Detailed Surgical Anatomy Research Articles

Left Internal Mammary Artery Operative Topography for MIDCAB and TECAB Procedures.

The left internal mammary artery (LIMA) is a common arterial graft in minimally invasive coronary surgery (MICS), such as minimally invasive coronary artery bypass grafting (MIDCAB) or totally endoscopic coronary artery bypass (TECAB). The aim of this study was to perform an analysis of the LIMA operative topography during MICS. A total of 104 computed tomography angiographies were analyzed retrospectively using 3-dimensional reconstruction and visualization software. Measurements were developed in relation to the anatomical midpoint of the sternal body (SBMP). Parameters were evaluated as lengths, distances, diagonals, or categorical descriptions. A total of 208 internal mammary arteries of each side were analyzed with the following results: (1) LIMA width = 2.7 mm, (2) SBMP-LIMA bifurcation length = 6.2 cm, (3) SBMP-LIMA distance = 3.2 ± 0.5 cm, (4) xiphoid midpoint-LIMA distance = 3.5 ± 0.7 cm, (5) sternal line-LIMA distance = 1.7 ± 0.3 cm, (6) xiphoid end projection-LIMA bifurcation length = 2.2 ± 1.0 cm, (7) midsternal line-LIMA bifurcation distance = 3.3 ± 0.8 cm, (8) xiphoid end-LIMA bifurcation diagonal = 4.1 ± 0.9 cm, (9) LIMA-left coronary artery distance = 7.0 ± 1.4 cm at the proximal and 7.1 ± 1.3 cm at the distal segment, and (10) LIMA-left anterior descending artery distance = 5.5 ± 1.1 cm at proximal, 4.3 cm at middle, and 4.2 ± 1.5 cm at distal segment. The extent of LIMA bifurcation ranged from the level of 5 (1%) to 7 (6%) rib cartilages. Based on the detailed surgical anatomy of LIMA, it was concluded that the fourth intercostal space should be considered as an appropriate approach for MIDCAB or TECAB in the studied region.

Implementing Live Virtual Surgery in the COVID Era: Overcoming Medicolegal, Technical, and Educational Hurdles.

Due to current health concerns related to the coronavirus disease of 2019, remote learning has been adopted at every academic level. In congruence with policies drafted by academic surgical societies, a majority of medical schools nationwide have decided against accepting visiting medical students.1,2 As such, there has been an emergence of virtual adaptations of educational sessions and clinical rotations across a variety of medical specialties.3,4 Because surgical education occurs primarily in the operating room, adopting a virtual model for surgical education presents distinct challenges. At the Yale School of Medicine, we designed the first virtual surgical rotation format to center around livestream plastic surgeries across key areas of the specialty.5 Successfully implementing this teaching modality required overcoming medicolegal challenges, the logistical and technical details involved in the creation of this educational modality, and educational hurdles. In coordination with the Yale School of Medicine and the Yale Graduate Medical Education office, the virtual rotation was registered as a formal course for credit through the Association of American Medical College’s Visiting Student Application Service, identical to in-person visiting electives. By formally registering for the virtual rotation through the Visiting Student Application Service, virtual rotators met the same medical malpractice liability coverage and Health Insurance Portability and Accountability Act requirements as in-person rotating subinterns. Many of the participating students used the virtual rotation toward clinical credit for their graduation requirements. In addition, patients completed written consent forms for the hospital and university, giving permission to livestream surgery. (See Document, Supplemental Digital Content 1, which shows the photographic consent form for patients agreeing to participate in the livestream surgery, https://links.lww.com/PRS/E735.) These steps enabled clinical information to be shared freely with students in a remote learning environment. The technical challenges included high-quality visual capture of the surgery, real-time transmission to enrolled students, and real-time interactive communication between students and the surgical team. For image capture, we utilized a high-definition resolution, loupe-mounted camera with two-times and three-times magnification options. Loupe magnification enabled optimal macro image transmission for viewing of detailed surgical anatomy. For more macroscopic surgeries, a nonmagnified camera would be preferable. The high-definition camera captured images onto a computer that livestreamed images to the virtual participants using a Zoom platform (Zoom Video Communications, San Jose, Calif.) with password protection. To enable real-time two-way communication, speakers were strategically placed in the operating room to allow faculty and students to continuously discuss the case (Figs. 1 and 2).Fig. 1.: Setup of the live-stream surgery, with images transmitted to participants via Zoom, with password protection and communication between surgeon and applicants in real time.Fig. 2.: High-definition resolution, loupe-mounted camera was used for the video streaming of the procedures from the surgeon point of view.The virtual surgery curriculum included one live surgery per day spanning the breadth of plastic surgery, which replicated many of the benefits of being physically present in the operating room. Students could view a surgery step by step from the attending’s viewpoint. In addition, a multitude of students can simultaneously participate in the same case, unlike with in-person rotations. Participants were able to reference case-relevant study materials during the operation, which may enhance understanding of the procedure. The development of live virtual surgery poses some initial challenges, but ultimately it can be replicated with ease to create a surgical rotation more authentic to the in-person experience as pandemic restrictions continue. By elucidating the process by which we implemented livestreamed surgeries, other interested institutions will be able to easily traverse the necessary medicolegal and technical aspects of constructing similar models.

Surgical anatomy of the transcanal infracochlear approach.

The objective of this study is to describe the detailed surgical anatomy of the infracochlear approach to prevent complications and to compare the postauricular transcanal microscopic and endoscopic approaches to reach the petrous apex. Cadaver heads were dissected using a binocular surgical microscope, endoscopes, and an electric drill. The dimensions of the access field that could be reached and manipulated with surgical instruments and straight drill via postauricular transcanal microscopic and endoscopic approaches were evaluated. Both postauricular microscopic and transcanal endoscopic approaches were considered to be inapplicable in cases with a tympanic cavity located jugular bulb closer than 3mm to the cochlea. This relationship was seen in 3 (9%) sides of the cadavers. In 4 specimens (12%), a cochlear aqueduct with an open lumen was detected. Both postauricular microscopic and transcanal endoscopic approaches reached a nearly identic dissection area. Detailed anatomy of the approach and measurements about the topography of the third portion of the facial nerve from the tympanic cavity were presented. Both traditional microscopic postauricular and endoscopic transcanal approaches provided comparable access areas to the inferior petrous apex with wide exposure, and radiologic measurements were compatible. A tympanic cavity located jugular bulb in close relation with cochlea was the only instance that restricted the applicability of this technique.

Depiction of detailed surgical anatomy and CSF flow information using a single MRI technique

We describe a novel MRI sequence (T2 SPACE) capable of demonstrating detailed structural anatomy and functional CSF flow information simultaneously. While traditionally, a variety of sequences are utilised for this purpose, we have highlighted the advantages of this technique over traditional approaches, using example of a patient with CSF loculation in prepontine/suprasellar cistern, causing third ventricular compression and hydrocephalus. The sequence depicted the surgical anatomy by showing the web/cyst wall as well as CSF flow entering the cyst potentially causing increased pressure.

Surgical anatomy of the breast revisited

With the advent of breast conservation options in the 1970s, as well as wider acceptance of breast reconstruction in cancer patients in 1980/1990, ending up with evolution of oncoplastic concepts in the early 2000s, detailed surgical anatomy of the breast became important. This short article reviews surgical anatomy of breast with particular emphasis on innervation and blood supply to the skin and nipple-areolar complex, as well as points out the concept of compartmental breast cancer anatomy. Meticulous dissection and avoidance of transection of major vessels and nerves constitutes the crucial factor for satisfactory results of surgery in terms of preservation of sensation as well as appropriate vitality of skin.

Surgical Anatomy of the Human Round Window Region: Implication for Cochlear Endoscopy Through the External Auditory Canal.

To enable development of an endoscope for cellular-level optical imaging of the inner ear. A prospective study of 50 cadaveric human temporal bones to define detailed surgical anatomy of the round window (RW) region and the range of angles necessary to reach the RW membrane perpendicularly via the external ear canal. The transcanal angle to the RW membrane was surgically measured in 3D intact specimens, and correlated with the angle calculated from temporal bone computed tomography (CT) scans of the same specimens obtained before and after measurements in situ. Surgically measured transcanal angles to the RW membrane correlated well with the radiographically measured angles. The angles ranged from 110 to 127 degrees, with the median of 115 degrees and the middle 50% ranging from 109 to 119 degrees. Four temporal bones were excluded because of pathology. The opening of the RW niche was located posteriorly in six bones (13%), inferiorly in 18 bones (39%), and postero-inferiorly in 22 bones (48%). The angles were not statistically different among the three orientations of the RW niche. By correlating measurement from cadaveric human temporal bones and their CT scans, we defined key parameters necessary for designing an endoscope for intracochlear imaging using a minimally invasive approach through the external auditory canal. The excellent correlation between the measurement on the CT scan and the actual shape of the probe that was able to reach the RW through the ear canal enables selection of the probe using the CT data.

Detailed Surgical Anatomy of Prostate: Relationship between Urethra and Dorsal Vein Complex with Apex

Aim: To describe our surgical technique for dissecting the apex of prostate during robotic-assisted laparoscopic radical prostatectomy (RALP) and detailed surgical anatomy of prostate including relationship between urethra and dorsal vein complex with apex. Materials and Methods: In retrospective view of prospective collected data, 73 patients underwent RALP between December 2012 and September 2014. Surgical anatomy of prostate was revealed in all procedures. Quality of life (QoL) scores were assessed before, immediately after catheter removal, and 1 month after surgery. We divided urinary continence into 3 groups, as very early continence; continence at time of urethral catheter removal, early continent; and continence 1 month after surgery. The rest of the patients were accepted as continence. Results: The mean follow-up was 10.2 ± 5.4 months and mean age was 61.5 ± 6.6. Maximum protection of urethra could be provided in all. Mean catheter removal was 8.9 ± 1.7 days, and all patients were continent at the time of catheter removal. QoL scores before RALP could be protected after surgery (p = 0.2). Neither conversion to open/conventional laparoscopic surgery nor complications related with bladder neck were detected. Conclusions: Our surgical technique can be a strong candidate for being a surgical technique for preserving urethra and very early continence could be provided after surgery.

Endovascular Embolization of Iatrogenic Vertebral Artery Injury During Anterior Cervical Spine Surgery

Case description. To report 2 cases of vertebral artery injury (VAI) during anterior cervical decompression surgery and review the pertinent medical literature. The incidence of VAI during an anterior surgical approach to the cervical spine is rare but potentially lethal. The spine surgeon should be aware of the detailed surgical anatomy and be prepared to manage an inadvertent injury to the vertebral artery. In the first case presented, infection was the cause of VAI. During aggressive irrigation and pus drainage, massive bleeding was encountered. For the second case, the vertebral artery was injured during decompression of cervical spondylosis while drilling the neural foramen. Intraoperative direct packing with hemostatic agents provided effective control of hemorrhage. Ten days after surgery, sudden neck swelling and mental deterioration occurred because of rebleeding from a pseudoaneurysm in the first case. In the second case, a pseudoaneurysm was detected by angiography, obtained 4 days after surgery. Both pseudoaneurysms were successfully occluded by an endovascular technique without any neurologic sequelae. In case of bleeding control by hemostatic packing, there remains a risk of delayed hemorrhage from pseudoaneurysm. Postoperative vertebral angiography is helpful to avoid life-threatening complications. Endovascular treatment can be a good alternative in the treatment of VAI.

Surgical Anatomy of the Innervation of the Major Duodenal Papilla in Human and Suncus Murinus, From the Perspective of Preserving Innervation in Organ-saving Procedures

Few studies have focused on the detailed surgical anatomy of the innervation of the major duodenal papillary region, especially in relation to duodenum-preserving pancreatic head resection (DPPHR) and its modified procedures, which is crucial to preserving the innervation of the papillary region. The aim of this study is to clarify the neural distribution of the major duodenal papilla in humans. The pancreas, duodenum, and surrounding structures were dissected in 10 cadavers and immersed in a 0.001% solution of alizarin red S in ethanol to stain the peripheral nerves. The details of the innervation in the above areas were confirmed using a binocular microscope. Similarly, the distribution in 10 Suncus murinus was examined by whole mount immunohistochemistry method with antineurofilament protein antibody. The innervation of the papillary region in humans involved 2 systems. One arose from the celiac plexus, which through the anterior hepatic plexus running along the arcades of the superior pancreaticoduodenal arteries and through the posterior hepatic plexus running along or accompanying the common bile duct (CBD) or Wirsung's duct, innervated the papillary region. The other arose from the superior mesenteric plexus wound around the arcades of the inferior pancreaticoduodenal arteries innervating the papillary region. The results in S. murinus supported those in humans. We emphasize the importance of the nervus-preserving of the major duodenal papilla and CBD by a suitable pancreatic head remnant, preserving the pancreaticoduodenal arterial arcades and avoiding kocherization of the CBD in DPPHR and its modified procedures.

Extrafascial excision of the rectum: surgical anatomy of the fascia propria.

It is now agreed that it is of vital importance to maintain the fascia propria as an intact envelope around the mesorectum to prevent tumor spillage while performing rectal excision for cancer. There are several surgical techniques described to achieve an intact fascial envelope, each arising from differing descriptions of the fascia propria of the rectum. The aim of this study was to describe the detailed surgical anatomy of the fascia propria. Thirteen rectal specimens surgically removed by the technique of extrafascial excision were subjected to gross inspection, dissection, and histologic and electron microscopic examination. The attachments, thickness, and composition of the fascia propria were determined. The fascia propria is a continuous fascial sleeve surrounding the rectum and mesorectum that can be dissected as a complete "sock" off a fresh extrafascial specimen. It is 154 (+/- 1 standard deviation = 61-391) microm thick, is thinner anteriorly than posteriorly (P < 0.05), and is composed predominantly of collagen. It can be identified surgically at the pelvic brim as a shiny membrane and lies inside the hypogastric nerves and the pelvic plexuses. The fascia propria forms a sleeve around the mesorectum, offering a surface against which to dissect, enabling safe removal of the rectum with its intact mesorectum while preserving the autonomic nerves of the pelvis. The term "extrafascial excision" highlights the importance of the fascia propria in this operation.

Study of surgical anatomy for duodenum-preserving resection of the head of the pancreas.

The authors precisely examined the topography of the duodenum, pancreas, bile duct, and supplying vessels from the perspective of performing duodenum-preserving resection of the pancreatic head. Little has been reported regarding the detailed surgical anatomy that is crucial in this procedure. The authors precisely examined the local anatomy of the pancreas head and duodenum, using materials from 40 autopsy cases. Arcade formation between the anterior superior pancreaticoduodenal (ASPD) artery and the anterior inferior pancreaticoduodenal (AIPD) artery was found in all of the cases. After departing from the gastroduodenal artery, the ASPD ran toward a point 1.5 cm below the papilla of Vater, then turned to the posterior aspect of the pancreas to joint the AIPD. In 88% of the cases, an arcade was found between the posterior superior pancreaticoduodenal (PSPD) artery and the posterior inferior pancreaticoduodenal (PIPD) artery. The ASPD, AIPD, PSPD, PIPD, or their branches to the duodenum, the bile duct, and the papilla of Vater were not completely buried in the pancreatic parenchyma in any of these cases. Generally, it was easy to dissect the pancreas from the duodenum because of the loose connection. Near the accessory papilla, however, dissection of the vessels was difficult, and the pancreatic parenchyma sometimes was found in the wall of the duodenum. Dissection of the pancreas from the common bile duct and identification of the main pancreatic duct at the junction with the terminal portion of the bile duct were straightforward in all cases. It may be possible to remove the head of the pancreas while preserving of the vascular arcades and their branches to the duodenum, the bile duct, and the papilla of Vater.

Reducing lingual nerve damage in third molar surgery: a clinical audit of 1350 cases.

Several publications reporting lingual nerve damage in the region of 11% caused the author to undertake a retrospective personal clinical audit of 100 cases which demonstrated a comparable complication rate of 10%. This audit prompted a re-evaluation of the detailed surgical anatomy, the design and manufacture of a new type of periosteal elevator and lingual nerve retractor and a modification of the surgical technique. A subsequent prospective personal clinical audit of 1001 consecutive wisdom tooth operations has resulted in a 20-fold improvement (0.5%) in the incidence of lingual nerve damage. The technique and instrumentation has been used under local anaesthesia and under general anaesthesia by surgeons of varying experience and has a group audit complication rate of only 1% in 300 consecutive cases. The value of clinical audit has become self evident.

Premature closure of the foramen ovale and congenital pulmonary cystic lymphangiectasis in aortic valve atresia or in severe aortic valve stenosis

Because hypoplasia of the left heart is considered inoperable, few studies deal with detailed surgical anatomy and the state of the pulmonary vessels. 1–3 Recently, surgical techniques derived from the Fontan operation have been developed that separate the pulmonary and systemic circulations, thus achieving a physiologic “correction.” 4 However, this type of palliative procedure is unlikely to succeed in infants with severe pulmonary venous congestion and secondary congenital pulmonary cystic lymphangiectasis (CPCL), which has been described in some cases of hypoplastic left heart syndrome. 5–15 Alerted by the index case, which showed severe CPCL and a sealed foramen ovale (FO), we focused our attention on the state of the atrial septum and the anatomic and histologic aspects of the lung tissue and pulmonary vasculature, particularly the pulmonary veins and lymphatic system, in 7 other consecutive cases of hypoplastic left heart syndrome. This study reports on the association of premature closure of the FO and CPCL.

Anatomical considerations for surgery of the rat abdominal vagus: distribution, paraganglia and regeneration.

In order to provide a detailed surgical anatomy of the rat abdominal vagus, we examined pyridine silver-stained tissue from one group of normal animals and a second group that survived 9 months after vagotomy. In the normal sample, as has been established for man, there was considerable variability in the levels at which each of the vagal branches separated from the main trunks. Contrary to reports from dissection studies, most of the branches were not single fiber bundles but rather consisted of two or more separate bundles. At the extreme, the posterior gastric and coeliac branches each consisted of as many as 15 individual bundles. Even the main trunks of the subdiaphragmatic vagus were occasionally observed to have multiple components (anterior trunk, 13% of the cases; posterior, 25%). In addition to the classically recognized hepatic, anterior gastric, coeliac, and posterior gastric branches, we also observed an accessory coeliac branch of the anterior trunk in all animals. This accessory coeliac division originated just caudal to the hepatic branching and extended first laterally and then dorsally while running caudally to exit from the esophagus just before the separation of the coeliac branch from the posterior trunk. The vagi were observed to contain paraganglia consisting of islands of glomus cells, neurons, and extensive capillary beds, all situated within the perineurium. The paraganglia occurred in greatest frequency at the sites where the hepatic and coeliac branches divide from their respective trunks. Paraganglia were also observed peripherally within vagal branches; there they were most numerous within the coeliac branch and least numerous in the accessory coeliac. Other studies yielded evidence that regeneration had occurred after complete vagotomy. First, stumps of the branches distal to the resection scar contained axons. Central to the scar, axons grew out in all directions from the neuroma; some of them appeared to cross the scar and to reinnervate the distal stumps. Secondly, 30% of the animals in which regeneration was thought to be possible increased their insulin secretion in response to electrical stimulation of the cervical vagus. The implications of the above findings for experiments that involve manipulation or recording of the vagus are discussed.