Fascial Layers Research Articles

Frontotemporal Branch of the Facial Nerve and Fascial Layers in the Temporal Region: A Cadaveric Study to Define a Safe Dissection Plane.

Anatomy of the temporal region is complex with controversy over the relationship of fascial planes with the upper division of the facial nerve. This study aimed to identify the safe surgical landmarks to preserve the frontotemporal branch of the facial nerve during surgery and define the safest approach for surgical procedures in this region. The anatomical relationship of the frontal branch of the facial nerve, superficial temporal artery (STA), fascial planes, and fat pads was determined after dissection on 10 cadaveric heads, that is (20 sides) Dissection was performed layer by layer from skin to bone. The temporoparietal fascia was made up of multiple (3-4) layers above the zygomatic arch and these layers were integrated with thin fibrous septa. The frontotemporal branch of the facial nerve (FTFN) was observed in a deeper part of temporoparietal fascia and superficial fat pad. The frontotemporal branch of the facial nerve (FTFN) crossed the zygomatic arch as two branches in 25%, as three branches in 65% and as four branches in 10% of specimens. Interfascial dissection between two layers of deep temporal fascia through the intermediate fat pad is superior to other approaches because of the lack of facial nerve branches in this plane. The Intermediate fat could be easily separated from deep layer of deep temporal fascia.

Lymph node metastasis in suprasternal space and intra-infrahyoid strap muscle space from papillary thyroid carcinoma

BackgroundThis study was performed to evaluate the clinicopathologic characteristics of Lymph Node metastasis between investing layer of Cervical fascia and deep fascia of infrahyoid strap Muscles (LNCM) in papillary thyroid carcinoma (PTC).MethodsRetrospective review of patients with PTC who underwent thyroidectomy and central compartment neck dissection (CND) from January 2016 to January 2018 was performed in two tertiary referral academic medical centers. A total of 2104 consecutive patients with PTC who underwent thyroidectomy and CND were included in the retrospective review. The LNCM was resected as a separate specimen by the surgeon and the clinicopathologic characteristics of the patients were recorded. Multivariate logistic regression analysis was performed to identify risk factors for LNCM metastasis.ResultsOf 2104 PTC patients, 451 patients (21.4%) had lymph nodes in the LNCM. Among them, 68 (15.1%) cases were confirmed to be positive in the LNCM. In total, the metastasis rate of LNCM in PTC patients was 3.2% (68/2104). Univariate analysis revealed that the metastasis of LNCM were more likely to have a primary site in the inferior pole, extrathyroidal extension (ETE), central cervical metastasis, level III and level IV metastasis. Multivariate analysis further showed tumor location in the inferior pole, ETE, level III and level IV metastasis conferred a significantly increased odds ratio for LNCM metastasis.ConclusionAttention should be paid to the lymph tissue in the LNCM for PTC patients, especially in presence of a primary site in the inferior pole, ETE, level III and level IV metastasis.

Evaluation of Different 'Tensioning' of Apical Suspension in Women Undergoing Surgery for Prolapse and Urinary Incontinence.

According to the literature, restoration of pelvic organ prolapse also restores urinary continence. However, it is difficult to determine which exact surgical procedure actually led to urinary continence due to a lack of standardisation among these techniques. For example, an apical fixation is broadly defined in terms of type and shape of implanted material, anatomical fixation sides and tensioning. The aim of this study was to evaluate the effect of bilateral uterosacral ligament replacement with alloplastic tapes of defined lengths on symptoms of urinary incontinence. Patients with urinary incontinence and pelvic organ prolapse underwent an apical suspension. Thereby, both uterosacral ligaments (USL) were replaced by alloplastic structures of defined length. These alloplastic tapes had defined lengths in all patients of 9, 10, or 11 cm in length. They were sutured on both sides of the cervix, placed in the left and right peritoneal fold of the USL, and were sutured laterally to the prevertebral fascial layer of the sacral vertebra at the level of S2. Furthermore, all patients received additional transobturator tape. Pelvic organ prolapse was classified according to the Baden-Walker system, and urinary incontinence symptoms according to validated questionnaires. Four months after bilateral USL replacement, apical suspension was restored in all 31 patients. In addition, urinary continence was re-established in 18 out of these 31 patients (58%). The highest continence rate was observed in patients in which both USL were replaced with alloplastic tapes of 9 cm in length. The findings indicated the importance of USL integrity for urinary continence. In particular, a defined length for both USL seems to be important for (re-)establishing urinary continence.

The need for supplemental blocks in single versus triple injections in infraclavicular brachial plexus blocks with a medial approach: a clinical and anatomic study

Background and objectivesTo evaluate the single-injection and triple-injection techniques in infraclavicular blocks with an ultrasound-guided medial approach in terms of block success and the need for supplementary blocks. MethodsThis study comprised 139 patients who were scheduled for elective or emergency upper-limb surgery. Patients who received an infraclavicular blocks with a triple-injection technique were included in Group T (n = 68). Patients who received an infraclavicular blocks with a single-injection technique were included in Group S (n = 71). The number of patients who required supplementary blocks or had complete failure, the recovery time of sensory blocks and early and late complications were noted. ResultsThe block success rate was 84.5% in Group S, and 94.1% in Group T without any need for supplementary nerve blocks. The blocks were supplemented with distal peripheral nerve blocks in 8 patients in Group S and in 3 patients in Group T. Following supplementation, the block success rate was 95.8% in Group S and 98.5% in Group T. These results were not statistically significant. A septum preventing the proper distribution of local anesthetic was clearly visualized in 4 patients. The discomfort rate during the block was significantly higher in Group T (p < 0.05). ConclusionIn ultrasound-guided medial-approach infraclavicular blocks, single-injection and triple-injection techniques did not differ in terms of block success rates. The need for supplementary blocks was higher in single injections than with triple injections. The presence of a fascial layer could be the reason for improper distribution of local anesthetics around the cords.

Bloqueio complementar de nervos no bloqueio de plexo braquial infraclavicular com técnica medial de injeção única versus tripla: estudo anátomo‐clínico

Background and objectivesTo evaluate the single‐injection and triple‐injection techniques in infraclavicular blocks with an ultrasound‐guided medial approach in terms of block success and the need for supplementary blocks. MethodsThis study comprised 139 patients who were scheduled for elective or emergency upper‐limb surgery. Patients who received an infraclavicular blocks with a triple‐injection technique were included in Group T (n=68). Patients who received an infraclavicular blocks with a single‐injection technique were included in Group S (n=71). The number of patients who required supplementary blocks or had complete failure, the recovery time of sensory blocks and early and late complications were noted. ResultsThe block success rate was 84.5% in Group S, and 94.1% in Group T without any need for supplementary nerve blocks. The blocks were supplemented with distal peripheral nerve blocks in 8 patients in Group S and in 3 patients in Group T. Following supplementation, the block success rate was 95.8% in Group S and 98.5% in Group T. These results were not statistically significant. A septum preventing the proper distribution of local anesthetic was clearly visualized in 4 patients. The discomfort rate during the block was significantly higher in Group T (p <0.05). ConclusionIn ultrasound‐guided medial‐approach infraclavicular blocks, single‐injection and triple‐injection techniques did not differ in terms of block success rates. The need for supplementary blocks was higher in single injections than with triple injections. The presence of a fascial layer could be the reason for improper distribution of local anesthetics around the cords.

Ultrasound tour of the anterior neck for the interventional pain physician

Ultrasound tour of the anterior neck for the interventional pain physician

Yonsei Criteria, a Potential Linkage to Intratumoral Foxp3⁺/CD8⁺ Ratio for the Prediction of Oncologic Outcomes in Resected Left-Sided Pancreatic Cancer.

PurposeThis study sought to investigate associations among Yonsei criteria (tumor confined to the pancreas, intact fascia layer between the distal pancreas and the left adrenal gland and kidney, and tumor located more than 1–2 cm from the celiac axis) and tumor infiltrating lymphocytes in pancreatic cancer.Materials and MethodsPatients who underwent curative distal pancreatectomy due to left-sided pancreatic cancer from January 2000 to December 2011 were enrolled. Follow-up was completed September 30, 2015.ResultsFifty patients were enrolled. Having ≥ two metastatic lymph nodes (LNs, p=0.002), intraoperative transfusion (p=0.011), low levels of tumor infiltrating CD8+ T-cells (p=0.001), and a high Foxp3+/CD8+ ratio (p=0.009) were independent risk factors for disease-free survival. Not satisfying the Yonsei criteria (p=0.021), having ≥ two metastatic LNs (p=0.032), low levels of tumor infiltrating CD8+ T-cells (p=0.040) and a high Foxp3+/CD8+ ratio (p=0.032) were associated with unfavorable overall survival. High levels of CA19-9 and not satisfying the Yonsei criteria were significantly associated with a high Foxp3+/CD8+ ratio [Exp(β)=3.558; 95% confidence inverval: 1.000–12.658; p=0.050].ConclusionYonsei criteria may be clinically detectable biologic marker with which to predict immunologic status and survival in pancreatic cancer patients.

Mechanical effects of acupuncture

Acupuncture, a physiotherapy, has been widely accepted all around the world. This study focuses on the influence of membrane structures and explains the acupuncture sensations from the aspect of mechanical properties. By mathematical modeling and numerical simulation, the scientific meaning of the acupuncture depth is investigated and phenomena and theory of acupuncture are discussed. The simulation results show that (a) the fascial structure is the main contributor to the force on the needle, the axial force will gradually increase before piercing the fascial, and suddenly decrease after piercing the fascial; (b) there is an inverse relationship between the needle radius and the maximum radial stress, which indicates that the needle should not be too sharp to cause local stress concentration and piece the fascia layer; and (c) the simulation results of comprehensively considering the static friction and sliding friction is identical with the experiment results. This study proposes a preliminary study of mechanical effects of acupuncture manipulation, clarifies key factors affecting the stress on the needle, and explains the objective requirement of acupuncture depth to effective treatment.

Deep cervical fascia as an anatomical landmark of lingual lymph nodes: An anatomic and histologic study

ObjectivesWe aimed to discuss the definition of lingual lymph nodes based on the deep cervical fascia anatomy. MethodsA total of 11 cadavers were histopathologically evaluated. Specimens were dissected into serial stepwise cross-sections. The deep cervical fascia and lymph nodes were evaluated by staining the cross-sections with Elastica van Gieson and hematoxylin and eosin stains, respectively. The gross anatomy of the deep cervical fascia was evaluated in 1 cadaver after bilateral dissection. ResultsA single severely degenerated medial lingual lymph node (MLLN) was identified in the lingual septum of 1 cadaver. A single lateral lingual lymph node (LLLN) was identified in 1 cadaver, between the genioglossus and the hyoglossus. The superficial layer of deep cervical fascia (SLDF) was found to split into two layers encapsulating the submandibular gland. The deeper portion of this fascia was in close contiguity with the hyoglossus and formed the boundary between the mouth and the neck. The SLDF was found to be discontinuous with the area between the sublingual space and the submandibular gland. ConclusionsThe SLDF could serve as an anatomical landmark for lingual lymph nodes, since it is considered to be the demarcating boundary during neck dissection. When lymph nodes that are located deeper than the SLDF were defined as lingual lymph nodes, 1 MLLN and 1 LLLN were identified.

Sentinel vein and middle temporal vein in Chinese: an anatomic study

Objective To study the characteristics of sentinel vein (SV) and middle temporal vein (MTV) and influence in surgery of periorbital and temporal areas. Methods From January 2018 to August 2019, 20 donated fresh/frozen head specimens (12 males and 8 females) were collected in various regions of China, with an average age of 47.2 (21 to 88) years. Temporal region of 29 hemi-facial area was dissected in layers, and the occurrence rate, route, geometric parameters, branchesand correlation of SV and MTV were observed and measured. Results Occurrence rate of SV was 96.6% (28/29), the subcutaneous subordinate branches of SV were 2.5±1.0 in average, with both joining together in 6 kinds of mode. The horizontal section length was (5.8±3.8) mm, and outside diameter was (1.0±0.1) mm. The vertical section length was (8.2±4.3) mm, and outside diameter was (1.2±0.4) mm, steering vertically to the deep through the superficial temporal fascia, middle temporal fascia (MTF) and superficial layer of deep temporal fascia (SDTF), continuing to the MTV. The minimal average distance between the SV and TFN was (6.0±2.7) mm. Occurrence rate of MTV was 96.6% (28/29). The first half of MTV was parallel to the zygomatic arch and ran across the superficial temporal fat pad, then turned down near the upper pole of the external ear wheel, and run vertically in front of the ear, and 5.9±2.7 peripheral branches were collected along the way. The length of temporal middle vein was (82.3±8.6) mm, and outer diameter of the thickest point was (3.6±0.7) mm. Conclusions Sentinel vein is the main branch of middle temporal vein. It passes through several layers of soft tissue vertically and directly into the MTV. Position of sentinel vein is relatively constant, which is an important localization marker in the operation of the temporal region. The middle temporal vein has large diameter, fixing in the superficial temporal fat pad, collecting the venous reflux of the temporal area at both superficial and deep, which may be the main cause of pulmonary infarction produced by the temporal fat transplantation, and injury should be avoided. Key words: Autopsy; Middle temporal vein; Sentinel vein; Temporalanatomy; Filler injection

Duraplasty with Cervical Fascia Autograft to Reduce Postoperative Complications of Posterior Fossa Tumor Surgery with Suboccipital Midline Approach

The suboccipital midline approach is common dealing with posterior fossa tumors but has a high risk of postoperative complications, such as pseudomeningocele, cerebrospinal fluid (CSF) leak, and meningitis. Neurosurgeons used various kinds of method to lower its rate. A retrospective, single-center review of patients diagnosed with posterior fossa tumor underwent a suboccipital midline approach. Compare the rates of pseudomeningocele, CSF leak, and meningitis between 2 groups (artificial dura mater or cervical fascia autograft). We get the cervical fascia autograft from the superficial layer of deep cervical fascia just above the trapezius. Our retrospective review involved 123 patients matching the inclusion criteria between January 2009 and April 2019. The complication rate of pseudomeningocele, CSF leak and meningitis were 8.9%, 4.9%, and 17.9%, respectively. The presence of pseudomeningocele or CSF leak for group "artificial" was 11 of 75 (14.67%) and for group "autograft" it was 3 of 48 (6.25%). The rate of meningitis for group "artificial" (24.0%, 18 of 75) was significantly higher (P= 0.027) than the one for group "autograft" (8.33%, 4 of 48). Multivariate regression analysis suggested that the age was negatively correlated with postoperative pseudomeningocele or CSF leak (P= 0.006), with meningitis (P < 0.001). Using cervical fascia autograft decreased the rate of meningitis (P= 0.021) while showing no statistically significant clinical impact on pseudomeningocele or CSF leak. Applying the cervical fascia autograft to reconstruct the dura during posterior fossa surgery is a simple and effective method to reduce the rate of meningitis as compared with artificial dura mater.

MRI of the penis.

This article reviews the anatomy and magnetic resonance imaging (MRI) appearance of the penis. The recommended technique for MRI of the penis is outlined, with discussion of the benefits and drawbacks to imaging the penis after artificial erection. Common penile pathologies are reviewed, with a summary of their clinical features, MRI appearance, and treatment. The ability to demonstrate the erectile bodies and vasculature helps to evaluate vascular pathologies such as priapism, Mondor disease, and cavernosal thrombosis. MRI is also a useful tool to assess for traumatic abnormalities of the penis, with the depiction of soft tissue anatomy and fascial layers allowing for evaluation of penile fracture and penile contusion. Malignant disease of the penis is also reviewed, including squamous cell carcinoma, urethral carcinoma, metastases, and rare neoplasms. Staging of these neoplasms is addressed, with discussion of how MRI can be used to assess the extent of tumor involvement. MRI also clearly demonstrates the tunica albuginea, which allows for evaluation of Peyronie's disease.

Influence of injectate volume on paravertebral spread in erector spinae plane block: An endoscopic and anatomical evaluation.

The paravertebral spread that occurs after erector spinae plane block may be volume-dependent. This cadaveric study was undertaken to compare the extent of paravertebral spread with erector spinae plane block using different dye volumes. After randomization, twelve erector spinae plane blocks were performed bilaterally with either 10 ml or 30 ml of dye at the level of T5 in seven unembalmed cadavers except for two cases of unexpected pleural puncture using the 10 ml injection. Direct visualization of the paravertebral space by endoscopy was performed immediately after the injections. The back regions were also dissected, and dye spread and nerve involvement were investigated. A total of five 10 ml injections and seven 30 ml injections were completed for both endoscopic and anatomical evaluations. No paravertebral spread was observed by endoscopy after any of the 10-ml injections. Dye spread to spinal nerves at the intervertebral foramen was identified by endoscopy at adjacent levels of T5 (median: three levels) in all 30 ml injections. In contrast, the cases with two, four, and three out of five were stained at only the T4, T5, and T6 levels, respectively, with the 10 ml injection. Upon anatomical dissection, all blocks were consistently associated with posterior and lateral spread to back muscles and fascial layers, especially with the 30 ml injections, which showed greater dye expansion. In one 30 ml injection, sympathetic nerve involvement and epidural spread were observed at the level of the injection site. Although paravertebral spread following erector spinae plane block increased in a volume-dependent manner, this increase was variable and not pronounced. As the injectate volume increased for the erector spinae blocks, the injectate spread to the back muscles and fascial layers seemed to be predominantly increased compared with, the extent of paravertebral spread.

Anatomical relationship between fascia propria of the rectum and visceral pelvic fascia in the view of continuity of fasciae

Objective: To perform an anatomical observation on the extension of the mesocolon to the mesorectum and the continuity of the fasciae lining the abdomen and pelvis, in order to clarify the appropriate surgical plane of total mesorectal excision. Methods: This is an descriptive study. The operation videos of 61 cases (28 males, 33 females, median age of 61) were collected. All the patients underwent laparoscopic colorectal surgery from January 2018 to December 2018 in Yangpu Hospital, including low anterior resection for rectal cancer in 25 cases, left hemicolectomy for descending colon cancer in 15 cases, and subtotal resection of the colon for intractable constipation in 21 cases. Among these 21 constipation patients, 8 received additional modified Duhamel surgeries. Gross anatomy was performed on 24 adult cadavers provided by Department of Anatomy, Shanghai Jiaotong University School of Medicine, including 23 formalin-fixed and 1 fresh cadaver (12 males, 12 females). Sixty-one patients and 24 cadavers had no previous abdominal or pelvic surgical history. The anatomy and extension of fasciae related to descending colon, sigmoid colon and rectum, especially the morphology of Toldt fascia, and the continuities of mesocolon and mesorectum were observed carefully. The distribution characteristics of the fasciae and anatomical landmarks during laparoscopic surgery were recorded and described. Results: The anatomical study on 24 cadavers showed that visceral fascia was the densest connective tissue in the pelvic, posterolateral to the rectum, and stretched as a hammock to lift all pelvic organs. Among 61 patients undergoing laparoscopic surgery, 36 (59.0%) needed to free the left colon during operation, and Toldt fascia in the descending colon segment presented as potential, avascular and extensible loose connective tissue plane between the mesocolon and posterior Gerota fascia; 33 (54.1%) needed to free the rectum during operation, and Toldt fascia extended downward to pelvis as loose connective tissue between the fascia propria of the rectum and visceral fascia; the fascia propria of the rectum exposed completely in 32 (32/33, 97.0%) cases, which ran downward and fused with visceral fascia at the level of the fourth sacral vertebra. The anatomy of 24 cadavers also showed that fascia propria of the rectum fused with visceral fascia at the level of Waldeyer fascia. The fusion line of these two fasciae was supposed to be the extension of Waldeyer fascia. There were two avascular planes behind the rectum: one between the fascia propria of the rectum and visceral fascia, and the other between the visceral fascia and parietal fascia. In 8 constipation cases undergoing laparoscopic subtotal colon resection plus modified Duhamel operation, both mesocolon and mesorectum needed to be mobilized. It was obvious that the mesocolon of descending colon extended and became the mesocolon of sigmoid colon, and ran further into the pelvic and became the mesorectum. The colon fascia of descending colon served as the natural boundary of mesocolon extended downward as the fascia of sigmoid colon and the fascia propria of the rectum, respectively. Toldt fascia locating between mesocolon of descending colon and Gerota fascia extended to pelvis as the 'presacral space' between the fascia propria of the rectum and visceral fascia. Gerota fascia in descending colon segment extended as urogenital fascia in sigmoid colon segment and visceral fascia in the pelvis, respectively. In the cadaver anatomy study, the visceral fascia served as a corridor carrying the hypogastric nerve, and ureter was observed in 23 (23/24, 95.8%) cases. The visceral fascia passed from posterior to anterior lateral of rectum, fusing with Denonvilliers fascia in a fan shape. The pelvic plexus located exactly external to the junction of visceral fascia and Denonvilliers fascia. Pelvic splanchnic nerves went through the parietal fascia toward to the inferolateral of the pelvic plexus. Conclusion: Fascia propria of the rectum and the visceral pelvic fascia are two independent layers of fascia, and the TME surgical plane is between the fascia propria of the rectum and visceral pelvic fascia instead of between the visceral and the parietal pelvic fascia.

Ultrasound Imaging of the Fascial Layers: You See (Only) What You Know.

Journal of Ultrasound in MedicineVolume 39, Issue 4 p. 827-828 Commentary Ultrasound Imaging of the Fascial Layers: You See (Only) What You Know Carmelo Pirri MD, PT, Corresponding Author Carmelo Pirri MD, PT [email protected] orcid.org/0000-0002-0119-6549 Department of Physical and Rehabilitation Medicine, University of Rome Tor Vergata, Rome, Italy Address correspondence to Carmelo Pirri, MD, PT, Department of Physical and Rehabilitation Medicine, University of Rome Tor Vergata, Via Montpellier, 1 00133, Rome, Italy. E-mail: [email protected]Search for more papers by this authorCarla Stecco MD, Carla Stecco MD Department of Neuroscience, Institute of Human Anatomy, University of Padua, Padua, ItalySearch for more papers by this authorCaterina Fede PhD, Caterina Fede PhD Department of Neuroscience, Institute of Human Anatomy, University of Padua, Padua, ItalySearch for more papers by this authorVeronica Macchi MD, Veronica Macchi MD Department of Neuroscience, Institute of Human Anatomy, University of Padua, Padua, ItalySearch for more papers by this authorLevent Özçakar MD, Levent Özçakar MD Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, TurkeySearch for more papers by this author Carmelo Pirri MD, PT, Corresponding Author Carmelo Pirri MD, PT [email protected] orcid.org/0000-0002-0119-6549 Department of Physical and Rehabilitation Medicine, University of Rome Tor Vergata, Rome, Italy Address correspondence to Carmelo Pirri, MD, PT, Department of Physical and Rehabilitation Medicine, University of Rome Tor Vergata, Via Montpellier, 1 00133, Rome, Italy. E-mail: [email protected]Search for more papers by this authorCarla Stecco MD, Carla Stecco MD Department of Neuroscience, Institute of Human Anatomy, University of Padua, Padua, ItalySearch for more papers by this authorCaterina Fede PhD, Caterina Fede PhD Department of Neuroscience, Institute of Human Anatomy, University of Padua, Padua, ItalySearch for more papers by this authorVeronica Macchi MD, Veronica Macchi MD Department of Neuroscience, Institute of Human Anatomy, University of Padua, Padua, ItalySearch for more papers by this authorLevent Özçakar MD, Levent Özçakar MD Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, TurkeySearch for more papers by this author First published: 23 October 2019 https://doi.org/10.1002/jum.15148Citations: 18 All of the authors of this article have reported no disclosures. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume39, Issue4April 2020Pages 827-828 RelatedInformation

The 'multilayer' theory of Denonvilliers' fascia: anatomical dissection of cadavers with the aim to improve neurovascular bundle preservation during rectal mobilization.

Denonvilliers' fascia is thought to be a multilayered fascial structure, based on its embryological development with the neurovascular bundle embedded within it. Recently, this theory had been proven histologically and by confocal microscopy in many published articles. However, the literature does not report on how surgeons can identify these structures. We aimed to determine the optimal surgical approach for preserving these critical structures. Eighteen cadavers (13 male/five female) were included and treated according to the ethical considerations stated in the donation consent of our institution. Dissection was performed with the assistance of binocular loupes for better anatomical detail. The compositions of the prerectal fascia and the neurovascular bundle were observed and recorded at different levels of dissection using a high-definition camera. The theoretical multilayered fascia was found in male specimens as three fascial layers originating from the perineal body, seminal vesicles and posterior bladder neck. The first layer merged posterolaterally and fused with the rectosacral fascia (Waldeyer's fascia). The neurovascular bundle in male specimens was observed piercing the second and third layers, while the first layer acted as a protective cover. Dissection of female specimens demonstrated only one layer in the prerectal space. Intiating anterior rectal mobilization by incising the peritoneum posterior to its reflection seems to be anatomically correct to preserve DVF. However, its applicability may be difficult in a narrow chanllenging pelvis. The lateral rectal ligaments and Waldeyer's fascia should be dissected from their attachments to the proper fascia of the rectum.

Effect of perforator flap with preserved Choke vessel area in repairing the defect induced by tumor removal

Objective To explore the clinical significance of protection Choke vessel in the application of perforator flap to repair large defect of trunk after tumor resection. Methods A total of 62 patients (38 males and 24 females, aged from 19 to 79 years) from the Department of Plastic Surgery, Second Affiliated Hospital of Suzhou University underwent reconstructive surgery for large area defects of the trunk from March 2012 to January 2016. The perforator flap was designed according to the perforator location detected by Doppler before surgery. The flaps were harvested on the pedicle of perforators and dissected on the deep layer of deep fascia (including part of the myolemma). The areas of flap ranged from 5.0 cm × 10.0 cm to 19.0 cm × 22.0 cm. The donor site was sutured directly or local flap was transferred to repair. Results Flaps survived well in 59 of the 62 cases. The tip of flap was necrotic and healed after dressing change in 1 diabetic patient. The distal part of flap was necrotic on cuticular layer and healed after dressing change in another patient with scrotal defect. One patient had flap necrosis 10 days after operation and was repaired twice. The results were satisfied after following-up from 3 months to 2 years for 17 cases and from 6 months to 2 years for 25 cases. Fibrosarcoma protuberant and squamous cell carcinoma recurred in 1 case each, but the function and appearance were satisfactory after primary repair. Conclusions The procedure of preserving Choke vessel area can improve the blood supply of perforator flap and obtain larger survival area and survival quality. It is worthy of clinical application. Key words: Neoplasms; Defects; Body surface area; Free-style perforate flap; Choke vessel; Survival quality

Port site hernia: What are the risk factors?

&lt;p&gt;&lt;strong&gt;Background &amp;amp; Aim&lt;/strong&gt;: The port site hernia is a type of incisional hernia that occurs at port sites after laparoscopic surgery. Various factors have been implicated in the development of port site hernia.&lt;/p&gt;&lt;p&gt;The aim of this study was to know the risk factors of the port site hernia.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Patients &amp;amp; Methods:&lt;/strong&gt; A retrospective study of patients who underwent different elective laparoscopic procedures in Rizgary Teaching Hospital in Erbil in a period from March 2013 to September 2014.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results&lt;/strong&gt;: Out of 300 patients only 8 (2.7%) patients developed port site hernia. The time of the hernia occurrence ranged from 3 weeks to six months postoperatively. Half of the hernias were found in cases of age group (60-80) years. Six (75%) of the cases were female patients. All 8 hernias developed after laparoscopic cholecystectomy. Six (75%) hernias developed after open port entrance technique. All hernias occurred when the fascia in 10 mm port was not closed. Seven hernias (87.5%) occurred in patients with BMI ranged (25-34).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; Age of the patients, technique of entrance, site and size of the port with unclosed fascial layer are important factors for developing port site hernia.&lt;/p&gt;

Mastering the Anterior Approach of Laparoscopic Hysterectomy for the Huge Uterus

Video Objective To expand laparoscopic surgical skills, we need to strategies to cope with the very large uterus.Traditionally, there are three techniques to detect and mobilize the ureter and uterine artery: the anterior, lateral and posterior approach. Generally, the lateral approach is most common as one can easily detect the ureters transperitoneally at the rim of psoas muscle. But, in the case of a large and bulky uterus, advanced techniques are required. Design Laparoscopic demonstration of fascial planes and surgical techniques used to cope with the huge uterus. Setting Kurashiki medical center, private hospital, in Japan. Patients Total laparoscopic hysterectomy for uterus greater than 800 grams. Interventions In anterior approach, by making a bladder flap one can firstly detect and ligate uterine arteries to reduce bleeding. Measurements and Main Results In the case of adenomyosis and endometriosis, bleeding from severe fibrosis may be encountered in the parametrium. Ligation of the uterine arteries first will help to avoid bleeding. Open the bladder flap wide and lifting it sufficiently and cutting the loose connective tissue caudally will expose the palpable ascending and inward vessel. That is the uterine artery. The separation between the uterine artery and the ureter opens Latzko's pararectal space. In the case of fibroid, we find the ureter first as the broad ligament is more elastic allowing for stretching. By making the broad ligament tense, you can elevate the posterior leaf of broad ligament to separate the mesoureter. This procedure allows entry into Okabayashi's pararectal space. The entry point is at about 1cm medially to the root of the lateral umbilical ligament. This space is avascular and stretches to easily find the mesoureter containing the ureter above it. Conclusion Mastering an anterior approach and recognizing fascial layers contributes to our surgical toolbox in coping with more complicated hysterectomies.

From muscle to food: oxidative challenges and developmental anomalies in poultry breast muscle

The glycolytic capacity in the "white muscle fibers" found predominantly in broiler and turkey breast muscle have long been recognized as being key components contributing to optimal pH changes post-harvest and the quality of breast muscle products. The pectoralis major (PMAJ) is the predominant breast muscle and is almost exclusively comprised of fast-twitch glycolytic (anaerobic) type IIb muscle fibers (white). In nature, the pectoralis muscles are designed to meet the intense, periodic energy demands of flight in contrast to the continual, oxidative metabolism (aerobic) inherent to the type I slow twitch fibers (red) in the thigh and drum. Within the past decade, it has been recognized that increased breast muscle yield in modern broiler strains may have contributed to muscle myopathies characterized by visible white striations (white striping; WS) often accompanied by surface hemorrhages and areas of extreme firmness (woody breast; WB). The research to date has primarily addressed differences in muscle physiology and processing characteristics in "normal" and "abnormal" muscle samples from older broilers. One hypothesis is that the extensive accretion of protein in a poorly vascularized breast muscle overwhelms the capacity for coping with excessive production of reactive oxygen species and the term "oxidative stress" has been used to describe this condition. There are few recent reports in poultry, however, which have addressed the potential negative physiological effects imposed by multiple layers of fascia surrounding individual muscle fibers, fiber bundles, and intact muscles on circulation and oxidative stability. The objective of this review is to support our hypothesis that the extensive accretion of breast muscle in a poorly vascularized and tightly bound PMAJ could be creating a "compartment syndrome" like condition leading to the development of the WS and WB anomalies in heavy, high yielding birds. Recent gene expression data support this hypothesis.