Anatomical Approach Research Articles

Technique of Microvascular Decompression for Hemifacial Spasm Based on Surgical Anatomy

This article describes the anatomical approach and operative points of microvascular decompression for hemifacial spasm based on the author's personal experience with 1,000 cases. As vascular compression of the facial nerve is often quite caudal, it is necessary to ensure that the compressing arteries in this area are moved. Neither the vessels nor the prosthesis used to move them should not touch the root exit zone of the nerve(vascular transposition nerve isolation technique). It should also be emphasized that every effort should be made to avoid complications such as hearing impairment and postoperative subcutaneous spinal fluid accumulation.

Integrated anatomical and functional approach for tailored renal interventions-in patients with resistant arterial hypertension.

Integrated anatomical and functional approach for tailored renal interventions-in patients with resistant arterial hypertension.

Nuclear Molecular Imaging of Cardiac Remodeling after Myocardial Infarction.

The role of molecular imaging technologies in detecting, evaluating, and monitoring cardiovascular disease and their treatment is expanding rapidly. Gradually replacing the conventional anatomical or physiological approaches, molecular imaging strategies using biologically targeted markers provide unique insight into pathobiological processes at molecular and cellular levels and allow for cardiovascular disease evaluation and individualized therapy. This review paper will discuss currently available and developing molecular-based single-photon emission computed tomography (SPECT) and positron emission tomography (PET) imaging strategies to evaluate post-infarction cardiac remodeling. These approaches include potential targeted methods of evaluating critical biological processes, such as inflammation, angiogenesis, and scar formation.

Biomechanical Assessment of Knee Laxity After a Novel Posterolateral Corner Reconstruction Technique

Background: Different techniques to restore knee stability after posterolateral corner (PLC) injury have been described. The original anatomic PLC reconstruction uses 2 separate allografts to reconstruct the PLC. Access to allograft tissue continues to be a significant limitation of this technique, which led to the development of a modified anatomic approach utilizing a single autologous semitendinosus graft fixed on the tibia with an adjustable suspensory loop to enable differential tensioning of the PLC components. Purpose/Hypothesis: The purpose of this study was to compare the modified anatomic technique with the original anatomic reconstruction in terms of varus and external rotatory laxity in a cadaveric biomechanical model. The hypothesis was that both techniques would restore varus and external rotatory laxity after a simulated complete PLC injury. Study Design: Controlled laboratory study. Methods: Eight pairs of fresh-frozen cadaveric knee specimens were tested to compare the 2 techniques. Varus and external tibial rotation laxity of the knee were measured while applying 10-N·m varus and 5-N·m external rotatory torques at 0°, 30°, 60°, and 90° of flexion. These measurements were tested under 3 conditions: (1) intact fibular collateral ligament, popliteal tendon, and popliteofibular ligament; (2) complete transection of the fibular collateral ligament, popliteal tendon, and popliteofibular ligament; (3) after PLC reconstruction with either the modified (n = 8) or the original (n = 8) technique. Results: After PLC reconstruction, varus laxity was restored with no statistically significant differences from the intact condition after both reconstruction techniques. Similar outcomes were observed for external rotation in extension; however, in terms of the external rotation limit with respect to the intact joint, significant reductions of mean ± SD 4.1°± 6.3° (P = .036) and 5.1°± 6.6° (P = .016) were recorded with the modified technique at 60° and 90° of flexion, respectively. No significant effect was observed on the neutral flexion kinematics from 0° to 90° of flexion, and no significant differences were observed between reconstructions (P = .222). Conclusion: Both PLC reconstruction techniques restored the normal native varus as compared with the intact knee. Although the modified technique constrained end-range external rotation at 60° and 90° of flexion, no differences were noted with neutral flexion kinematics. Care should be taken when tensioning in the modified technique so that the tibia is in a neutral position to avoid overconstraining the knee. Clinical Relevance: The modified technique may prove useful in situations where there are limited graft options, particularly where allografts are not available or are restricted.

Factors predicting hip joint aspiration yield or \u201cdry taps\u201d in patients with total hip arthroplasty

BackgroundImage-guided joint aspirations used to assist the diagnosis of periprosthetic joint infection (PJI) may commonly result in a dry tap–or insufficient fluid for culture and cell count analysis. Dry tap aspirations are painful and invasive for patients and often utilize a subsequent saline lavage to obtain a microbiology sample. Currently, there is a paucity of the literature addressing predictors that could suggest whether a dry tap will occur. The purpose of this study was to examine the effects of various factors on “dry tap” occurrence in patients with suspected PJI following total hip arthroplasty (THA).MethodsA retrospective review was performed among THA patients suspected for PJI who received image-guided joint aspiration procedures at our institution from May 2016 to February 2020. The procedural factors included the imaging modality used for aspiration, anatomic approach, needle gauge size used, and the presence of a trainee. The patient-specific factors included number of prior ipsilateral hip surgeries, femoral head size, ESR/CRP values, and BMI.ResultsIn total, 336 patients met our inclusion criteria. One hundred and twenty hip aspirations resulted in a dry tap (35.7%) where the patients underwent a saline lavage. Among the procedural and patient-specific factors, none of the factors were found to be statistically different between the two cohorts nor conferred any greater odds of a dry tap occurring.ConclusionNo associations with dry tap occurrence were found among the procedural and patient-specific factors studied. Further research is needed to identify additional factors that may be more predictive of dry taps.

Mucosal Bridge Reconstruction: A Novel Approach for the Vocal Fold Mucosal Bridge.

Mucosal Bridges (MBs) are defined as benign connective tissue abnormalities of unclear etiology that extend over the free surface of the vocal fold, are attached to the front and back of the vocal fold but are not attached to its free surface, and are histologically covered by stratified squamous epithelium. In order to overcome these drawbacks, we aimed to retrospectively evaluate and present the preoperative and postoperative results of patients with MB, who were applied the method we call "Mucosal Bridge Reconstruction" (MBR), which we apply as suturing rather than resection of the MB. Between January 2016 and February 2020, 5 patients who applied to the voice clinic due to dysphonia and were diagnosed with MB via laryngostroboscopic examination and direct laryngoscopy under general anesthesia were included in the study. Dr Speech software was used for acoustic analysis; mean fundamental frequency (fo), jitter %, shimmer %, and noise to harmonic ratio (NHR) were objectively measured and recorded. Voice Handicap Index-10 (VHI-10) was used for positive self-reporting of the severity of vocal symptoms. GRBAS scale (G: Grade, R: Roughness, B: Breathiness, A: Asthenia, and S: Strain) was also used (by the same clinician) for clinic subjective evaluation. Patient age ranged from 33 to 55 years and mean patient age was 42 years. Mean duration of symptoms was 22 months (range 16-30). Mean postoperative follow-up time was 14 months (range 6-24). Unilateral MB was observed in all patients (2 left, 3 right). There was a significant improvement in objective and subjective assessment methods in all our patients after surgery. According to the results of our few patients, MBR offers a physiological and anatomical approach to the treatment of patients with MB. The outcomes of delicate microlaryngeal surgery are promising.

Anatomia foliar e parâmetros fotossintéticos de Vellozia squamata Pohl (Velloziaceae) desenvolvendo-se sob diferentes intensidades luminosas ao longo do cultivo in vitro

ABSTRACT The present work evaluates photosynthetic parameters and the leaf anatomy of plants of Vellozia squamata Pohl (Velloziaceae) in each phase of in vitro production, with wild plants serving as a control. The anatomical approach was done for the leaf middle portion. The photosynthetic curves were obtained with an infra-red gas analyzer. The in vitro plantlets showed the thinner and poorest developed leaves, the wild plants had the thickest and most developed leaves, and the plants in acclimatization showed intermediate features. The physiological pattern was similar, and the in vitro plantlets were not capable of net carbon absorption. The young seedlings at the garden showed a maximal net carbon assimilation rate inferior to the wild plants. In conclusion, the light intensity for the in vitro phase should be adjusted to produce seedlings.

Anatomical approaches in locally advanced and recurrent pelvic malignancy

Pelvic exenteration is a complex, technically challenging procedure requiring detailed anatomical knowledge. Understanding the complexity of the pelvis beyond TME is an essential requirement for both operative planning and execution. This paper highlights the key anatomical approaches to extended pelvic resection as relevant to the Colorectal Surgeon.

A macroscopic anatomical study of the appropriate palpation zone of the gluteus medius muscle.

[Purpose] Few previous studies have delimitated the palpation zone of the gluteus medius muscle with a focus on its fiber bundles. The purpose of this study was to clarify the morphological characteristics of the gluteus medius muscle using an anatomical approach, and to define its proper palpation zone. [Participants and Methods] In this study, we evaluated thirteen halves of the pelvic region in seven formalin-fixed cadavers. We identified the borders between the iliotibial band and gluteus medius muscle, and between the gluteus medius and gluteus maximus muscles, on the iliac crest. Furthermore, we quantified the border points of the gluteus medius’ fiber bundles and observed its anatomical and morphological characteristics. [Results] We identified two fiber bundles in the gluteus medius muscle, an anterior and a posterior fiber bundle, and detected that a portion of the posterior fibers was located subcutaneously. [Conclusion] We propose that the region where the posterior fibers of the gluteus medius muscle are located subcutaneously is an appropriate zone for the palpation of this muscle.

Comparison of Paresthesia Mapping With Anatomic Placement in Burst Spinal Cord Stimulation: Long-Term Results of the Prospective, Multicenter, Randomized, Double-Blind, Crossover CRISP Study

ObjectivesSpinal cord stimulation (SCS) is an effective therapy for chronic intractable pain. Conventional SCS involves electrode placement based on intraoperative paresthesia mapping; however, newer paradigms like burst may allow for anatomic placement of leads. Here, for the first time, we report the one-year safety and efficacy of burst SCS delivered using a lead placed with conventional, paresthesia mapping, or anatomic placement approach in subjects with chronic low back pain (CLBP). Materials and MethodsSubjects with CLBP were implanted with two leads. The first lead was placed to cross the T8/T9 disc and active contacts for this lead were chosen through paresthesia mapping. The second lead was placed at the T9/T10 spinal anatomic landmark. Subjects initially underwent a four-week, double-blinded, crossover trial with a two-week testing period with burst SCS delivered through each lead in a random order. At the end of trial period, subjects expressed their preference for one of the two leads. Subsequently, subjects received burst SCS with the preferred lead and were followed up at 3, 6, and 12 months. Pain intensity (visual analog scale), quality-of-life (EuroQol-5D instrument), and disability (Oswestry Disability Index) were evaluated at baseline and follow-up. ResultsForty-three subjects successfully completed the trial. Twenty-one preferred the paresthesia mapping lead and 21 preferred the anatomic placement lead. Anatomic placement lead was activated in one subject who had no preference. The pain scores (for back and leg) significantly improved from baseline for both lead placement groups at all follow-up time points, with no significant between-group differences. ConclusionsThis study demonstrated that equivalent clinical benefits could be achieved with burst SCS using either paresthesia mapping or anatomic landmark-based approaches for lead placement. Nonparesthesia-based approaches, such as anatomic landmark-based lead placement investigated here, have the potential to simplify implantation of SCS and improve current surgical practice.

Thoracoscopic anatomical individual basilar segmentectomy.

Thoracoscopic anatomical single or combined anatomical individual basilar segmentectomy, including subsegmentectomy, is technically challenging due to variations and the deep location of vessels and bronchi in the parenchyma. However, the long-term perioperative outcomes of various anatomical subsegmentectomy approaches have not been reported. Thus, we investigated the effectiveness of thoracoscopic basilar segmentectomy. We evaluated the records of 119 patients who underwent thoracoscopic single or complex basilar segmentectomy between January 2005 and December 2020 and compared the fissure and non-fissure approach for S9 and/or S10. A total of 29 patients underwent single segmentectomy, and 90 patients underwent various combined anatomical segmentectomies via video-assisted thoracoscopic surgery and planning using three-dimensional simulation. There were 39 cases of S9 and/or S10 segmentectomy. The median chest tube in-dwell duration and postoperative hospital stay were 1 and 4 days, respectively. The postoperative morbidity (Clavien-Dindo grade II/IIIa) rate was 5.9% without perioperative mortality. Pathological examination revealed 83 cases of lung cancer, 21 cases of metastasis and 15 cases of benign lesions. The postoperative hospitalization duration showed significant differences in the perioperative outcomes between the fissure and non-fissure approaches for S9 and/or S10. Thoracoscopic anatomical basilar individual segmentectomy has emerged as a safe and feasible procedure. The non-fissure approach enabled anatomic resection of a single segment or combined basal segments, helped avoid dissection of an incomplete fissure and facilitated surgical outcomes similar to the fissure approach.

Brain Tumor Classification with Hybrid Algorithm Convolutional Neural Network-Extreme Learning Machine

Brain tumor is a disease that attacks the brains of living things in which brain cells grow abnormally in the area around the brain. Various ways have been done to detect this disease, one of which is through the anatomical approach to medical images. In this study, the authors propose a Convolutional Neural Network (CNN)-Extreme Learning Machine (ELM) hybrid algorithm through Magnetic Resonance Imaging (MRI). ELM was chosen because of its superiority in the training process, which is faster than iterative machine learning algorithms, while CNN was chosen to replace the traditional feature extraction process. The result is CNN-ELM, which has 8 filters in the convolution layer and 6000 nodes in the hidden layer, has the best performance compared to CNN-ELM another model which has different number of filters and number of nodes in the hidden layer. This is evidenced by the average value of precision, recall, and F1-score which is 0.915 while the accuracy of the test is 91.4%.

Pericardiocentesis Procedure: Anatomical Structures and Approaches

Knowledge of accurate surface anatomy is essential for safe clinical practice. Different views and opinions for clinically important surface markings exist between clinicians. Pericardiocentesis is performed as an emergency procedure in conditions aggravating cardiac tamponade. The approach of pericardiocentesis should be held by the hands of an experienced operator because of the surrounding relations. Nowadays, the introduction of imaging-guided procedures, especially echo-guided procedures, has significantly improved the safety and feasibility of pericardiocentesis and has provided the possibility of choosing the best anatomical approach among the apical, subcostal and parasternal approaches. This case report also emphasizes the importance of instillation of agitated saline as a supplementary technique while performing echo-guided pericardiocentesis in order to reduce the likelihood of cardiac chamber perforations.

Preoperative Classification System Used to Determine Release Performed during Endoscopic Brow Lift.

The techniques presented in article will allow the facial plastic specialist to use the anatomy of each individual patient as a guide for the surgical release of the brow performed during endoscopic brow lift. The author presents his 15 years of experience in which he developed this approach. Five different surgical releases of the brow will be demonstrated and discussed in terms of which patients would best benefit from which release. Adopting this approach has made the predictability of the authors brow lift results much better and therefore improved patient satisfaction. This concept has not been described in the literature and the author firmly believes using a preoperative anatomical approach is a better way to approach endoscopic brow lift surgery.

What an Interventionalist Needs to Know About INOCA.

Ischaemia with non-obstructed coronary artery disease (INOCA) remains a diagnostic and therapeutic challenge. An anatomical investigationbased approach to ischaemic heart disease fails to account for disorders of vasomotion. The main INOCA endotypes are microvascular angina, vasospastic angina, mixed (both) or non-cardiac symptoms. The interventional diagnostic procedure (IDP) enables differentiation between clinical endotypes, with linked stratified medical therapy leading to a reduced symptom burden and a better quality of life. Interventionists are therefore well placed to make a positive impact with more personalised care. Despite adjunctive tests of coronary function being supported by contemporary guidelines, IDP use in daily practice remains limited. More widespread adoption should be encouraged. This article reviews a stratified approach to INOCA, describes a streamlined approach to the IDP and highlights some practical and safety considerations.

International expert consensus on precision anatomy for minimally invasive pancreatoduodenectomy: PAM-HBP surgery project.

The anatomical structure around the pancreatic head is very complex and it is important to understand its precise anatomy and corresponding anatomical approach to safely perform minimally invasive pancreatoduodenectomy (MIPD). This consensus statement aimed to develop recommendations for elucidating the anatomy and surgical approaches to MIPD. Studies identified via a comprehensive literature search were classified using the Scottish Intercollegiate Guidelines Network method. Delphi voting was conducted after experts had drafted recommendations, with a goal of obtaining >75% consensus. Experts discussed the revised recommendations with the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. Three clinical questions were addressed, providing six recommendations. All recommendations reached at least a consensus of 75%. Preoperatively evaluating the presence of anatomical variations and superior mesenteric artery (SMA) and superior mesenteric vein (SMV) branching patterns was recommended. Moreover, it was recommended to fully understand the anatomical approach to SMA and intraoperatively confirm the SMA course based on each anatomical landmark before initiating dissection. MIPD experts suggest that surgical trainees perform resection based on precise anatomical landmarks for safe and reliable MIPD.

Clinician needs and perceptions about cardioneuroablation for recurrent vasovagal syncope: An international clinician survey.

Cardioneuroablation (CNA) targets the intrinsic cardiac autonomic nervous system ganglionated plexi located in the peri-atrial epicardial fat. There is increasing interest in CNA as a treatment of vasovagal syncope (VVS), despite no randomized clinical trial (RCT) data. The purpose of this study was to poll the opinion on CNA) for VVS. A REDCap (Research Electronic Data Capture) survey was administered to international physicians treating patients with VVS on their opinion about patient selection criteria, ablation approach, RCT design, and most appropriate end points for CNA procedures. The survey was completed by 118 physicians; 86% were cardiac electrophysiologists. The majority of respondents (79%) would consider referring a patient with refractory VVS for CNA, and 27% have performed CNA for VVS themselves. Most felt patient selection should require a head-up tilt test with a cardioinhibitory response (67%) and suggest a minimum age of 18 years with a median of 3 (interquartile range 2-5) episodes in the past year. There were differences in patient selection between physicians who have performed CNA themselves and those who have not. The majority felt that the ablation strategy should include both atria (70%) with an anatomical approach in combination with autonomic stimulation (85%). Performing a sham procedure in the control arm was supported by 56% of respondents, providing equipoise in RCT design. The preferred primary outcome was freedom from syncope within 1 year of follow-up. There is widespread support for well-designed RCTs to confirm the hypothesized clinical benefit of CNA, provide data to guide the risk-benefit equations during patient selection, and appropriately estimate the placebo effect.

Suboccipital Microsurgical Resection of Pediatric Ependymoma in the Foramen of Luschka: 2-Dimensional Operative Video.

Ependymoma tumors are the third most common pediatric brain tumor. They can be found along the entirety of the neuroaxis, but pediatric ependymomas are most commonly found in the posterior fossa.1 We provide videographic2 description of an anatomic approach to the foramen of Luschka in a pediatric patient through a redo suboccipital craniotomy. In this surgical video, we present a 5-yr-old patient with previously resected ependymoma with recurrence in the foramen of Luschka. The patient underwent microsurgical gross total resection of the ependymoma by using a suboccipital approach. He tolerated the surgery well with an uneventful postoperative course followed by radiation therapy. Regardless of molecular subgroup, numerous studies have shown that near or gross total surgical resection followed by radiation therapy provides the greatest progression-free survival.1,3-6 Ependymomas of the posterior fossa, particularly recurrences or second look resections, can present a challenge to the surgeon because of scarred tissue and precarious location along the brainstem and cranial nerves. Although it has been our institution's observation that these tumors are often debulked, it has been our experience that with an appropriate approach by anatomic dissection, near and gross total resections can be achieved safely and confidently by the surgeon and thus maximize the patient's potential for progression-free survival. The legal guardian of the patient in the presented operative case has given consent for publication of this operative video, and the patient's family provided consent to the procedure.

The Lymphatic System in Breast Cancer: Anatomical and Molecular Approaches.

Breast cancer is one of the most important causes of premature mortality among women and it is one of the most frequently diagnosed tumours worldwide. For this reason, routine screening for prevention and early diagnosis is important for the quality of life of patients. Breast cancer cells can enter blood and lymphatic capillaries, then metastasizing to the regional lymph nodes in the axilla and to both visceral and non-visceral sites. Rather than at the primary site, they seem to enter the systemic circulation mainly through the sentinel lymph node and the biopsy of this indicator can influence the axillary dissection during the surgical approach to the pathology. Furthermore, secondary lymphoedema is another important issue for women following breast cancer surgical treatment or radiotherapy. Considering these fundamental aspects, the present article aims to describe new methodological approaches to assess the anatomy of the lymphatic network in the axillary region, as well as the molecular and physiological control of lymphatic vessel function, in order to understand how the lymphatic system contributes to breast cancer disease. Due to their clinical implications, the understanding of the molecular mechanisms governing lymph node metastasis in breast cancer are also examined. Beyond the investigation of breast lymphatic networks and lymphatic molecular mechanisms, the discovery of new effective anti-lymphangiogenic drugs for future clinical settings appears essential to support any future development in the treatment of breast cancer.

A foreign body lodged in the sub-mental space through to the retro-pharyngeal area: a review of anatomical risks and surgical approaches

BackgroundForeign body inclusions are rare in head and neck. They are challenging in regard to anatomical risks and surgical approaches. This is the case of a particular foreign body with a curious trajectory, associated with a brief review of anatomical risks and surgical approaches.Case presentationThis is the case of a 25-year-old male who has been attacked with a sharp object, which caused an inclusion of a part of the foreign body in the sub-mental and pharyngeal areas.The clinical exam showed a painful bulging in the sub-mental area, with moderately hemorrhagic sputum and difficulty while swallowing. The intra-oral exam showed a foreign body that was located at the right side of the base of the tongue, and which goes backwards and outwards to penetrate retro-pharyngeal mucosa.The patients underwent an angio-CT scan, which showed a curious fine and sharp metallic object, without direct signs of lesions to the jugular vein or carotid artery or any collateral branches.The patient underwent extraction through cervical approach, with satisfying bleeding control. Intra-oral exploration showed a retro-pharyngeal lesion of 2 cm, without particular bleeding. The cervical lesion and retro-pharyngeal lesions were closed. The lesion at the base of the tongue was of 1 cm, palpable but not accessible to sutures, and a naso-pharyngeal tube was inserted.The patient presented very satisfying post-operative outcome, without any complications.ConclusionWhen dealing with foreign bodies of head and neck, physicians must be precocious and prepared for the risk of bleeding after extraction. Thorough radiological exploration is necessary as long as the patient is stable. Direct and indirect radiological signs allow the clinician to understand the nature and the trajectory of the object, as well as the damage to collateral structures.