Nerve Dissection Research Articles

Anatomic variations of the recurrent laryngeal nerve according to the inferior thyroid artery and their clinical impact in patients undergoing thyroidectomy.

Recurrent laryngeal nerve identification is the 'gold standard' in thyroidectomy, to determine nerve function security and prevent severe complications. This study assessed the topographical relationship between the recurrent laryngeal nerve and the inferior thyroid artery in patients undergoing total thyroidectomy, and determined its clinical impact. A retrospective study was performed of patients undergoing total thyroidectomy in a single tertiary centre over a six-month period. Sixty-four patients were included. Among the 128 recurrent laryngeal nerve dissections, the nerve was identified traversing the inferior thyroid artery anteriorly in 27.3 per cent, with equal distribution between the two sides. No significant sex association was reported. One patient had transient vocal fold palsy, and hypocalcaemia was observed in 21.9 per cent, yet there was no statistical association with the topographical variation of the recurrent laryngeal nerve. Almost one-third of patients had an anatomical variation in which the recurrent laryngeal nerve ran superiorly to the inferior thyroid artery. Recurrent laryngeal nerve variation had no clinical impact on local complications or hypocalcaemia.

Intraoperative Management of the Recurrent Laryngeal Nerve Transected or Invaded by Thyroid Cancer.

Thyroid cancer often invades the recurrent laryngeal nerve (RLN), causing vocal cord paralysis. In such patients, the invaded portion of the RLN usually needs to be resected through curative surgery. We attempt to preserve the nerve by performing sharp dissection in such cases. During nerve dissection, an intraoperative nerve monitoring system helps identify the course of the RLN in the fibrous tissue around the tumor or even within the tumor, and also helps evaluate the nerve integrity. Because of extensive dissection, the preserved RLN may become much thinner than its original thickness. We refer to this procedure as “partial layer resection” of the RLN. In our cases, although the dissected RLNs became thinner, we found that vocal cord function recovered in most patients. If the RLN is fully involved by thyroid cancer or response of the vocal cord against electric stimulation to the RLN is lost, we resect the portion of the RLN together with the tumor and repair it using one of the reconstruction techniques. When a unilateral RLN is resected, the vocal cord on that side is paralyzed. Symptoms include hoarseness, mis-swallowing, and short phonation. RLN reconstruction using one of the reconstruction techniques leads to the recovery of phonatory and swallowing function, although the normal motion of the vocal cord on the side of the anastomosis is not restored. We used direct anastomosis, free nerve grafting, ansa cervicalis-RLN anastomosis, and vagus-RLN anastomosis to reconstruct the RLN. Thyroid cancer often invades the RLN near the Berry’s ligament. In such patients, surgeons might assume that reconstruction of the RLN may not be possible because the peripheral stump of the RLN cannot be observed. However, if we divide the inferior pharyngeal constrictor muscles along the lateral edge of the thyroid cartilage, the peripheral RLN can be identified, and nerve reconstruction can be performed. We refer to this procedure as “laryngeal approach”.In summary, of the patients with thyroid cancer who required resection of the RLN, RLN reconstruction led to the recovery of phonatory function. We suggest that all thyroid surgeons familiarize themselves with these reconstruction techniques.

Метод макромікроскопічного препарування для встановлення фетальної анатомічної мінливості структур пахвової ділянки

The purpose of the study was to determine a more sophisticated method of the most rational sequence of actions of dissection of the fascia, muscles, vessels and nerves of the axillary cavity in human fetuses in order to obtain standard results suitable for comparison in the age aspect. Materials and methods. The study of fetal anatomy of the structures of the axillary area was performed on 25 preparations of 4-10-month human fetuses of 81.0-375.0 mm parietal-coccygeal length using macromicroscopic dissection. Results and discussion. The axillary area is characterized by age and individual anatomical variability of the muscles that form its walls, fascia and cellular spaces, as well as vascular and nervous formations that pass in it, which is a common cause of complications during surgery. To study the fetal anatomical variability of the components of the axillary area, the algorithm of anatomical dissection of fascia, muscles, lymph nodes, blood vessels and nerves of the axilla in the human fetus is of priority importance. Adherence to the sequence of actions during the anatomical dissection of the components of the axillary area provides not only high representativeness and scientific value of the results, but also the rational use of biological material. The delta-thoracic sulcus fossa and the beak-shoulder muscle can be used to determine the topography and projection of the vascular nerve trunks of the axillary area. The obtained data on the variant anatomy of the pectoralis major and anterior dentary muscles, as well as the widest back muscle are consistent with the studies of individual authors. The study of the structure and topography of fascia, muscles, lymph nodes, nerves, arteries and veins of the axillary fossa in human fetuses from a macroscopic point of view in modern anatomy remains relevant and promising because micro- and ultramicroscopic anatomy does not provide a comprehensive answer and does not fully reveal the versatility of fetal anatomical variability, in the study of which the algorithm of anatomical dissection of the constituent formations of the axillary area becomes a priority. Conclusion. The projected and tested method of dissection of fascial-muscular and vascular-nervous formations of the axillary area in human fetuses provides a standard for obtaining data on their typical, individual and age anatomical variability. The order of actions used during the dissection of the muscles that form the walls of the axilla, fascial-cellular formations, vessels and nerves, as well as axillary lymph nodes in human fetuses preserves the naturalness of the appearance and relationships between the structures of the object of study. Macromicroscopic preparation revealed fetal anatomical variability of muscles, arterial and venous vessels and axillary nerves

Polyhydroxybutyrate (PHB) Scaffolds for Peripheral Nerve Regeneration: A Systematic Review of Animal Models.

Simple SummaryCurrently, polymeric biomaterials are the choice for the design of scaffolds for the regeneration of peripheral nerves. Polyhydroxybutyrate (PHB) is a polymer belonging to the class of polyesters that are produced naturally in nature by microorganisms. To gain a better understanding of the efficacy of therapeutic approaches involving PHB scaffolds for peripheral nerve regeneration, we conducted a systematic review of the literature with the aim of discussing the current knowledge of PHB scaffolds applied to nerve regeneration. The use of PHB as a biomaterial to prepare tubular scaffolds for nerve regeneration was shown to be promising. The incorporation of additives appears to be a trend that improves nerve regeneration.In the last two decades, artificial scaffolds for nerve regeneration have been produced using a variety of polymers. Polyhydroxybutyrate (PHB) is a natural polyester that can be easily processed and offer several advantages; hence, the purpose of this review is to provide a better understanding of the efficacy of therapeutic approaches involving PHB scaffolds in promoting peripheral nerve regeneration following nerve dissection in animal models. A systematic literature review was performed following the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) criteria. The revised databases were: Pub-Med/MEDLINE, Web of Science, Science Direct, EMBASE, and SCOPUS. Sixteen studies were included in this review. Different animal models and nerves were studied. Extension of nerve gaps reconnected by PHB scaffolds and the time periods of analysis were varied. The additives included in the scaffolds, if any, were growth factors, neurotrophins, other biopolymers, and neural progenitor cells. The analysis of the quality of the studies revealed good quality in general, with some aspects that could be improved. The analysis of the risk of bias revealed several weaknesses in all studies. The use of PHB as a biomaterial to prepare tubular scaffolds for nerve regeneration was shown to be promising. The incorporation of additives appears to be a trend that improves nerve regeneration. One of the main weaknesses of the reviewed articles was the lack of standardized experimentation on animals. It is recommended to follow the currently available guidelines to improve the design, avoid the risk of bias, maximize the quality of studies, and enhance translationality.

198: ROBOTIC ASSISTED TRANS CERVICAL ESOPHAGECTOMY (RACE PROCEDURE): DESCRIPTION OF THE SURGICAL TECHNIQUE AND PRELIMINARY RESULTS

Abstract Background and aim A combined trans-hiatal and transcervical approach to perform esophagectomy has been described in the literature for patients who are not candidates for a transthoracic approach. In this context, the technical limitations of conventional laparoscopy might be overcome by the application of robotic systems such as the DaVinci Xi. We aimed at describing the technical details and the feasibility of our technique for the robotic-assisted trans-cervical esophagectomy (RACE) and a preliminary case series. Methods In the abdominal phase the DaVinci Xi is docked using the standard 5-trocar configuration used for Ivor-Lewis esophagectomy. After gastric mobilization, tubulization and D2 lymphadenectomy, the dissection is advanced trans-hiatally until the tracheal carina. Infra-tracheal lymph-node dissection is normally feasible from the abdomen. A left cervical incision and neck lymph node dissection are performed, the esophagus is encircled. The robot is docked at the neck using a gel port with a 3-trocar configuration and an assistant-trocar for suction. The upper mediastinal preparation starts by dissecting the esophagus from the mediastinal pleura bilaterally, the pars membranacea anteriorly and the aortic arch proceeding caudally. Dissection of the left recurrent laryngeal nerve (l-RLN) lymph nodes can be achieved; care should be taken to avoid nerve injuries. Proceeding caudally, the tracheal dissection is advanced to the left bronchus. The azygos vein is encountered at the right tracheobronchial angle. Dissection of bronchial lymph nodes is performed bilaterally, the plane is connected to the previous abdominal plane. After retrieval of the specimen an end-to-side circular stapled anastomosis is performed at the neck. Results The procedure was completed in 4 patients with mid-esophageal squamous cell carcinoma who were not candidate for a trans-thoracic approach due to cardio-pulmonary comorbidities. Median hospital stay was 14 (9–18) days, median ICU stay was 4 (1–6) days. Left vocal cord palsy requiring rehabilitation therapy occurred in 2 patients (50%). No postoperative mortality was recorded. R0 resection was achieved in all patients with a median of 19 (15–22) retrieved lymph nodes. Conclusion RACE using the robotic system is feasible and provides an adequate surgical radicality. The procedure is safe, although the rate of RLN injury is higher.

Robotic subxiphoid-optical thymectomy.

Robot-assisted thymectomy through a subxiphoid scopic approach can provide a good surgical view, similar to that of median sternotomy. We originally used the subxiphoid port only for the robotic scope to avoid instrument collision with the assistant device. This approach, robotic subxiphoid-optical thymectomy, is advantageous for the safe and accurate dissection of the bilateral phrenic nerves and the left brachiocephalic vein, which are especially needed in extended thymectomy for patients with myasthenia gravis.

How to dissect the pelvic nerves: from microanatomy to surgical rules. An evidence-based clinical review.

Advanced gynaecological procedures often include extensive pelvic dissections, with the nervous structures involved in the disease. Nerve-sparing and preservation is a key factor in reducing postoperative morbidity. The goal of this review is to describe in detail the structure of the pelvic nerves and to gather information from other surgical specialties to give recommendations for safe nerve dissection applied in different gynaecological subspecialties. An extensive literature review was carried out in PubMed and Google Scholar. The search included articles concerning peripheral nerve anatomy, mechanisms of injury and different dissection techniques, with the most exhaustive being analysed for the review. Articles from different fields of medicine like orthopaedics, plastic surgery, maxillofacial surgery dealing with peripheral nerve injuries and repair have been reviewed. The following review demonstrates the in-depth anatomy and mechanism of injury of the peripheral nerves, describes the different techniques for neurolysis and proposes some directions for safe nerve dissection. When performing complex gynaecological surgeries, the surgeon should avoid unnecessary nerve handling, apply nerve-sparing techniques whenever possible and use the new devices to preserve the nervous structures. Advanced gynaecological surgeries should be performed in specialised centres by expert surgeons with comprehensive knowledge in neuropelveology. To our knowledge, this is the first article focused on peripheral nerves that collects data from such a wide range of specialties in order to propose the most comprehensive recommendations that could be applied in pelvic surgery.

Combination of Ultrasound-Guided Serratus Anterior Plane Block and Rectus Sheath Block Provide Analgesia for Open Hepatectomy: A Report on 3 Cases

Perioperative analgesia in open hepatectomy is challenging because a large subcostal arc incision is often required. Extensive dissection of muscles and nerves is associated with severe intraoperative hemodynamic fluctuations and postoperative pain. Serratus anterior plane block (SAPB) and rectus sheath block (RSB) are commonly used for anesthesia and postoperative analgesia in patients undergoing chest wall surgery and abdominal surgery, respectively. In this case-series report, we present our experience with three patients in whom open hepatectomy and early extubation were performed successfully under a combination of ultrasound-Guided SAPB and RSB. Three patients were scheduled for open hepatectomy, all of them were diagnosed with severe hepatitis B cirrhosis. After due deliberation and with the consent of patients and their family, ultrasound-guided right SAPB and bilateral RSB were performed with the patient in the supine position. A total of 0.7mL/kg of 0.25% ropivacaine was used for nerve block. Sensory loss to pinprick from T5 to T10 was achieved in all three patients 20 min after administration of blocks. The operation went smoothly for all the patients. All three patients experienced quiet recovery and early extubation, and none of them complained of discomfort in the surgical site in the first 12 h after surgery. Here we present three cases of a combination of ultrasound-guided SAPB and RSB that may be an attractive option for anesthetic management of open hepatectomy in clinical practice.

Comparing Antegrade and Retrograde Parotidectomy: Surgical Parameters and Complications.

Introduction:Patotidectomy is the treatment of choice for superficial parotid gland lesions. The present study aimed to assess the facial nerve status, as well as peri-and postsurgical complications, in two surgical techniques (antegrade and retrograde) for parotidectomy.Materials and Methods:This study was conducted on 56 patients diagnosed with parotid neoplasms from 2013-2015. The patients were randomly assigned to two groups of antegrade and retrograde. In the retrograde group, the dissection was performed initially to expose the facial nerve branches, while in the antegrade approach, the facial nerve trunk was exposed initially. Different values, such as intraoperative bleeding, mass characteristics, and the time for different sections of the surgery, were noted. The facial nerve was examined after the surgery; moreover, hospital stay and drain removal time was also noted. During the six-month postoperative period, complications and squeals were also noted. Results:Based on the results, antegrade nerve dissection was performed in 24 patients, while retrograde nerve dissection was carried out in 25 patients. The two groups were compared for intraoperative bleeding, drain output, and drain removal time. Hospital stay was found to be statistically higher in the retrograde group (P<0.05). Other complications and morbidities, such as facial nerve trauma, sialoceles, salivary fistulas, Frey’s syndrome, skin sensory changes, and surgery time, were not statistically different (P≥0.05). Conclusions:As evidenced by the obtained results, retrograde dissection had higher intraoperative bleeding and longer hospital stay. It seems that skin flap dissection is more extensive in retrograde dissection, leading to more bleeding in this approach. These differences, although statistically significant, are not clinically important; consequently, surgeons’ experience and knowledge about the two approaches are of utmost importance.

Endoscopic Sciatic Neurolysis for Deep Gluteal Space Syndrome

Background: Deep gluteal syndrome (DGS) encompasses a spectrum of pathologies causing symptomatic sciatic nerve compression deep to the gluteus maximus muscle. Endoscopic sciatic neurolysis is an option for management of DGS when conservative treatment fails. Indications: Endoscopic sciatic neurolysis is indicated for retro-trochanteric pain, sciatica-like burning in the posterior thigh, and sitting discomfort that is reproducible on physical examination after failing conservative management. Technical Description: The technique presented here introduces a standard endoscopic sciatic neurolysis technique with an accessory posterolateral portal placed distally and in line with the sciatic nerve. Use of a switching stick through an accessory distal posterolateral portal can allow for in-line protection and retraction of the sciatic nerve while it is carefully released from compressive fibrous bands using an arthroscopic shaver. It is important that the accessory portal be placed under direct visualization with caution not to injure the sciatic nerve. An arthroscopic radiofrequency device can be used for hemostasis and further release of fibrous bands. At the end of the procedure, the sciatic nerve should be visualized fully released and freely mobile from the piriformis muscle to the level of the lesser trochanter. Results: In properly selected patients, the procedure is very successful. In a series of 35 cases, the procedure reduced sitting pain (present in 97% of patients preoperative, 17% of patients postoperative), reduced narcotic use, improved visual analog scale (VAS) pain scores, and improved modified Harris hip scores without major complications. Discussion: Although rare following hip arthroscopy, postoperative scarring and fibrous bands are a common cause of DGS which can be effectively treated by endoscopic sciatic nerve decompression. Results of endoscopic sciatic neurolysis have thus far been encouraging with improvements in patient reported outcome scores and high rates of satisfaction. However, complications do occur and can result in neurologic deficits. Nevertheless, with careful patient selection and meticulous sciatic nerve dissection, endoscopic sciatic neurolysis for DGS is a safe and effective technique for decompression of fibrous bands and adhesions that can lead to sciatic neuralgia.

Ventricular Infusion and Nanoprobes Identify Cerebrospinal Fluid and Glymphatic Circulation in Human Nerves.

Background:Growing evidence suggests that cerebrospinal fluid circulates in human nerves. Several conditions encountered by the plastic surgeon may be related to dysregulation of this system, including nerve transection, stretch injuries, and peripheral neuropathy. The purpose of this study was to show how ventricular infusion and nanoprobes identify CSF and glymphatic circulation in neural sheaths of human nerves.Methods:The technique of ventricular infusion using buffered saline was developed in 2017. The technique was used in a series of eight fresh cadavers before dissection of the median nerve, and combined with fluorescent imaging and nanoprobe injections in selected specimens.Results:Eight cadaver specimens underwent ventricular infusion. There were six female and two male specimens, ages 46–97 (mean 76.6). Ventricular cannulation was performed successfully using coordinates 2 cm anterior to coronal suture and 2.5 cm lateral to sagittal suture. Depth of cannulation ranged from 44 to 56 mm (mean 49.7). Ventricular saline infusion complemented by nanoprobe injection suggests CSF flows in neural sheaths, including pia meninges, epineurial channels, perineurium, and myelin sheaths (neurolemma).Conclusions:Ventricular infusion and nanoprobes identify CSF flow in neural sheaths of human nerves. CSF flow in nerves is an open circulatory system that occurs via channels, intracellular flow, and cell-to-cell transport associated with glial cells. Neural sheaths, including neurolemma, may participate in glucose and solute transport to axons. These techniques may be used in anatomic dissection and live animal models, and have been extended to the central nervous system to identify direct ventricle-to-pia meninges CSF pathways.

The learning curve and safety of continuous intraoperative vagus nerve monitoring in thyroid surgery.

Continuous intraoperative nerve monitoring allows for continuous feedback on the integrity of the recurrent laryngeal nerve (RLN) and the quality of its induced myogenic potential. The aims of this study were to assess the time requirements and risks associated with vagus nerve electrode placement when learning the technique. This is a prospective observational study carried out in a single otolaryngology department at the start of a trainee's placement. A total of 40 vagus nerve dissections in 31 consecutive operations (22 hemithyroidectomies, 9 total thyroidectomies) using automatic periodic stimulation (APS, Medtronic) are included. Of the electrode placements, 10 were performed by the trainer and 30 by the trainee. The time required for each surgical step and complications relating to vagus nerve dissection were recorded. The average (median+IQR) total additional time attributable to vagus nerve dissection, electrode placement and baseline electromyogenic assessment was 3.1mins (2.5-3.3) for the trainer and 4.8mins (4.1-5.3) for the trainee (p<0.0001). There was a downward trend in time requirement for the trainee (not statistically significant, p=0.080). Total operative time was 38min (35-45) for hemithyroidectomy and 56min (53-62) for total thyroidectomy. There was a mix of benign (74%) and malignant (26%) histology, no intraoperative complications relating to autonomic dysfunction and one (2.5%) transient nerve palsy. Operative time attributable to vagus nerve electrode placement is short and the procedure is easy to learn. Appropriate surgical technique and careful anaesthetic considerations allow monitoring to be performed safely, and may reduce the rate of RLN palsy.

Long-Term Outcome of Patients with Postoperative Refractory Diarrhea After Tailored Nerve Plexus Dissection Around the Major Visceral Arteries During Pancreatoduodenectomy for Pancreatic Cancer.

For pancreatic ductal adenocarcinoma (PDAC) surgery, extended dissection of the nerve plexus (pl) around the superior mesenteric artery (SMA) or celiac artery (CA) is sometimes necessary. This consequently results in postoperative refractory diarrhea. This study aimed to evaluate the clinical impact of extended nerve plexus dissection around major arteries on postoperative diarrhea. Patients who underwent pancreatoduodenectomy (PD) for PDAC between January 2013 and December 2016 were included. The frequency of diarrhea (defined as a condition requiring opioid antidiarrheal drug for at least 6months after surgery) and its short- and long-term outcomes were reviewed. Of 200 consecutive patients who underwent PD, 78 (39.0%) developed postoperative refractory diarrhea (diarrhea group), and 73 of them (93.6%) underwent hemi-circumferential or more nerve dissection for SMA or CA; both plSMA and plCA dissection were associated with diarrhea. Borderline resectable artery (BR-A) PDAC was included more in the diarrhea group (32.0% vs. 13.1%, P = 0.001); however, the local recurrence rate in the diarrhea group was significantly lower than that in the non-diarrhea group (14.1% vs. 26.2%, P = 0.036). The completion of adjuvant chemotherapy and overall survival were comparable between the two groups. The pre-albumin level improved in 2years, and 61.3% of patients with diarrhea could stop opioid antidiarrheal drugs within 3years of surgery. Although the frequency of diarrhea increased following nerve plexus dissection around arteries, diarrhea was controllable and resulted in a reduced local recurrence rate. Aggressive dissection of the nerve plexus may be justified for local disease control in BR-A PDAC.

Endotracheal Tube Electrode Neuromonitoring for Placement of Vagal Nerve Stimulation for Epilepsy: Intraoperative Stimulation Thresholds

ABSTRACT Vagal nerve stimulators (VNS) are indicated as a palliative treatment for medically refractory epilepsy. The vagus nerve may have a variable position within the carotid sheath and may be confused with a prominent ansa cervicalis. The objective of this study was to describe an intraoperative neuromonitoring technique for VNS placement and provide stimulation thresholds that may aid in the creation of stimulation protocols. A retrospective study was performed assessing 40 patients undergoing intraoperative vocal cord monitoring during vagal nerve stimulator placement surgery. Endotracheal electrodes were utilized to record vocal cord activity at various surgical time points. The stimulation thresholds were tested at the time of opening of the carotid sheath (mean 0.35 mA [range 0.08–1.00]), after full and circumferential dissection of the vagus nerve (0.34 mA [0.10–0.90]), after tenting of the vagus nerve in preparation for placement of the electrode (0.22 mA [0.06–1.20]), and after electrode placement (0.26 mA [0.05–1.20]). The vagus nerve was identified in all patients; it was located behind the common carotid artery (CCA) in two patients, on top of the internal jugular vein (IJV) in one patient, and in the typical location between the CCA and IJV in the remainder of patients. The average size of the vagus nerve was 2.9 mm [1.5–5.0]. Intraoperative vagus nerve stimulation represents a safe adjunctive tool that can help localize the nerve, particularly in the setting of varying anatomy or hazardous dissections. It may help reduce the potential for vagal trunk damage or electrode misplacement and potentially improve clinical outcomes.

Neurotization of Musculocutaneous Nerve with Intercostal Nerves Assisted with Videothoracoscopy. Clinical Case of a Patient with Brachial Plexus Palsy

In total brachial plexus preganglionic lesions (C5 for T1), different extraplexual neurotizations are indicated for partial motor function restitution specially for the elbow flexion. Neurotization with intercostal nerves (ICN) [Spanish Acronym] to musculocutaneous nerve has been known and accepted during many years with different results. The customary technique as described by various authors is carried out by means of a large submammary incision to harvest three or four intercostal nerves. Then are anatomosed by direct suture or grafts to the musculocutaneous nerve or its motor branches. Based on a previous study by the author on the possibility of performing the dissection of the intercostal nerves by videothoracoscopy, we present a clinical case of a 29-year-old patient with a complete brachial plexus injury in which we performed this technique and its results at 2 years.

Distance of Recurrent Laryngeal Nerve in Relation to Superior Parathyroid Gland During Thyroid Surgery.

In thyroid surgery, it is essential to identify and preserve recurrent laryngeal nerve to avoid injury to the nerve which will lead to nerve paralysis or paresis. The meticulous dissection of recurrent laryngeal nerve is important for careful identification and preservation of the nerve to prevent post operative vocal cord paresis and hoarseness. A single centre prospective, cross sectional study was conducted from May 2019 to January 2021 in Department of ENT and Head and Neck surgery in Kathmandu Medical College Teaching Hospital. The data on distance between recurrent laryngeal nerve and superior parathyroid gland during thyroidectomy were collected. The mean distance of recurrent laryngeal nerve in relation to superior parathyroid gland during thyroid surgery was 5.03±1.79 millimeters. The recurrent laryngeal nerve lies within 5mm of superior parathyroid gland in 83.05% cases and between 6 and 10mm in 15.25 % of cases. The recurrent laryngeal nerve is found in the close proximity to the superior parathyroid gland. The visual method of identification of recurrent laryngeal nerve can be widely adopted in thyroid surgery to prevent recurrent laryngeal nerve injury.

Anatomy of the optic nerve based on cadaveric dissections and its neurosurgical approaches: a comprehensive review

Vision is a complex sense that is widely represented in the cortex and involves multiple pathways that can be affected by conditions amenable to surgical treatment. From a neurosurgical point of view, the treatment of major lesions affecting the optic nerve, such as tumours, intracranial hypertension, trauma and aneurysms, can be approached depending on the segment to be worked on and the surrounding structures to be manipulated. Therefore, surgical manipulation of the visual pathway requires a detailed knowledge of functional neuroanatomy. The aim of this review is to present the functional and microsurgical anatomy of the second cranial nerve, through illustrations and cadaveric dissections, to support the choice of the best surgical approach and avoid iatrogenic injuries. For this purpose, a literature search was performed using the PubMed database. Additionally, cadaveric dissections were performed on adult cadaver heads fixed with formaldehyde and injected with coloured silicone.

Pelvic Nerves in Laparoscopy: A Review of Anatomy and Approach to Dissection

<h3>Study Objective</h3> Our objective is to review the anatomic course, sensory and motor functions, and approach to dissection of important pelvic nerves encountered during advanced gynecologic laparoscopy. <h3>Design</h3> Using annotated intraoperative footage, we illustrate surgical approaches to safe dissection of the following pelvic nerves: Ilioinguinal, iliohypogastric, lateral femoral cutaneous, femoral, genitofemoral, obturator, sciatic, hypogastric and pudendal nerves, lumbosacral trunk and sacral nerve roots. <h3>Setting</h3> Patients were placed in dorsal lithotomy position with legs in Yellowfin stirrups. The umbilicus was used for camera port placement, and three accessory ports were placed (in the bilateral lower quadrants and a second to the left of the umbilicus). <h3>Patients or Participants</h3> Patients requiring dissection of the aforementioned nerves for surgical treatment of deep infiltrating endometriosis, adhesiolysis, or treatment of pudendal neuralgia were selected. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Surgeons must have a comprehensive understanding of pelvic anatomy and comfort operating in deep pelvic spaces in order to minimize risk of inadvertent nerve injury. A systematic approach to nerve dissection enables adequate exposure of the operative field and safe space for lysis of adhesions, excision of endometriosis, and surgical treatment of pelvic pain syndromes.

Extralaryngeal branching of the recurrent laryngeal nerve. Autopsy case series

Background. The thesis «thyroid surgery is the surgery of the recurrent laryngeal nerve», which was defined in the XX ­century, remains relevant to this day. Thus, despite the use of modern scientific and technological achievements, vocal cord paresis is diagnosed on average in 9.8% patients after thyroid and parathyroid surgery.According to many authors, the main problem which a surgeon encounters is a difficult and sometimes individual anatomy of the recurrent laryngeal nerve. For example, in one study authors identified 28 variants of relationships between the ­recurrent laryngeal nerve and the inferior thyroid artery. In a recent meta-analysis, it was noted that the frequency of extralaryngeal branching remains underestimated and reaches 73% of cases. Anatomical variants of the recurrent laryngeal nerve or its thin branches, which have not been noticed in time, can lead to inevitable consequences — to nerve injury and a laryngeal dysfunctions, and if anatomical features are not detected on both sides — to a tragedy.Aim. The aim of this study is to determine anatomical variants of the extralaryngeal branches of the recurrent laryngeal nerve and their frequency in autopsy case series.Materials and methods. 46 (100%) recurrent laryngeal nerves were dissected in 23 cadavers. Their path was traced, their relationships with the inferior thyroid artery were determined, and the extralaryngeal branches of the recurrent laryngeal nerve were identified.Results. Few extralaryngeal branches of the recurrent laryngeal nerve were identified during dissection: tracheoesophageal branches, laryngeal branches, aberrant branches. Tracheoesophageal branches were determined in all cadavers. In 37 (80.4%) cases the recurrent laryngeal nerve had got two or more extralaryngeal laryngeal branches. In 6 (13.0%) cases aberrant branches were presented.The inferior thyroid artery was detected in 42 (91.3%) cases. The vessel was in close location with the recurrent laryngeal nerve, forming a neuro-arterial chiasm. In 39.1% of cases the recurrent laryngeal nerve was located between the branches of the inferior thyroid artery, in 39.1% of cases — deeper than the artery, and in 10.9% of cases — more superficial than the artery.Conclusion. The variable anatomical configuration of the recurrent laryngeal nerve inevitably causes difficulties during intraoperative nerve dissection. Tardy identification of these anatomical features can lead to the injury of nerves or its branches, which determines the amount of postoperative vocal cord paresis.

Enigmatic Neural Pathways: Potentiating Viral Neuroinvasion Into the CNS.

Enigmatic Neural Pathways: Potentiating Viral Neuroinvasion Into the CNS.