsal surface of the hand are supplied by the radial and ulnar nerves with the boundary between these two nerves classically being the midline of the fourth digit. Overlap and variations of this division exist and a communicating branch (RUCB) between the radial and ulnar nerves could potentially explain variations in the sensory examination of the dorsal hand. The aim of this study was to examine the origin and distribution of the RUCB thereby providing information that may potentially decrease iatrogenic injury to this connection. We grossly examined 200 formalin-fixed adult human hands. A RUCB was found to be present in 120 hands (60%). Of the specimens with RUCBs, we were able to identify four notable types. Type I (71, 59.1%) originated proximally from the radial nerve and proceeded distally to join the ulnar nerve. Type II (23, 19.1%) originated proximally from the ulnar nerve and proceeded distally to join the radial nerve. Type III (4, 3.3%) traveled perpendicularly between the radial and ulnar nerves so that it was not possible to determine which nerve served as its point of origin. Type IV (18.3%) had multiple RUCBs arising from both the radial and ulnar nerves. With the continual development of new surgical techniques and the ongoing effort to decrease postoperative complications, it is hoped that this study will provide useful information to both anatomists and surgeons.

An unusually-wide human bregmatic Wormian bone: anatomy, tomographic description, and possible significance.

Abstract: Supernumerary ossicles (or Wormian bones) of the cranial vault are formations associated with insufficient rate of suture closure, and regarded as “epigenetic” and “hypostotic” traits. These bones rest along sutures and/or fill fontanelles of the neonatal skull. In this autoptic report of a 66-year-old Caucasian woman, a peculiar supernumerary bone is described, unusual size and shape, filling completely the bregmatic fontanelle. The skull was CT-scanned through coronal sections at 80 kV and 60 mA, with a slice thickness of 1.0 mm and a resolution of 0.35 mm/pixel. Segmentation and 3D rendering were computed using MIMICS 7.0 (digital endocast). The bone was pentagonal and remarkably large, more on the exocranial surface than on the endocranial one, involving both tables and diploe of the vault. This feature might represent a wedge to completion of the vault architecture. Considering the functional and structural matrix of cranial morphogenesis, this case displays the possibility of discrete diversification of the ossification centres, as well as the relative stability of the structural skull matrix in response to discrete changes.

Bile duct anatomy of the Anatolian Caucasian population: Huang classification revisited

Abstract: Living donor liver transplantations (LDLT) donor candidates are being assessed with MRCP (magnetic resonance cholangiopancreatography) to identify their suitability for standard surgical techniques. Variations of the bile duct anatomy play an important role in donor selection and in the selection of the resection technique. If bile duct anatomy is misrecognized, complications may occur. Anatomic variations are classified according to the origin of the right posterior hepatic duct (RPHD). According to the so called Huang classification, type A1 is the most, and type A5 is the least frequent variation. These frequencies were initially validated on Chinese population. Later studies revealed significant variability in frequency for the so called trifurcation, the variation in which a common junction of RHPD, right anterior hepatic duct (RAHD) and left hepatic duct (LHD) (A2) exists. In this study we aimed to determine the bile duct anatomy variations for the Anatolian Caucasians. One hundred and thirty-four healthy subjects were investigated under 1.5 T MRI, with breath-hold (expiration) heavily T2-weighted turbo spin echo (TSE) static fluid imaging (TR/TE = 8,000/800). The sequence has permitted three to five oblique coronal thick sections (40 mm) around a common axis. Sequences were repeated until anatomically interpretable images were obtained. Diagnostic images could not be obtained in 22 subjects. Radiologists who were fully experienced in LDLT assessment investigated these images, and classified them for the surgical variations of the bile duct anatomy. One hundred and twelve subjects (58 men, 54 women) who were classified were between 14 and 81 years of age (mean: 39.3; SD 14.1). According to Huang classification, 61 of them (55%) were classified as type A1 (normal right and left hepatic duct junction), 16 (14%) as type A2 (common junction of RAHD, RHPD and LHD), 24 (21%) as type A3 (aberrant drainage of RPHD to left main duct), and 11 (10%) as type A4 (aberrant drainage of RPHD to main hepatic duct). When subjects, in whom the distance (d) between RPHD insertion and the right and left hepatic duct junction is less than 1 cm, are classified as type A2, the type A1 prevalence decreases to 28%. For the entire population that distance was between 3 and 25 mm (mean: 9.8, SD: 4.8). Accordingly, the frequency of type A1 anatomy was 8–29% lower than the respective frequency in Chinese population. From the surgical perspective, close proximity (d < 1 cm) of RPHD to right and left hepatic duct junction is considered as type A2 variation. According to that concept, type A1, usually accepted as the dominant anatomic variation, is encountered only in 28% of the Anatolian Caucasians. We have proposed a modified surgical classification in which Huang type 2 was subdivided into types K2a (close proximity) and K2b (trifurcating). The predominance of K2 types in the population of the study may necessitate the use of bench ductoplasty in many liver grafts.

Anatomical optimization of skin electrode placement to record electromyographic activity of erector spinae muscles

Abstract: Fine analysis of body movements is now technologically feasible, together with simultaneous recording of multiple muscle activity. This is especially true for the trunk and back muscles during human walking. However, there have been few anatomic studies of the area where deep back muscle activity is recordable by skin electrodes. We therefore attempted to optimize skin electrode location for recording erector spinae muscle activity at different levels of the back. For this purpose, 20 dissections of the posterior wall of the trunk were performed. The cutaneous plane was reclined on both sides to expose the superficial muscles of the posterior wall of the trunk. We dissected then plane-by-plane until we exposed the erector spinae muscles. The widths of the fascial spinal muscle insertions were measured at spinal levels easily identified clinically, i.e., C7, T3, T7, T12 and L4. Electromyographic assessment of the electrode location at these levels was performed in three subjects. Erector spinae muscle activity proved possible to record on several areas of the posterior wall through a superficial muscle aponeurosis. We propose a protocol for placing skin electrodes to record erector spinae muscle activity based on clinical anatomical references.

Peri-hilar branching patterns and morphologies of the renal artery: a review and anatomical study.

Abstract: The peri-hilar (extra-parenchymal) branching pattern of the renal artery is important for surgeons to know prior to kidney transplantation. The aim of this study was to identify the variations in peri-hilar branching pattern and morphology of the main renal artery. Arteriograms of 81 kidneys were examined. After marking the renal shadow, the main renal artery was traced laterally from its origin. Morphologically, the arterial branching patterns were classified into ladder (with sequential branching points) and fork (with a common branching point) types. The latter was either duplicated or triplicated. The peri-hilar morphology of the main renal artery was then categorized according to its primary and secondary divisions and their patterns. If a single category encompassed at least 5% of the observed figures, it was recorded as a “cardinal” peri-hilar arterial morphology. Otherwise, it was counted within the category of “infrequent” morphologies. At the level of the main artery, a fork pattern was observed in 92.6% (n = 75) (80.2% duplicated (n = 65) and 12.4% triplicated (n = 10)) and a ladder pattern in 7.4% (n = 6) of kidneys. Of 160 primary branches off the fork-type main artery, a secondary division was found in 68.8%. Only one further division (4.4%) was noted from the ladder-type primary arteries. Eight “cardinal” peri-hilar renal arterial morphologies were identified and represented 82.7% of all cases. At least ten “infrequent” morphologies were also found. These patterns showed some alteration with the presence of a supernumerary renal artery. We concluded that the peri-hilar branching of main renal artery is highly variable, though this may follow certain patterns. We believe that the results may be useful to surgeons operating at the renal hilum especially during kidney transplantation.

Detailed Anatomy of a Left Accessory Aberrant Colic Artery

Abstract: In an aged human female cadaver a left accessory aberrant colic artery (LAACA) was observed and studied. It originated from the superior mesenteric artery at 3 cm proximal to the middle colic artery, at the inferior border of pancreas, passing over Treitz's muscle and continued covered by the superior duodenal fold where it crossed the inferior mesenteric vein. Further, it continued with a satellite vein anterior to the left renal vein and the anterior branch of the renal artery. The LAACA divided into an ascending branch and a descending one, anastomosed with the middle colic and proper left colic arteries; between its two primary branches and the splenic flexure of colon, a hypovascular area was observed. The surgical relevance of the LAACA detailed anatomy mainly relates to specific procedures performed in left colectomies and nephrectomies.

Anatomic evaluation of the carotid artery bifurcation in cadavers: implications for open and endovascular therapy.

Abstract: Knowledge of carotid bifurcation (CB), common carotid artery (CCA) and its branches and their recognition during diagnostic imaging are also important for vascular surgical procedures in the region, such as carotid endarterectomy or radical neck dissection, catheterization and aneurysms. The surgical anatomy of the carotid arteries was studied in 20 cadavers. Micrometric values of the CB and its relation with surrounding structures, measurements belonging to the external carotid artery (ECA) and internal carotid artery (ICA), and metric data, such as lower face including the greater horn, laryngeal prominence have been evaluated by making linear measures. The diameter of the CCA at the CB under 2 cm and CB diameter was measured as 8.1 ± 2.24 mm and 12.79 ± 2.87 mm, respectively. Evaluating data related to the ICA and the ECA in samples, the aspect was measured the ICA and the ECA in the CB discrimination point as 21.52 ± 20.53°. In the most location of the ECA origin according to the ICA has been determined as medial position in 35 specimens. The origin of the superior thyroid artery (STA) was found to be at the same level with the CB in 40% and below it in 25% specimens. This study has provided measured objective criteria for the arterial features of the neck region, which are crucial during surgery. The origins of the branches of the CCA act as key landmarks for adequate and appropriate placement of the cross-clamp on the carotid arteries.

The phrenico-esophageal ligament: an anatomical study

Abstract: The phrenico-esophageal ligament (PEL), which is claimed by some to be an important anti-reflux barrier, has been accepted as an important structure by some surgeons dealing with the surgical treatment of hiatal hernias. However, the characteristics of its anatomical structure and the physiological importance of this ligament is still a subject of discussion. The aim of this study was to define this anatomic structure and to point out the clinical importance of the PEL. This study has been carried out on samples taken from 2 fresh and 12 fixed cadavers. The PEL was observed to be derived from the transversalis and endothoracic fascia attaching the esophagus to the diaphragmatic crura at the region of the esophageal hiatus. While the transversalis fascia covered the inferior surface of the diaphragm, it was observed to divide into upper and lower leaflets when it approached the esophageal hiatus. The endothoracic fascia turned superiorly at the level of esophageal hiatus and attached on to the esophagus by uniting with the upper leaflet of the transversalis fascia in 11 of the specimens. In three of the specimens, it attached on the esophagus at a higher level than the transversalis fascia. The histologic sections of our study revealed that the PEL is formed by collagen and elastic fibers composed of fibroblasts and blood vessels. Since the PEL is a strong structure that firmly attached to the esophageal wall and surrounded the upper part of the distal esophagus like a skirt, it is reasonable that it may play an important role in the gastroesophageal sphincteric mechanism. Histological evidence for decrease in collagen fibers with age and the loose arrangement of the elastic fibers due to this decrement might decrease the resistance and the elasticity of the PEL. This situation may explain the predisposition to hiatal hernias seen with increased in age.

A rare case of inferior mesenteric artery arising from the superior mesenteric artery, with a review of the review of the literature

Abstract: Anatomical variations of the inferior mesenteric artery (IMA) are uncommon. Generally, the IMA is very stable, arises directly from the abdominal aorta at the level of the third lumbar vertebra. We describe here an extremely rare case in which the IMA arose from the superior mesenteric artery. The findings were made during routine dissection of the cadaver of a 79-year-old Japanese man. This present case is the ninth report of this variation and was associated with gastrophrenic trunk, hepatosplenic trunk, hypoplastic spleen and accessory spleen. Clinically, cases like this highlight the importance of knowing the IMA anatomy and the possibility of its numerous variations in surgical procedures such as right hemicolectomy, resection of the transverse colon, left hemicolectomy, sigmoidectomy, and en bloc resection of the head of the pancreas and the superior mesenteric vessels. The developmental significance of this variation is also discussed with a detailed review of the literature.

Evaluation of small bowel measurement in alive patients.

Abstract: Introduction Based on the importance of bowel length in massive bowel resection, the aim of this study is to evaluate the small bowel length in patients who had laparotomy.