Superior Vessels Research Articles

A case series: 3-dimensional computed tomographic study of the superior orbital vessels: Superior orbital arcades and their relationships with the supratrochlear artery and supraorbital artery

Vascularcomplications from periorbital intravascular filler injection are major safety concerns. To thoroughly describe the superior orbital vessels near the orbital rim and propose considerations for upper eyelid and forehead injections. Fifty-one cadaver heads were infused with lead oxide contrast media through the external carotid artery, internal carotid artery, and facial and superficial temporal arteries. Computed tomography (CT) images were obtained after contrast agent injection, and 3-dimensional CT scans were reconstructed by using a validated algorithm. Eighty-six qualified hemifaces clearly showed the origin, depth, and anastomoses of the superior orbital vessels, which consistently deployed 2 distinctive layers: deep and superficial. Of all hemifaces, 59.3% had deep superior orbital vessels near the orbital rim, including 44.2% with deep superior orbital arcades and 15.1% with deep superior orbital arteries, which originated from the ophthalmic artery. Additionally, 97.7% of the hemifaces had superficial superior orbital arcades, for which 4 origins were identified: ophthalmic artery, superior medial palpebral artery, angular artery, and anastomosis between the angular and ophthalmic arteries. The arterial depth estimated from 3-dimensional CT needs to be confirmed by standard cadaver dissection. This study elucidated novel arterial systems and proposed considerations for upper eyelid and forehead injections.

The Superior Laryngeal Nerve and its Vulnerability in Surgeries of the Neck

Knowledge of anatomical considerations of the superior laryngeal nerve, a branch of the vagus, provides information to prevent intraoperative injuries and associated dysfunctions. The superior laryngeal nerve has external and internal branches providing motor innervation to the cricothyroid muscle and sensory innervation to the supraglottic mucosa of the larynx, respectively. The external laryngeal branch travels for a relatively greater distance together with the superior thyroid artery and the internal laryngeal branch accompanies, for a shorter distance, the superior laryngeal artery, though their relationship with their respective artery varies. Isolation and identification of the superior pole and superior laryngeal vessels, which are intimately related to the external and internal laryngeal branches, respectively, is clinically important. Both branches can potentially be severed, compressed, or stretched during surgical procedures of the neck such as thyroidectomy and anterior cervical discectomy. Injury to the external laryngeal nerve results in a reduction in the highest attainable frequency of the voice, while injury to the internal laryngeal nerve results in a loss of sensation in the laryngeal vestibule, increasing the risk of aspiration pneumonia. The consequences of superior laryngeal nerve injury are variable in growing literature and are commonly disregarded compared to the recurrent laryngeal nerve. The present study aims to assess the anatomical considerations of the superior laryngeal nerve pertaining to its course and relationship to the superior thyroid and superior laryngeal arteries. The study was done on 35 formalin‐fixed cadavers at Oakland University William Beaumont School of Medicine in 2018–2020. Following critical observation and careful dissection, photographs were taken and the data was analyzed quantitatively and in a descriptive manner. In our investigation, we found that out of twenty‐one cadavers, 52.4% of the external laryngeal branches are related posteromedial to the superior thyroid artery, while 47.6% are related anteromedial to it. On the other hand, our findings indicate that out of fourteen cadavers, 64.3% of the internal laryngeal branches are related superoposterior to the superior laryngeal artery, while 35.7% are inferoposterior to it. In addition, in most cases, the superior laryngeal artery crosses above the external laryngeal branch while traveling to pierce the thyrohyoid membrane to reach the larynx. The data portrays that both the external and internal laryngeal branches display a variation in their relationship with the superior thyroid artery and the superior laryngeal artery. The findings show a clinically important variation in the course and relationship of the superior laryngeal nerve and its related vessels, especially the posteromedial and superoposterior relationships, which exposes the nerves during ligation of the respective vessels. Awareness of these variable relationships is critical for identification and isolation of the neurovascular structures in order to preserve the nerve, prevent a reduction in the highest attainable frequency of the voice, and minimize the risk of aspiration pneumonia during surgical procedures of the neck.

Factors Influencing the Relationship of the External Branch of the Superior Laryngeal Nerve with the Superior Pole Vessels of the Thyroid Gland.

Objectives:In a thyroidectomy, the external branch of the superior laryngeal nerve (EBSLN) is a potential risk during the superior pole dissection due to its close anatomical relationship with the superior thyroid artery and its highly variable anatomy. In this study, we aimed to evaluate the relationship of EBSLN with the superior pole considering Cernea classification and the factors affecting this relationship.Methods:The data of thyroidectomized 126 patients (95 female, 31 male) with 200 neck sides (mean age of 45.6±12.1 years) using intraoperative neuromonitoring (IONM) for the EBSLN exploration were evaluated retrospectively. During the superior pole dissection, the EBSLN course was classified according to Cernea classification after being confirmed with IONM. It was defined as a large goiter in the case of the thyroid lobe volume being >50 cc. The factors influencing the presence of type 2b, which has the highest risk of injury, were evaluated using logistic regression analysis.Results:Of the 200 EBSLNs evaluated, 52 (26%) were type 1, 134 (68%) were type 2a, and 14 (7%) were type 2b. The mean volumes of the resected thyroid lobes were 22±25 cc (min-max: 2-136), 23±20 cc (3-163), and 39±24 cc (3-65) in type 1, 2a and 2b, respectively, which was significantly higher in type 2b (p=0.035). Presence of large goiter rates were 5.8% (n=3), 8.2% (n=11), 64.3% (n=9) in type 1, 2a, and 2b, respectively, and was significantly higher in type 2b (p=0.0001). There was no significant difference between EBSLN Cernea types concerning age, sex, nerve side, presence of cancer and hyperthyroidism. In logistic regression analysis, large goiter was the only independent factor associated with Cernea type 2b. In case of a lobe volume greater than 50 cc, the probability of type 2b presence was approximately 25 times higher (p<0.001, odds ratio: 25.262).Conclusion:Type 2b course of EBSLN is more common in large goiters, and it is 25 times more likely to be seen in the presence of a lobe volume over 50 cc. Thus, it should be considered that the probability of this high-risk course is significantly higher in large goiters.

Determinación de la parábola de la vasculatura de la retina mediante un algoritmo computacional de segmentación

El análisis cuantitativo de la arquitectura de las venas temporales superior e inferior y su monitoreo sobre el tiempo puede facilitar el diagnóstico y tratamiento oportuno de la retinopatía diabética. En este trabajo se presenta un novedoso método que consiste de dos etapas correspondientes a la segmentación automática y modelado parabólico de las venas temporales superior e inferior en imágenes de fondo de ojo. En la primera etapa, el detector lineal multiescala (DLM) es empleado para detectar estructuras de tipo arterial en imágenes de la retina. Debido a que DLM es un método de realzado arterial, es necesario aplicar una estrategia de umbralización para clasificar pixeles de tipo arterial con respecto al fondo de la imagen, donde un valor de umbral determinado de forma experimental es comparado con cinco métodos de umbralización del estado del arte. En esta etapa, el método de segmentación propuesto es comparado con seis métodos especializados del estado del arte en términos de eficiencia de segmentación. En la segunda etapa, se desempeña un modelado parabólico mediante una estrategia de optimización utilizando un Algoritmo de Distribución Marginal Univariada sobre las arterias previamente segmentadas, y los resultados son comparados con dos métodos paramétricos del estado del arte y con las delineaciones realizadas por especialistas. Los resultados de segmentación arterial utilizando el detector lineal multiescala demostraron una alta eficiencia de segmentación obteniendo un valor de 0.9618 utilizando la base de datos DRIVE de imágenes de fondo de ojo. De igual forma, los resultados de modelado parabólico entregaron una eficiencia promedio de 0.825 con respecto a las delineaciones realizadas por especialistas oftalmólogos de las venas temporales superior e inferior. En base a los resultados de eficiencia y al tiempo computacional (5.62 segundos), el método propuesto puede considerarse como altamente apropiado para desempeñar diagnóstico asistido por computadora en el área de oftalmología.

Focal/multifocal and geographic retinal dysplasia in the dog-In vivo retinal microanatomy analyses.

To examine the in vivo microanatomy of retinal folds and geographic lesions in dogs with acquired or inherited retinal dysplasia. Thirteen dogs had retinal microanatomy evaluation under general anesthesia using cSLO/sdOCT; two eyes had noninherited multifocal retinal folds, five had inherited multifocal retinal folds (drd1 or drd2), and 10 geographic retinal dysplasia. Retinas from two drd2 carrier dogs were examined by histology and immunohistochemistry (IHC) after in vivo imaging. Retinal folds are the common feature of acquired focal/multifocal or geographic retinal dysplasia, are indistinguishable structurally from those associated with syndromic oculoskeletal dysplasia, and represent outer nuclear layer invaginations and rosettes visible by sdOCT. In dogs heterozygous for oculoskeletal dysplasia, the folds form clusters in a perivascular distribution along superior central vessels. IHC confirmed photoreceptor identity in the retinal folds. The geographic dysplasia plaques are not focally detached, but have inner retinal disorganization and intense autofluorescence in cSLO autofluorescence mode that is mainly limited to the geographic lesion, but is not uniform and in some extends beyond the plaques. We propose that the autofluorescent characteristic of the geographic lesions is associated with an inner retinal disruption associated with perivascular or infiltrating macrophages and phagocytosis of cellular debris. As well, we suggest restructuring the examination forms to distinguish the folds that are sporadically distributed from those that have a perivascular distribution as the latter likely represent carriers for drd. In this latter group, DNA testing would be a helpful tool to provide specific breeding advice.

OBSERVATION OF VITREOUS FEATURES USING ENHANCED VITREOUS IMAGING OPTICAL COHERENCE TOMOGRAPHY IN HIGHLY MYOPIC RETINOSCHISIS

To observe features of the posterior vitreous and vitreoretinal interface in highly myopic eyes with retinoschisis using enhanced vitreous imaging optical coherence tomography. Comprehensive ophthalmologic examination and enhanced vitreous imaging optical coherence tomography were performed in 77 eyes of 63 patients with highly myopic retinoschisis. Two different modes of spectral domain optical coherence tomography were employed to estimate retinoschisis and the posterior vitreous features in optical coherence tomography images, respectively. The types and distribution of vitreoretinal interface abnormalities were also analyzed. Complete posterior vitreous detachment (PVD) was identified in 55 eyes (71.4%) with a Weiss ring. Residual cortex was found in 39 eyes (70.9%) with complete PVD. Vitreoretinal interface changes, including vitreoretinal adhesion and epiretinal membrane (ERM), most frequently appeared in the macular area (47.3%), followed by the inferior arched vessels region (34.5%). In partial PVD eyes, vitreoretinal traction, vitreoretinal adhesion, and epiretinal membrane tended to be observed in the inferior and superior arched vessels regions (54.5 and 40.9%, respectively). Among all types of vitreoretinal interface abnormalities, epiretinal membrane comprised the largest proportion (46.8%) despite the status of PVD. The presence of inner layers of retinoschisis connoted a relatively high possibility of vitreoretinal interface abnormalities occurring. Enhanced vitreous imaging optical coherence tomography reveals a high prevalence of vitreoretinal interface abnormalities in highly myopic eyes with retinoschisis. Vitreous cortex tends to remain on the macular area in eyes with complete PVD. Our findings may lead to better guidance for the surgical treatment of highly myopic retinoschisis.

RS01. Planned Exclusion of the Celiac Artery During Complex Thoracic Endovascular Aortic Repair Procedures: Is It Safe?

Achieving adequate proximal and distal fixation and maintaining visceral branch flow make thoracic endovascular aortic repair (TEVAR) procedures for thoracoabdominal aneurysm (TAAA) complex. Whereas superior mesenteric artery (SMA) and renal vessels must be preserved, there may be selected cases in which patent celiac arteries may be intentionally excluded. We sought to define the incidence of ischemic complications of celiac exclusion during complex TEVAR procedures and to define specific conditions in which the celiac can be safely covered. We performed a retrospective 12-year audit in two tertiary care institutions of patients with a suprarenal aneurysm or TAAA treated by standard TEVAR involving the distal thoracic aorta with intentional celiac fabric coverage or bare distal stent across the celiac (preserved), custom or modified aortic endografts (complex TEVAR/fenestrated EVAR [FEVAR]) involving multiple visceral branch endoprostheses with and without planned celiac exclusion, or a transabdominal hybrid approach with visceral debranching bypasses (with or without celiac revascularization) from distal inflow sites and staged or simultaneous long length thoracoabdominal endografting. The decision to exclude celiac arteries was made from preoperative computed tomography findings of a small diameter, stenotic origin, presence of replaced right hepatic artery, or existing large SMA celiac collaterals. Cases with a chronically occluded celiac were excluded. Primary end points were 30-day mortality, spinal cord ischemia, and any foregut ischemia occurring early or during late follow-up (ischemic acalculous cholecystitis or splenic infarction). There were 223 patients who met inclusion criteria (Table I). In the standard/complex TEVAR/FEVAR group, 26 patients (15%) had celiac coverage with 144 cases of celiac preservation. In the hybrid group, 11 cases (21%) had celiac exclusion, whereas 42 patients had a separate celiac bypass. In the standard/complex TEVAR/FEVAR group, celiac coverage did not result in significant increase in foregut ischemic events (3.8% vs 2.1%; P = .6; Table II). However, exclusion of the celiac artery during hybrid cases resulted in an increase in foregut ischemia (two early and one case presenting 1 year later) compared with patients having celiac bypass revascularization (27% vs 7%; P = .06). The incidence of spinal cord ischemia and 30-day all-cause mortality was not different with regard to celiac exclusion or between treatment groups. Selected celiac exclusion appears safe during standard/complex TEVAR/FEVAR procedures as long as SMA patency is ensured. A hybrid approach to complex TAAA requires separate bypass to all patent visceral branches including the celiac to minimize foregut ischemia.Table IDemographicsVariableTEVAR with celiac coverageTEVAR with celiac revascularizationHybrid without celiac revascularizationHybrid with celiac revascularizationNo.261441142M/F69/3174/2655/4568/32Urgent/emergent35131810History of aortic surgery27515536Dissection present12102710TEVAR, Thoracic endovascular aortic repair.Values are reported as percentage. Open table in a new tab Table IIPostoperative outcomesVariableTEVAR with celiac coverageTEVAR with celiac revascularizationTEVAR covered celiac vs TEVAR revascularized celiac, χ2 comparison P valueHybrid without celiac revascularizationHybrid with celiac revascularizationHybrid with and without revascularization, χ2 comparison P valueNo.26144114230-Day mortality7.7 (2)3.5 (5).319.1 (1)11.9 (5).79SCI3.8 (1)15.3 (22).120 (0)11.9 (5).57Foregut ischemia3.8 (1)2.1 (3).5927.2 (3)7.1 (3).06SCI, Spinal cord ischemia; TEVAR, thoracic endovascular aortic repair.Values are reported as % (No.). Open table in a new tab

Vascular supply of the femoral head in sheep-Implications for the ovine femoroacetabular impingement model.

Sheep hips have a natural non-spherical head similar to a cam-type deformity in human beings. By performing an intertrochanteric varus osteotomy, cam-type femoroacetabular impingement can be induced experimentally. In sheep, the aspherical portion is located superiorly-exactly matching the region where the superior retinacular vessels enter the femoral head-neck junction in human beings. In order to fully exploit the potential of this experimental FAI model, a safe osteochondroplasty of the superior asphericity would need to be done without the risk of avascular necrosis. The aim of this study was to describe the vascular anatomy of the femoral head in sheep from the aorta to the retinacular vessels in order to perform safe femoral osteochondroplasty of the superior femoral asphericity in sheep. Sixty-two ovine hips were analyzed using CT angiography (30 hips), post mortem intravascular latex injection (6 hips), vascular corrosion casting (6 hips), and analysis of the distribution of vascular foramina around the femoral head-neck junction in macerated ovine femora (20 hips). The ovine femoral head receives its blood supply from anterior retinacular arteries from the lateral femoral circumflex artery, and from posterior retinacular arteries from the medial femoral circumflex artery. The superior aspherical portion is free of vessels. Detailed knowledge about vascular anatomy of sheep hips is of clinical significance since it allows to perform osteochondroplasty of the superior aspherical portion in the experimental ovine FAI model safely without the risk of osteonecrosis. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2340-2348, 2018.

Identification of external branch of superior laryngeal nerve during thyroid surgery: a prospective study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Identification of external branch of superior laryngeal nerve (EBSLN) according to Cernea et al classification and to describe a surgical technique of superior pole dissection to preserve EBSLN during thyroid surgeries.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The study was done over 2 years period in a tertiary care hospital. 105 nerves were studied among the 90 patients who underwent thyroid surgeries. Avascular dissection over the JOLL’S triangle was carried out and identified EBSLN were classified according to Cernea et al classification. Individual ligation of superior pole vessels was carried out after identifying the nerve. Outcome was studied relating the identified nerve with sides of thyroidectomy performed, size of thyroid gland and nerves at risk according to Cernea et al classification. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Of the 105 nerves studied, in 81.90% of patients the nerve was identified. There were 34.88% of Type 1 nerves, 52.33% of Type 2A nerve and 12.79% of Type 2B nerves identified. Less number of nerves could be identified on the left side. Type 2B nerves were more common on left side inspite of less number of dissections carried out on left. Type 2 variation was more common in large goiters.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Careful dissection should be done in superior pole in avascular cricothyroid space, with lateralization of superior pole and individual identification of superior pole vessels once the nerve is identified. Identification of the nerve is mandatory in all patients who undergo thyroid surgery for optimal functions of the larynx. These results showed a better identification of nerves by proper surgical techniques without use of any sophisticated equipments. &lt;/p&gt;

Non-invasive method of monitoring retinal vasculitis in patients with birdshot chorioretinopathy using optical coherence tomography

Background/aimsTo investigate the utility of using montaged optical coherence tomography (OCT) thickness maps to monitor perivascular thickness as a marker of vasculitic activity in patients with large-vessel retinal vasculitis.MethodsThis is...

Relationship between vessel diameter and depth measurements within the limbus using ultra-high resolution optical coherence tomography

PurposeTo establish a relationship between the diameter and depth position of vessels in the superior and inferior corneo-scleral limbus using ultra-high resolution optical coherence tomography (UHR-OCT). MethodsVolumetric OCT images of the superior and inferior limbus were acquired from 14 healthy subjects with a research-grade UHR-OCT system. Differences in vessel diameter and depth between superior and inferior limbus were analyzed using repeated measured ANOVA in SPSS and R. ResultsThe mean (± SD) superior and inferior diameters were 29±18μm and 24±18μm respectively, and the mean (± SD) superior and inferior depths were 177±109μm and 207±132μm respectively. The superior limbal vessels were larger than the inferior ones (RM-ANOVA, p=0.004), and the inferior limbal vessels were deeper than the superior vessels (RM-ANOVA, p=0.041). There was a positive linear association between limbal vessel depth and size within the superior and inferior limbus with Pearson correlation coefficients of 0.803 and 0.754, respectively. ConclusionThis study demonstrated that the UHR-OCT was capable of imaging morphometric characteristics such as the size and depth of vessels in the limbus. The results of this study suggest a difference in the size and depth of vessels across different positions of the limbus, which may be indicative of adaptations to chronic hypoxia caused by the covering of the superior limbus by the upper eyelid. UHR-OCT may be a useful tool to evaluate the effect of contact lenses on the microvascular properties within the limbus.

Dark Signals in the Choroidal Vasculature on Optical Coherence Tomography Angiography: An Artefact or Not?

Optical coherence tomography angiography (OCTA) based on mathematical processing of sequentially acquired structural OCT images has been applied widely in both retinal and choroidal research and may have advantages over traditional angiography. Images obtained by OCTA are rendered under the assumption that the only moving entity in the retina is blood flow. Optical phenomena and image processing algorithms may create imaging artefacts. Therefore, OCTA images require careful interpretation. This review discusses the dark signals seen in the choroidal vasculature on OCTA using multiple factor analysis. For accurate and comprehensive interpretation of the choroidal vasculature, we recommend simultaneous consideration of the laser light penetration depth and masking effect of retinal pigment epithelium, the orientation of vessels in relation to the scanning lasers and blood flow, the range of regional detectable velocity of blood flow, atrophic tissues in the periphery, and absorption of superior vessels on the scanning laser.

The Relationships of the Maxillary Sinus With the Superior Alveolar Nerves and Vessels as Demonstrated by Cone-Beam CT Combined With μ-CT and Histological Analyses.

There are no available detailed data on the three-dimensional courses of the human superior alveolar nerves and vessels. This study aimed to clarify the relationships of the maxillary sinus with the superior alveolar nerves and vessels using cone-beam computed tomography (CT) combined with μ-CT and histological analyses. Digital imaging and communication in medicine data obtained from the scanned heads/maxillae of cadavers used for undergraduate/postgraduate dissection practice and skulls using cone-beam CT were reconstructed into three-dimensional (3D) images using software. The 3D images were compared with μ-CT images and histological sections. Cone-beam CT clarified the relationships of the maxillary sinus with the superior alveolar canals/grooves. The main anterior superior alveolar canal/groove ran anteriorly through the upper part of the sinus and terminated at the bottom of the nasal cavity near the piriform aperture. The main middle alveolar canal ran downward from the upper part of the sinus to ultimately join the anterior one. The main posterior alveolar canal ran through the lateral lower part of the sinus and communicated with the anterior one. Histological analyses demonstrated the existence of nerves and vessels in these canals/grooves, and the quantities of these structures varied across each canal/groove. Furthermore, the superior dental nerve plexus exhibited a network that was located horizontally to the occlusal plane, although these nerve plexuses appeared to be the vertical network that is described in most textbooks. In conclusion, cone-beam CT is suggested to be a useful method for clarifying the superior alveolar canals/grooves including the nerves and vessels.

C-Kit+ progenitors generate vascular cells for tissue-engineered grafts through modulation of the Wnt/Klf4 pathway

The development of decellularised scaffolds for small diameter vascular grafts is hampered by their limited patency, due to the lack of luminal cell coverage by endothelial cells (EC) and to the low tone of the vessel due to absence of a contractile smooth muscle cells (SMC). In this study, we identify a population of vascular progenitor c-Kit+/Sca-1- cells available in large numbers and derived from immuno-privileged embryonic stem cells (ESCs). We also define an efficient and controlled differentiation protocol yielding fully to differentiated ECs and SMCs in sufficient numbers to allow the repopulation of a tissue engineered vascular graft. When seeded ex vivo on a decellularised vessel, c-Kit+/Sca-1-derived cells recapitulated the native vessel structure and upon in vivo implantation in the mouse, markedly reduced neointima formation and mortality, restoring functional vascularisation. We showed that Krüppel-like transcription factor 4 (Klf4) regulates the choice of differentiation pathway of these cells through β-catenin activation and was itself regulated by the canonical Wnt pathway activator lithium chloride. Our data show that ESC-derived c-Kit+/Sca-1-cells can be differentiated through a Klf4/β-catenin dependent pathway and are a suitable source of vascular progenitors for the creation of superior tissue-engineered vessels from decellularised scaffolds.

Minilaparoscopy-Assisted Hemithyroidectomy and Central Neck Dissection (Level VI) Using Bilateral Breast Approach

Introduction: Minilaparoscopy-assisted thyroidectomy using the bilateral breast approach is a technique for thyroidectomy in patients with thyroid disease. This technique can promote the effect of cosmetology in thyroid surgery. In this video, we outline the instrument, operating room setup, and trocar position, present a minilaparoscopy-assisted hemithyroidectomy and central neck dissection (level VI), and demonstrate recurrent laryngeal nerve and two parathyroids in operation. Materials and Methods: In August 2014, we operated on a 35-year-old female patient. The patient underwent fine-needle aspiration cytology, diagnosed as left papillary thyroid carcinoma. After CT scan and ultrasonic inspection preoperation, the clinical staging is cT1aN0M0 staging I. According to the Chinese thyroid nodule and thyroid cancer guideline,1 we decided to perform left hemithyroidectomy and central neck dissection (level VI) using a bilateral areolar approach. 0.2 mL carbon nanoparticle suspension was injected to the thyroid gland with ultrasonic guidance 2 weeks before operation. The approach starts with the thyroid isthmus liberation that is dissected free from the anterior part of the trachea and transected. Then, the superior pole vessels are divided. The superior pole is then mobilized laterally and the recurrent laryngeal nerve is searched for at the inferior pole. The dissection continues between the nerve and the posterior part of the thyroid progressively, from bottom to top. After the recurrent nerve dissection, the gland can usually be extracted without difficulty, dividing the last vessels in berry ligament holding the gland. While in central neck dissection, first, we confirmed the lateral boundaries of central compartment and identified the recurrent laryngeal nerve. Then completed the central neck dissection. Finally, we present the superior thyroid artery, recurrent laryngeal nerve, and parathyroids after dissection, cleaning up, and closure. Results: The patient who was operated with this technique had a duration of hospitalization of 3 days without any postoperative complication. Carbon nanoparticle suspension is an ideal lymphatic tracer for endoscopic thyroidectomy and central neck dissection, although there is some leakage of carbon nanoparticle suspension in this patient. It does not affect the identification and preservation of recurrent laryngeal nerve and parathyroids. Conclusions: We prefer to operate cN0 thyroid cancer using this technique because it allows us to better identify and preserve the recurrent laryngeal nerve and parathyroids and same boundaries in central neck dissection. Moreover, it brings better cosmetic results for young patients. No competing financial interests exist. Runtime of video: 9 mins 57 secs

Thyroid Diseases

The thyroid plays a key role in normal metabolic and homeostatic processes, including thermomodulation, protein synthesis, carbohydrate and lipid metabolism, and modulation of adrenergic regulation. Surgical consultations are most often requested for control of hyperthyroidism or for treatment of euthyroid nodular disease. This review describes the approach to the patient with hyperthyroidism and with euthyroid nodular disease, including papillary, follicular, anaplastic, medullary, and primary thyroid cancer, and oncocytic (Hürthle cell) carcinoma. Operative techniques of thyroidectomy are described and include positioning, incisions-making, and troubleshooting. Postoperative care, including thyroid hormone management, is described. Complications and outcome evaluation are discussed. Tables list the etiologies of hyperthyroidism, benign and malignant etiologies of euthyroid nodular disease, familial syndromes of thyroid disease, the Bethesda classification of fine needle aspiration cytology and associated malignancy risk, the elements of common prognostic schemes for well-differentiated thyroid cancer, and the staging of differentiated, medullary, and anaplastic thyroid cancer. Figures show the six levels of cervical lymph nodes, the initial incision in a thyroidectomy, a midline incision, the superior pole vessels, the upper and lower parathyroid glands, the recurrent laryngeal nerve, and Delphian lymph nodes. An algorithm shows the approach to the patient with thyroid disease This review contains 7 figures, 8 tables, and 64 references.

Modifications of transaxillary approach in endoscopic da Vinci-assisted thyroid and parathyroid gland surgery.

Endoscopic surgery for treatment of thyroid and parathyroid pathologies is increasingly gaining attention. The da Vinci system has already been widely used in different fields of medicine and quite recently in thyroid and parathyroid surgery. Herein, we report about modifications of the transaxillary approach in endoscopic surgery of thyroid and parathyroid gland pathologies using the da Vinci system. 16 patients suffering from struma nodosa in 14 cases and parathyroid adenomas in two cases were treated using the da Vinci system at the ENT Department of Homburg/Saar University and in cooperation with the Department of General Surgery in New Sant'Agostino Hospital, Modena/Italy. Two different retractors, endoscopic preparation of the access and three different incision modalities were used. The endoscopic preparation of the access allowed us to have a better view during preparation and reduced surgical time compared to the use of a headlamp. To introduce the da Vinci instruments at the end of the access preparation, the skin incisions were over the axilla with one incision in eight patients, two incisions in four patients and three incisions in a further four patients. The two and three skin incisions modality allowed introduction of the da Vinci instruments without arm conflicts. The use of a new retractor (Modena retractor) compared to a self-developed retractor made it easier during the endoscopic preparation of the access and the reposition of the retractor. The scar was hidden in the axilla and independent of the incisions selected, the cosmetic findings were judged by the patients to be excellent. The neurovascular structures such as inferior laryngeal nerve, superior laryngeal nerve and vessels, as well as the different pathologies, were clearly 3D visualized in all 16 cases. No paralysis of the vocal cord was observed. All patients had a benign pathology in their histological examination. The endoscopic surgery of the thyroid and parathyroid gland can be performed using the da Vinci system and offers an excellent, intra-operative, 3D visualization of the neurovascular structures. The new incision modalities, use of a new retractor, and endoscopic preparation of the access made the surgery easier and safer using the transaxillary access to the thyroid and parathyroid glands. The modified skin incisions allowed an improved movement of the da Vinci arms during operation.

Néphrectomie polaire supérieure gauche robot assistée avec urétérectomie associée, dans le cadre d’un système urinaire double complet symptomatique

We report the case of a laparoscopic robot assisted left upper polar partial nephrectomy with total ureterectomy performed in a teenager. A 14 year-old girl was referred to our institution for stress urinary incontinence. The morphological assessment (ultrasound scan and uro-MRI) showed a double collecting system with a complete ureteral duplication complicated by a dysplasia of the upper moiety of the duplex left kidney and a mega ureter. The surgery started on a lateral decubitus position by the upper polar partial nephrectomy and the ureter section behind superior polar renal vessels. The patient was placed in a supine position and the mega ureter was released and sectioned at the level of the distal adynamic segment in the left uterine parameter. The transperitoneal route was chosen as it provides a large workspace and allows the dissection of the ureters into their pelvic portion by a simple repositioning of the robot ports without additional incision and without any modification of the operative field. No intraoperative and postoperative complication was noticed. Laparoscopic robotic assisted surgery in pediatric urology is increasing, and to our knowledge, we reported this technique and surgery for the first time in France and in children. In the reported case, we showed that the robotic minimally invasive surgery in children is an innovative and safe technique for the treatment of symptomatic upper urinary tract malformations.

Temporal and infratemporal hematoma

Background Upper third molar exodontia is one of the most common and simple dentoalveolar surgical procedures. Complications, such as bleeding from the posterior superior alveolar vessels are rare but potentially dangerous.

Retrosternal Thyroid Goiter: Recurrent Laryngeal Nerve Dissection According to the Charles Proye's Toboggan Technique

Introduction: We present a case report supported by a video of a case of recurrent retrosternal thyroid goiter with superior identification of the recurrent laryngeal nerve (also called the Charles Proye's toboggan technique).1 Materials and Methods: In November 2012, we operated a 71-year-old patient for a recurrent unilateral retrosternal thyroid goiter. The patient underwent a subtotal thyroidectomy 20 years earlier; she showed symptoms of airway and esophageal compression. After a CT scan and a laryngoscopy, the patient underwent a right thyroid lobectomy. The surgery of retrosternal goiter is at increased risk for iatrogenic recurrent laryngeal nerve lesion.2 Charles Proye described a surgical technique to avoid this lesion. To have a better exposition, a section of the prethyroid muscles can be considered, particularly if it is a voluminous and/or recurrent goiter.3–4 The approach starts with the thyroid isthmus liberation that is dissected free from the anterior part of the trachea and transected. Then, the middle thyroid vein is divided and the superior pole vessels are divided. The superior pole is then mobilized laterally, and the recurrent laryngeal nerve is searched for at its entry point into the larynx. The nerve function can be verified by the neuromonitoring, which also helps to find it in this vessel-rich area. The dissection continues between the nerve and the posterior part of the thyroid, progressively from top to bottom, descending as on a toboggan. After the recurrent nerve dissection, the goiter can usually be extracted without difficulty, dividing the last vessels holding the goiter inside.1–4 Results: With the toboggan technique, it is often possible to do the thyroidectomy for mediastinal goiter without sternotomy and recurrent nerve damage.1 Using this technique, the recurrent nerve is never put under tension. The patient operated with this technique had a duration of hospitalization of 3 days without any postoperative complication. Conclusions: Whenever possible, we prefer to operate intrathoracic goiters using this technique because it allows us to better recognize and preserve the recurrent nerve without putting it under tension. The Source of Work or Study: In 1981, Charles Proye described a new surgical technique to operate intrathoracic goiters without sternotomy and with preservation of recurrent nerve; the surgery of mediastinal goiter is at increased risk for iatrogenic recurrent laryngeal nerve lesion. We utilize in our clinic this technique for intrathoracic goiters. This video describes the details of the Charles Proye's technique. The authors have not received any payment or support. The article is based on a videocommunication during the congress of the IAES in Helsinki, August 2013. Running time of video: 4 mins, 53 secs