Cephalic Direction Research Articles

NEEDLE RENAL LIFTING TECHNIQUE IN MANAGEMENT OF COMPLICATED PROXIMAL URETERAL LITHOTRIPSY: A CASE REPORT

Objective: To described a needle renal lifting technique using an 18-gauge needle to adjunct ureterorenoscopy (URS) in the management of complicated proximal ureteral stones. Case(s) Presentation: A 46 years old man presented with right flank pain for 1 month. This patient was diagnosed with ureteral stone and ureteral kinking that prohibits access to the proximal side of the ureter. Due to difficult access to the proximal ureter, we perform a needle renal lifting technique which is initialized by puncturing the middle renal calyx with 18-gauge needle. Then, the proximal end of the needle was pushed to the caudal direction to move the kidney to the cephalic direction and straighten the kinked ureter. After that procedure, the URS sheat can easily enter the proximal ureter to the stone site. Discussion: The success rate of this procedure is based on the operator skills to access the calyx and perform URS simultaneously. Like a previous technique, needle renal lifting is effective only when the kidney is mobile. Conclusion: The needle renal lifting technique can be used to adjunct URS in the management of complicated ureteral stones which prohibited access to the proximal ureter. 

Morphometric measurements of safety zones and orientation angles for freehand placement of revision screws in atlas lateral mass.

To demonstrate the possibility of revision screw placement to the atlas, as well as define the safety zones and orientation angles. This retrospective study analysed the records of four patients who were operated for AAI earlier. Because they needed revision of Atlas screws, they were re-operated after obtaining the measurements mentioned in this study. In addition, measurements of 50 healthy subjects were included in the study as the control group. Maximum screw lengths were also measured. Safe zone in the ideal sagittal direction were wider. As the screw projection becomes more cephalic direction in the sagittal plane, the safe zone for the screw becomes narrower. With the sagittal angle moving forwards cranially, the screw length becomes longer. Atlas lateral mass screws could be safely revised whenever needed. The fact that needs to be considered is that the angular range becomes narrower, and the screw length becomes longer when the screw is directed more cranially.

The originating pattern of deep inferior epigastric artery: anatomical study and surgical considerations.

Studies focusing on the originating patterns of the deep inferior epigastric artery (DIEA) have not been conducted. Here, we analyzed the vascular anatomy of the DIEA with computed tomographic angiography (CTA) to provide assistance during proximal pedicle dissection of a DIEA-based flap. We conducted a retrospective study on patients who had undergone breast reconstruction with the transverse rectus abdominis musculocutaneous flap and the deep inferior epigastric perforator flap from March 2006 to October 2016. Preoperative three-dimensional computed tomographic angiograms of the abdominal wall (hemi-abdominal walls) were employed in this study, and three independent surgeons reviewed all CTA images. The originating angles and the distance from the originating point to the DIEA turning point were analyzed. Moreover, we assessed the relationship between the measured values and patients' characteristics, such as abdominal surgery history. CTA data of 184 patients and 368 hemiabdomens were reviewed and analyzed. Most of the DIEAs originated from the external iliac artery in the medial direction, proceeded caudally, and curved in a cephalic direction. The average descending length was 11.29mm. As the DIEA origin angle decreased (toward the caudal direction), the distance of the initial descent increased (r = 0.382, p < 0.01). In addition, the descending length was significantly larger (p < 0.01) in the operation group (12.22mm) than in the non-operation group (9.86mm). Surgeons should consider DIEA-originating patterns to ensure safe pedicle dissection during flap elevation.

Abstract: Reconstruction of Nasal Tip Defects with Superior-Based Pedicle Nasolabial Island Flap

INTRODUCTION: Nasal tip reconstruction is a very challenging surgical procedure in aesthetic and reconstructive surgery.1,2 The main purpose of nasal tip reconstruction is to repair with similar texture tissues without disturbing facial aesthetics and function. In this study, reconstruction of the nasal tip defects with superior-based tunnellized pedicle nasolabial island flap is presented. METHODS: 10 patients who were operated for non-melanoma skin cancer including nasal tip area were included in the study. Patient’s medical records were reviewed, digital photography was taken before surgery. All of patients were assessed by detailed physical, ultra-sonographic, endoscopic nasal-airway examination. Each lesion was excised with at least 5mm margin. An elliptical-shaped superior pedicle nasolabial flap was designed based on angular artery. Pedicle of flap was dissected cephalic direction and subcutaneously to the superior of the defect area. The flap was moved to the defect by a tunnel. At the 12th month postoperatively, symmetry of nasal shape and face were evaluated with patient satisfaction scale (-1: not satisfied, 0: neutral, 1: moderate, 2: good, 3: very satisfied). RESULTS: 4 patients were male, 6 female and ages ranged from 61 to 83 years (mean 72.1). In all patients, there was no pathological lymph-node and no internal and external nasal valve dysfunction. Defects were between 4 cm2 and 7.56 cm2 after surgical excision. There were no infection, hematoma and total flap failure; but a partial (20%) flap necrosis due to venous congestion was seen in one diabetic patient and treated conservatively. None of the patients had sensory, speech, chewing and laughing problems after surgery. Temporary sagging of upper lip related to levator muscle damage was seen in one patient, but it improved at 6th month. Three patients were good and 7 patients were very good satisfied with nasal shape and face symmetry. Nine patients reported that the donor side of the face looked like younger than other; one of them didn’t. Nasolabial scar healed uneventfully in all patients. CONCLUSION: Various flaps have been defined for nasal tip defects.3 However, many flaps cause donor site morbidity, seconder intervention for defatting and revision, stage repair. Superior pedicle nasolabial island flap is an alternative flaps used in nasal reconstruction because of texture and color matching, minimal donor site morbidity, good and constant nutrition, safety and transportability to all nasal subunits. Reference Citations: 1. Nogushi M, Matsuo K, Hirose T. Reconstruction of short nose deformity using nasolabial flaps pedicled on the infraorbital vessels. Br J Plast Surg. 1991;44:567–569. 2. Turan A, Kul Z, Tu¨rkaslan T, et al. Reconstruction of lower half defects of the nose with the lateral nasal artery pedicle nasolabial island flap. Plast Reconstr Surg. 2007;119:1767-1772 3.Cox A, Fort M. Nasal Reconstruction Involving Multiple Subunit Defects. Facial Plast Surg. 2017 Feb;33(1):58–66.

Palpable Undescended Testes: 15 Years of Experience and Outcome in Laparoscopic Orchiopexy.

Most of the current literature concerning laparoscopy in patients with cryptorchidism reports on those with nonpalpable testes. The purpose of this study is to share our experience and outcome in laparoscopic orchiopexy on patients with palpable undescended testes. From January 1999 to July 2014, 240 cryptorchid testes were treated of which 192 (155 patients) were palpable and were operated on by laparoscopy. Before starting, the bladder is emptied with a Foley catheter. Four trocars are used: One 5 mm for the lens (45 degree), one 10 mm (transscrotal), and two 3 mm placed at the subcostal midclavicular line for the instruments. We localize the deep inguinal ring and open the peritoneum. The spermatic vessels and vas deferens are dissected in a cephalic direction. The epigastric vessels are dissected and sectioned to facilitate the localization of the testicle inside the canal. Once found, the testis is dissected and taken into the abdominal cavity where the gubernaculum testis is cut. A 10-mm trocar is introduced through the scrotal sac into the peritoneal cavity. The testicle is grabbed and pulled down to the scrotum where it will be fixed with a 5-0 polypropylene suture in the usual manner. Of 192 cryptorchid palpable testes treated with laparoscopy, only one procedure was converted to conventional open orchiopexy because of an ectopic testicle (above the aponeurosis of the oblique muscle). The rest of the testicles could be moved down to the scrotal sac. Our follow-up ranges from 6 months to 15 years, and we have not found atrophy in any of the testicles. To date, only two (0.4%) testicles have reascended. Laparoscopy is a great and safe option for patients with palpable undescended testes, regardless of its position in the inguinal canal.

A comparison of two techniques of uterine closure in caesarean section

Objective: To compare the results of two different techniques of uterine closure in caesarean section operations in which assistant surgeons participated.Methods: A total of 765 patients were separated into two groups.In Group1(n = 380), the assistant surgeon, while pulling the suture in a caudal direction with the left hand, held the uterine wall from the joined site with the right hand to prevent upward tension of tissue. In Group 2 (n = 385), the suture was placed by the assistant surgeon by pulling it in the cephalic direction with the right hand. These two techniques were evaluated in respect of the postoperative decrease in haemoglobin level ,the need for additional sutures and operative outcomes.Results: The need for additional sutures was determined as statistically high in Group 2 at mean 0.5 ± 0.6 compared to mean 0.2 ± 0.5 in Group1 (p < 0.001). The mean operating time was determined as statistically significantly longer in Group 2 (Group1, 38.0 ± 5.6 mins and Group2, 41.3 ± 4.3 mins) (p < 0.001). The postoperative decrease in hb was statistically significantly greater in Group 2 (Group1, 1.1 ± 0.4, Group2, 1.2 ± 0.4) (p = 0.002).Conclusion: The cephalic direction placement of the suture with the right hand of the assistant surgeon in uterine closure leads to bleeding due to tissue cuts in the lower wound lip and thereby creating a need for additional sutures. Therefore, the suture should be placed in a caudal direction with the left hand.

Anatomical considerations for transanal minimal-invasive surgery: the caudal to cephalic approach.

Nerve-sparing surgery during laparoscopic rectal mobilization is still limited by anatomical constraints such as obesity, the narrowness of the male pelvis, an ultra low rectal cancer or all of these. The transanal approach for total mesorectal excision has overcome the shortcomings of limited access to the rectal 'no-man's land' close to the pelvic floor. The aim of this anatomical study was to define a roadmap of anatomical landmarks for the caudal to cephalic approach so as to standardize nerve-sparing rectal mobilization procedures. Macroscopic dissections of the pelvis in a caudal to cephalic direction were performed in eight alcohol-glycerol embalmed cadavers. A roadmap of anatomical landmarks was created at different levels of section to demonstrate the sites of nerve injury. Extrinsic autonomic nerves to the urogenital organs and the internal sphincter muscle are closely adjacent to the lowest portion of the rectum above the pelvic diaphragm. This anatomical guide for the pelvic surgeon should facilitate a safe and nerve-sparing dissection of the mesorectal plane with a meticulous overview of the lowest autonomic nerve fibres. New anatomical insights by a 'caudal to cephalic' approach to the 'no-man's land' should help overcome anatomical constraints of a narrow, obese and male pelvis during rectal mobilization procedures.

Bloqueo infraclavicular continuo guiado por ultrasonido para cirugía de mano. Reporte técnico de la posición del brazo para la colocación del catéter perineural

BackgroundContinuous perineural infusion of local anaesthetic provides better postoperative analgesia than intravenous administration of opioids or NSAIDs in upper limb surgery. The infraclavicular approach is a good option, due to the muscular stability to catheter; the abduction of the arm apparently makes the brachial plexus more superficial and which elevates the clavicle in the cephalic direction. AimThe aim of this study was to identify whether the abduction of the arm decreases the skin-plexus distance, making the perineural insertion of the catheter easier and for a better analgesia. This relationship between the arm and the insertion of catheter has not yet been established. Material and methodsThe study included 58 adult patients, undergoing forearm and hand surgery, initially divided into two groups, adduction and abduction. Ultrasound-guided infraclavicular block was performed, enabling the catheter tip to be positioned adjacent to the posterior cord. The group of patients with high technical difficulties were allowed to reposition the arm abduction. A record was made of the number of punctures, redirects, ease of insertion of the catheter, and skin-plexus distance. ResultsThe abduction of the arm moved the clavicle towards the cephalad and separated it from the linear transducer, this allowed to manoeuvre the needle right angle and redirect it. The skin-plexus distance did not decrease significantly with arm position. ConclusionsArm abduction allows better scanning, facilitates the infraclavicular puncture, and catheter introduction.

Feasibility of Detection of the 3‐Vessel and Trachea View Using 3‐Dimensional Sonographic Volumes

The purpose of this study was to investigate the ability to depict the 4-chamber and 3-vessel and trachea views of the fetal heart using 3-dimensional sonography. Three-dimensional color Doppler volumes of the fetal heart were acquired prospectively in 31 fetuses between 19 and 25 gestational weeks. The initial plane consisted of the 4-chamber view. Postprocessing included navigation within the volume solely in plane A in the caudal direction to visualize the stomach and in the cephalic direction to the plane of the 3-vessel and trachea view to visualize the pulmonary artery, the aorta, the V shape and color of the arches, the superior vena cava, and the trachea. The feasibility of showing these organs was evaluated. The estimated time for volume acquisition and manipulation was about 60 seconds. The detection rates for the 4-chamber view, stomach, 3-vessel view, trachea, and V sign were 100%, 93.5%, 92.0%, 77.4%, and 83.9%, respectively, with interobserver agreement of 0.76 to 1.0. We describe a simple technique in which a single sweep on 3-dimensional sonography starting at the level of the 4-chamber view can visualize the situs, stomach, 4-chamber view, and transverse view of the outflow tracts of the heart.

Evaluation of pelvic morphology in the sagittal plane

Background contextIt is generally accepted that for normal subjects the angle of pelvic incidence (PI) increases during childhood and then remains unchanged throughout adolescence and adulthood. However, recent findings show that PI increases linearly throughout the lifespan due to morphological changes of the pelvis. PurposeA retrospective study aiming to determine the extent of morphological changes of the pelvis related to the age of the subjects. Study designPelvic morphology was evaluated in a normal adult population by measuring the anatomical parameters of sagittal pelvic alignment. Patient sampleThe final study cohort consisted of 330 subjects (mean age, 45.3 years; standard deviation, 18.1 years; range, 18–87 years; 164 male and 166 female subjects). Outcome measuresPhysiologic measures, obtained as measurements of PI, sacral end plate width (S1W), and pelvic thickness (PTH). MethodsParameters of PI, S1W, and PTH were evaluated from computed tomography images of the subjects. The measured PTH was normalized according to S1W and age of the subjects, allowing the comparison among anatomies of different sizes. The normalized components of PTH in anteroposterior and cephalocaudal directions were computed to determine the configuration and extent of changes in pelvic morphology related to subject age. ResultsStatistically significant correlation with both age and PI was obtained for all normalized parameters (except for the anteroposterior component of PTH for male subjects), and no statistically significant differences were observed between the sexes. With increasing PI that occurs due to the aging process, a decrease of PTH can be observed that is manifested not only as an increase of the distance between the sacrum and the hip axis in the anterior direction but considerably more as a decrease of the distance between the sacrum and the hip axis in the cephalic direction. By considering these morphological changes in the pelvis simultaneously, the hip axis can move only within a narrow area. ConclusionsThe changes in pelvic morphology due to the aging process occur in the anterior direction, which may be due to the remodeling process affecting the coxal bone that results in an anterior drift of the acetabulum relative to the sacrum. More importantly, the changes are considerably more evident in the cephalic direction, which may be the result of the weight-bearing loads and consequent wear of acetabular cartilage.

V1723 UPPER CALYXES PERCUTANEOUS ACCESS USING THE RENAL DISPLACEMENT WITH THE 18-GAUGE PUNCTURE NEEDLE

You have accessJournal of UrologyTransplantation and Urolithiasis1 Apr 2013V1723 UPPER CALYXES PERCUTANEOUS ACCESS USING THE RENAL DISPLACEMENT WITH THE 18-GAUGE PUNCTURE NEEDLE Mohammed Lezrek, Khalil Bazine, Mounir Drissi Touzani, and Amoqurane Beddouch Mohammed LezrekMohammed Lezrek Meknes, Morocco More articles by this author , Khalil BazineKhalil Bazine Meknes, Morocco More articles by this author , Mounir Drissi TouzaniMounir Drissi Touzani Meknes, Morocco More articles by this author , and Amoqurane BeddouchAmoqurane Beddouch Meknes, Morocco More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2924AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We present a video of our experience of percutaneous renal upper pole access using a percutaneous renal displacement technique, to render the superior calyx reachable below the 11th rib. We describe a renal displacement technique using an 18-gauge needle, and its use in different situations. METHODS The needle renal displacement technique is performed under fluoroscopic guidance, with the X-ray beam perpendicular to the tract. Initially, a lower or middle calyx is punctured with an 18-gauge diamond-tipped needle. A stiff-shaft hydrophilic guidewire is inserted to protect urothelium from the needle-tip. The needle's proximal-end is progressively pushed in the cephalic direction. Consequently, the kidney is displaced caudally, by the lever manoeuvre. Secondly, the upper pole calyx is punctured, for tract formation. RESULTS Renal displacement has always been possible in kidneys with no surgical history. However, it failed when the kidney was fixed by post-surgical-adhesions. A caudal renal displacement, of many millimeters to few centimeters, is gained. There is also a slight inversion of the normal axis of the kidney. The renal upper pole becomes more accessible to puncture below the 11th-rib or even the 12th-rib, so decrease of intra-thoracic morbidity. This technique has also been used to immobilize mobile kidneys or to reorient complex malrotated kidneys. CONCLUSIONS percutaneous needle renal displacement technique may render the superior calyx more available while avoiding or decreasing intra-thoracic complications, but are effective only when the kidney is mobile. This technique can be used to perform some calyx reorientation and to fix very mobile kidneys. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e708 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mohammed Lezrek Meknes, Morocco More articles by this author Khalil Bazine Meknes, Morocco More articles by this author Mounir Drissi Touzani Meknes, Morocco More articles by this author Amoqurane Beddouch Meknes, Morocco More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Right-sided aortic arch with the retroesophageal left subclavian artery as the fourth branch

We present a rare variation of the right-sided aortic arch with the retroesophageal left subclavian artery as the forth branch found in a cadaver of an 89-year-old Korean woman during a routine dissection. In this case, the first branch that arose from the ascending aorta was the left common carotid artery, which crossed ventral to the trachea in a left cephalic direction, followed by the right common carotid artery and then the right subclavian artery. Distal to these branches the aortic arch ran dorsally, passing between the esophagus and the vertebra. The left subclavian artery arose from the descending portion of the aortic arch, crossing over to the left upper extremity behind the esophagus. This anomaly was not accompanied by congenital heart disease. Accurate information regarding this variation is of great importance to surgeons for its early identification and preservation during interventions and to radiologists for precise interpretation of angiograms.

Needle Renal Displacement Technique for the Percutaneous Approach to the Superior Calix

We describe a new renal displacement technique using an 18-gauge needle to facilitate superior calix puncture and consequently to decrease intrathoracic morbidity. Initially, a lower or middle calix is punctured with an 18-gauge needle. Then, the proximal end of the needle is progressively pushed in the cephalic direction. Therefore, the kidney is pushed caudally by the lever maneuver. This technique has also been used to immobilize the kidney or to reorient complex and malrotated kidneys.

Ultrasound and MRI Prenatal Diagnosis of Esophageal Atresia: Effect on Management

Ultrasound and MRI Prenatal Diagnosis of Esophageal Atresia: Effect on Management

Transvaginal endoscopic cholecystectomy using a simple magnetic traction system

Natural orifice transluminal endoscopic surgery (NOTES) is still at an early stage of clinical development. The development of new instruments is required to overcome some of the current limitations of NOTES. We thus performed transvaginal endoscopic cholecystectomies to determine the feasibility of using a magnetic traction system. Experiments were performed in a non-survival porcine model (n = 4). The magnet-fixed endoscopic clip was attached to the apex of the gallbladder fundus and held together with the external handheld magnet across the abdominal wall. The gallbladder fundus was then retracted to the cephalic direction by moving the external handheld magnet and the gallbladder was dissected from the liver bed. The gallbladder was placed in the endocatch material and delivered through the vagina. NOTES cholecystectomies via the transvaginal approach were successfully performed in a porcine model. The magnetic traction system was effective in achieving adequate exposure in all pigs. The magnetic traction system provides vigorous, multi-axial traction as required for the cholecystectomy procedure. There were no complications during the procedure other than minor bleeding from the liver bed. The mean procedure time was 133.8 minutes (range, 105 to 175 minutes). Our study successfully demonstrated the feasibility of the magnetic traction system in NOTES.

P08.03: Detection of the ‘3VT view’ using 3D ultrasound volumes acquired at the level of the ‘4CV’

Objectives: The four-chamber view (4CV) detects about 30% of major cardiac anomalies. Adding the outflow tract and the three-vessel trachea view (3VT) improve the detection of cardiac anomalies. 3-Dimensional ultrasound (3DUS) is more available than 4-Dimensional ultrasound for cardiac examinations. The aim of this study is to investigate the ability to demonstration of the 3VT of the fetal heart with 3DUS, and to test the reliability of the measurements of the arches. Methods: Prospective study of normal fetal heart volumes, acquired at the second trimester of gestation by 3DUS with color Doppler. Post processing off line manipulation of the volumes to demonstrate the 3VT view by two expert sonologists. The ‘V’ shape of the arches, the color of flow and the place of the trachea and superior vena cava were evaluated. Measurements of the aorticand ductal-arch diameter were calculated and compared to the value from literature of 2-Dimension ultrasound. Intraand inter-observer variability was calculated. Results: 31 healthy patients with normal fetuses by anomaly scan were evaluated prospectively. Mean gestational age was 22w6d (range 19w4d–25w0d). Navigation in the cephalic direction revealed the 3VT view in 87–90% by the two reviewers. Mean and 95CI diameter of the aortic and pulmonary arteries are presented in Table 1. The estimated time for volume acquisition and manipulation in the A plane is about 60 seconds. Conclusions: Combination of basic knowledge of 3DUS and demonstration of 4CV allows extension of the cardiac examination to the 3VT view in about 90% of cases. Information of the number of vessels, shape, diameter, flow direction and the relation of the two arches is collected with simple sonographic method.

Transient phrenic nerve paralysis after carotid endarterectomy in a patient with asthma

To the Editor: Transient phrenic nerve paralysis occurred in a patient with asthma after carotid endarterectomy (CEA). The patient, a 64-year-old male with a height of 164 cm and weight of 69 kg, had been suffering from asthma for 15 years for which he was taking 400 mg of theophylline daily. A respiratory examination showed a reduced percentage forced expiratory volume in 1 second (%FEV1.0: 61.2%), and he was assigned to class II in Hugh–Jone’s classification. The patient was scheduled for CEA due to cerebral infarction with left lower extremity paralysis and transient dizziness 1 year earlier. With respect to the patient’s positioning during surgery, the anterior edge of the skin on the sternocleidomastoid muscle was located at the highest point by placing a shoulder pillow under the right shoulder in the supine position and rotating the head 30 to the left side; the jaw was tracted in the cephalic direction and the right shoulder was also tracted in the caudal direction. Anesthetic management was performed without difficulty for 4 h and 2 min, and surgery was completed without complications in 2 h and 43 min. Since the neurosurgeons were concerned about possible respiratory disorders, such as atelectasis, due to the patient’s asthma and wanted to ensure that there was no problem, they requested an X-ray before extubation. The post-operative X-ray revealed right diaphragm elevation at the end-inspiratory phase during spontaneous breathing (Fig. 1). Since there were no problems in emergence from anesthesia or in respiratory functions, such as blood gas data or respiratory pattern or tidal volume, extubation was attempted in the sitting position. There was also no respiratory disorder after extubation. Diaphragm elevation was improved the next day. Post-operative transient phrenic nerve paralyses mainly occur after cardiac surgery due to direct injury or hypothermia, mainly on the left side, and can be caused after other surgery due to traction or compression caused by the patient’s position [1, 2]. Unilateral diaphragmatic paralysis in adults generally has minimal symptoms or no symptoms, but bilateral or unilateral diaphragmatic paralysis in children can cause serious medical problems [1, 3]. The cause in the patient described here is thought to be traction by the head position. Although extubation was performed in the sitting position because of the possibility of respiratory disorder caused by unilateral phrenic nerve paralysis with asthma, there was no problem in the respiratory system after extubation. In the present case, a post-operative X-ray, which was taken because the patient had asthma, revealed, by chance, transient phrenic nerve paralysis. However, X-rays are not standard procedures following CEA in many institutions. Presented at the Annual Meeting of the Japan Society for Clinical Anesthesia, Osaka, October 24, 2004.

Reply

Sir: We thank Drs. Hubmer and Feigl for their comments. We are well aware of the classic description of branches of the lateral circumflex femoral artery system. We agree that, based on these descriptions, the oblique branch could perhaps have been a low-lying transverse branch. In fact, that was our initial conclusion when we first noticed this vessel many years ago. However, with careful analysis and experience, it is quite clear that this vessel is not the transverse branch but a new vessel that we have called the oblique branch of the lateral circumflex femoral artery.1 As demonstrated in our article, from the standpoint of the use of the anterolateral thigh fasciocutaneous or myocutaneous flap, it is a vessel of profound clinical significance.2 The description of a “new” branch of the lateral circumflex femoral system is a responsibility that we do not take lightly. Accordingly, we have performed cadaver dissections to meticulously study the lateral circumflex femoral system before performing the clinical series (Fig. 1). Having performed the anatomical study and with the benefit of an extensive experience with the anterolateral thigh flap, a prospective clinical study was performed. The benefits of a clinical study over a cadaver study are that in addition to noting its prevalence, the reliability of the oblique branch as the flap pedicle and adequacy for microsurgical anastomoses can be evaluated conclusively. We found in our study that the oblique branch is present in 35 percent of cases and originates most commonly from the descending or the transverse branch (88 percent). The transverse branch, in contrast, is always present and identified when we traced the flap pedicle to its origin at the lateral circumflex femoral artery (i.e., it is never missed as the authors erroneously suggested).1 Finally, one only has to note the occasional “extreme” cases encountered to be convinced that the oblique branch exists (Figs. 2 and 5).1Fig. 1.: Photograph of a cadaver specimen showing an oblique branch arising from the descending branch of the lateral circumflex femoral artery. As demonstrated here, the oblique branch is an additional vessel that may be present in the lateral circumflex femoral system. The transverse branch, which is always present, is limited to the proximal thigh and runs in a more transverse and cephalic direction. LCFA, lateral circumflex femoral artery; TFL, tensor fasciae latae.Multiple types of the so-called anatomical variation of the anterolateral thigh flap have been described.3–5 Much of the past confusion regarding the surgical anatomy and failure of the anterolateral thigh flap could now be attributed to the unrecognized presence of the oblique branch of the lateral circumflex femoral artery. The description of the oblique branch is a certainly a step forward in our understanding of the surgical anatomy of the anterolateral thigh flap. To question its existence would take us back into the confusion that was so pervasive before. From a surgical standpoint, knowing that either the descending or the oblique branch of the lateral circumflex femoral artery can be used as the flap pedicle is a psychological breakthrough and liberates one from the need to base the flap on the descending branch in every case. It encourages the move away from the conventional approach to flap harvest to one that embraces the free-style approach.6 Chin-Ho Wong, M.R.C.S.(Ed.), F.A.M.S.(Plast. Surg.) Department of Plastic, Reconstructive, and Aesthetic Surgery Singapore General Hospital Singapore Fu-Chan Wei, M.D. Department of Plastic Surgery Chang Gung Memorial Hospital Taoyuan, Taiwan DISCLOSURE Neither of the authors has a financial interest in any of the products, devices, or drugs mentioned in this reply or the article being discussed.

Malposition of subclavian vein catheter inserted through indirect technique in a pediatric liver transplantation: a case report

IntroductionClinicians use either direct or indirect (Seldinger) techniques for internal juguler or subclavian vein catheterization. This report aims to point out that the success rate of the direct technique where the catheter is inserted directly through the cannula may be higher particularly in catheterization of pediatric cases.Case presentationA 7.5-month-old female infant weighing 7200 gm was operated on for liver transplantation. The patient suffered jaundice at one month of age and was diagnosed with neonatal colestatic hepatitis. After routine monitoring, via indirect technique, central catheterization was attempted through internal jugular vein. However, the attempt failed. Therefore, again via indirect technique, catheterization was achieved through the right subclavian vein and fixed at 8 cm. After the operation started, fluid replacement and central venous pressure monitoring were performed with this catheter. Immediately after the operation, a control postero-anterior chest radiograph of the patient was obtained. This graph revealed that the tip of the catheter was fixed in the right internal jugular vein. Since the vital symptoms of the patient were not stable, the catheter was not removed and fluid replacement was performed via this technique. The catheter was removed on the postoperative 2nd day.ConclusionThe J wire advanced via the indirect technique advances anatomically following the upper wall of subclavian vein. Because of the smaller vessel dimensions and sharper, more angulated routes the subclavian and internal jugular veins make in infants, the rigid J wire may advance in the cephalic direction. However, in the technique where the catheter (Cavafix ® catheter) is inserted directly through the cannula, this probability is less since J wire is not used and the catheter employed is flexible. We concluded that especially in pediatric cases, employment of the technique where the catheter is inserted directly through the cannula would be more convenient in order to decrease the catheter malpositioning probability.

Abstract No. 354: Does Tip of the Implantable Port Catheter Really Migrate to the Cephalic Direction Dragged by Downward Force of the Implantable Venous Access Port in Upright Position?

To reassess whether catheter tip of the implantable venous access port really migrates to the cephalic direction dragged by downward force of the port in upright position. A total of 87 patients who underwent placement of the port through internal jugular vein under fluoroscopic guidance were included in this study. There were 36 men and 51 women, aged 54.4 years (range, 23-76 years). The catheter position was evaluated on the image obtained in the supine position during the procedure and chest radiograph in the upright position just after the procedure. In each position, we calculated the vertical distance from the highest point of the catheter to the catheter tip (long segment) and point of port and catheter (short segment) junction. We drew a horizontal line crossing the upper margin of the transverse process of the first thoracic spine and measured the vertical distance from the line to the highest point of the catheter. Difference in magnification on both images was corrected by measurement of the height of the first 3 thoracic vertebral bodies including disc spaces. Length differences of matching two segments in each position were attained. Correlation analysis was used to demonstrate statistical significance. Vertical lengths from the first thoracic spine to the long and short segments increased by 10.3mm±7.37 and 15.3mm±2.12, respectively. They showed statistically significant (r=-0.425, p<0.01) proportional increase in length. The highest point of the catheter moved downward an average of 12.75mm±1.78 in the upright position. This tendency did not change according to sex or side of insertion. The length of the implantable port catheter tip from the highest point actually increased in the upright position rather than being dragged and shortened by the downward migration force of the port. We presume that both segments of the catheter simply appear to have moved downward in the upright position due to gravitational effects and redundant soft tissue of the anterior chest wall.