Topographic and anatomical features of muscular and vascular structures in lateral cervical region during prenatal period of human ontogenesis

Background. One of topical areas of morphological research is features of topographic a relationships of the vascular, nervous, muscular, fascial and cartilaginous structures of the neck in prenatal period of human ontogenesis, as data on their formation at different stages of development will improve diagnostic methods of visualization and surgical correction of congenital and acquired pathologies of head and neck. Objective. To find out the peculiarities of synthopia of vascular and muscular structures of the lateral cervical region in human prefetuses. Methods. 9 human prenatal specimens aged 9-12 weeks of prenatal development have been studied by using a set of morphological methods, according to existing bioethical norms. Results. During 9th week of development, bony and musclar boundaries of the lateral triangle of the neck, the carotid vagina, and the components of the vascular-nervous bundle of the neck have been determined. Within the carotid triangle, the external carotid artery is located superficially; it is crossed frontally by the cervical branch of facial nerve and the sublingual nerve. The superior thyroid artery departs from the external carotid artery at the level of the cartilaginous model of the large horns of hyoid bone and passes to the rudiment of thyroid gland. Retropharyngeal space is found at 9th week of development, moderately filled with adipose tissue. The anterior vertebral plate of the cervical fascia forms the bottom for posterior triangle of neck. Conclusion. The lateral cervical region in human prefetuses is represented by a multilayered topographic zone with formed boundaries and contents. Cervical fascia forms carotid vagina within the carotid triangle, and pharyngeal space. The course of blood vessels and nerves within the lateral cervical region is variable. Three-dimensional reconstructions of prefetuses serve as evidence of the early formation of definitive topographic connections within early bony and cartilaginous models in relation to the muscles of the anterior and lateral cervical regions.

Perforator flaps based on the deltoid branch of the thoracoacromial artery: anatomical study

Objectives: Tissue defects in the lateral triangle of the neck and the anterior cervical region represent a high demand for plastic and reconstructive surgery. Their management most often requires regional or free flaps. The perforator flap based on the deltoid branch of the thoracoacromial artery (TAA) may be a good solution for these indications. The objective of this work is to propose anatomical landmarks to raise perforator flaps pedicled on the deltoid branch of the TAA. Methods: We carried out dissection of 24 perforator flaps based on the deltoid branch of the TAA, in body donor specimens preserved in a glycerin-rich, formalin-free solution. The TAA was first injected with methylene blue. The vascular territory, location of perforators relative to known landmarks, along with the flap’s potential amplitude and arc of rotation were studied. Results: The main perforating arteries of the flap were located in the middle of the deltopectoral groove, often surrounded by adipose tissue in 18 out of 24 dissections. In 22 out of 24 dissections, there were at least 2 perforator arteries originating from the deltoid branch. The average diameter of the perforator arteries was 1 mm. The flap’s amplitude of movement made it possible to reach in all cases the lateral triangle of the neck and the anterolateral cervical region. Conclusion: The thoracoacromial artery has already been used for perforator flaps. However, the individualization of its deltoid branch offers to practitioners new surgical options. This anatomical study of the perforator flap based on the deltoid branch of the TAA made it possible to review the anatomical bases for the raising of this flap, and to fix useful landmarks for the surgeon in order to propose an easily feasible surgical technique.

MORPHOLOGICAL TRANSFORMATIONS OF TUBULAR STRUCTURES OF THE FETUSES HEPATODUODENAL LIGAMENT

The components of the hepatoduodenal ligament play an important role in the process of digestion. Calculi in the common bile duct are found in 10-15% of individuals suffering from chronic calculous cholecystitis, and obstruction of bile ducts is found in 59,1-67,4% of cases. The objective of the study was to investigate peculiarities of component morphogenesis of the hepatoduodenal ligament during the perinatal period of human ontogenesis, individual and age anatomical variability, spatial-temporal transformations, and anatomical-histological peculiarities of its structures. To achieve the stated purposes the following complex of methods was used: macroscopic – for visual detection of the state of the hepatoduodenal ligament components, vascular injection – to study peculiarities and variants of angioarchitectonics of the arterial components of the hepatoduodenal ligament, statistical – to determine peculiarities of morphological transformations of the components and adjacent structures of the hepatoduodenal ligament at different periods of prenatal and postnatal periods of human ontogenesis. According to the results of the study several accessory triangles of the hepatoduodenal ligament were found and described. The common bile duct, the common hepatic duct, cystic duct, left and right hepatic ducts, hepatic portal vein, common hepatic artery, right gastric artery, hepatic artery proper, right, left and accessory branches of the hepatic artery proper are permanent components of the ligament forming a number of combinations-crossings between themselves. Meanwhile, we have determined certain regularities of the formed pattern including minimum 5 permanent triangles to be distinguished: Calot’s triangle or "superior lateral triangle", "superior medial triangle", "inferior medial triangle", "inferior lateral triangle", "central space of the hepatoduodenal ligament".

The Lateral Triangle of the Middle Fossa

BACKGROUND The challenge of locating and isolating the internal maxillary artery (IMA) hinders its potential use as an arterial donor for extracranial-to-intracranial bypass surgery. OBJECTIVE To introduce a new approach through the middle cranial fossa for easy access and safe exposure of the IMA. METHODS Ten specimens were prepared for surgical simulation. After the pterional craniotomy, a 2-step drilling technique was performed (lateral triangle). First, a triangular craniectomy was completed anterolateral to the foramen spinosum. By following the middle meningeal artery and dividing the lateral pterygoid muscle, the proximal part of IMA was located. Second, a bone slot was drilled in a posterior-to-anterior direction from the anterior aspect of the first craniectomy. By tracing of the proximal part, the main trunk of the IMA was obtained. The size of the 2 craniectomies, the depth of IMA from the surface of the middle fossa, and the length of exposed IMA were measured. RESULTS Drilling within the lateral triangle allowed safe exposure of both the trunk and the branches of the mandibular nerve of the IMA. The total craniectomy measured 27.8 ± 4.2 mm in the anterior-posterior direction, and the posterior portion measured 13.3 ± 1.5 mm in the lateral-medial direction. The depth from the middle fossa to the IMA (16.8 ± 3.2 mm, mean ± SD) was equal to the length of IMA exposed (17.6 ± 3.3 mm, mean ± SD; P > .05). CONCLUSION This new approach provides an efficient and safe method to consistently find and isolate a segment of the IMA suitable for extracranial-to-intracranial bypass.

Midsubtemporal Ridge as a Predictor of the Lateral Loop Formed by the Maxillary Nerve and Mandibular Nerve: A Cadaveric Morphological Study

BACKGROUND: The lateral loop formed by the maxillary nerve (V2) and the mandibular nerve (V3) consists of a part of the far lateral triangle of the cavernous sinus. Because this triangle becomes a surgical corridor of the preauricular infratemporal fossa approach and a landmark of the extradural approach for the ganglion-type trigeminal schwannomas, identification of the lateral loop has important implications at the early stage of middle cranial base surgery. We realized that a bony ridge usually existed just lateral to the lateral loop. OBJECTIVE: To nominate midsubtemporal ridge (MSR) as the name for this anatomically unnamed bony ridge and to clarify its features. METHODS: Using 35 cadaver heads, we measured the shape of the MSR on both sides and the distance between the MSR and the adjacent structures. RESULTS: The MSR was recognized in 60 of 70 specimens (85.7%). The bony protrusion was 2.9 ± 1.1 mm in height, 6.0 ± 2.1 mm in width, and 9.1 ± 3.2 mm in length. A single peak with anteroposterior length was common in 47 of 60 specimens (78.3%). The MSR was located at the midpoint of the V2 and V3 in 28 specimens (46.7%) and existed 10.7 ± 3.6 mm lateral from the line that bound the foramen rotundum and the foramen ovale. CONCLUSION: We demonstrate morphological characteristics of the MSR. These data on the MSR will assist the surgeon in identifying the lateral loop as a surgical landmark during middle cranial base surgery.

The modified Lichtenstein technique for complex inguinal hernia repair: How I do it

The Lichtensein technique is modified for solving complex groin hernias such as huge hernias with massive transversal fascia destruction associated with the increased intraabdominal pressure or recurrent hernias with the destroyed Poupart?s ligament. Whilst these hernias are usually managed by preperitoneal techniques (open or laparoscopic) under general or regional anesthesia, as an "inpatient" procedure, they can be solved applying a modified Lichtenstein technique, most frequently under local anesthesia, as an "out-patient" procedure. The modifications of Lichtenstein technique include the following: a) lateral movement and fixation of the lower corner of the mesh, caudally to the tubercle, by 20-30 degrees in relation to its lower border, fully protecting the medial triangle (direct inguinal recurrence prevention); b) fixation of the lower border of the mesh by a running "U" suture to both Poupart?s and Coopers?s ligaments, from the tubercle to the femoral vein, fully protecting the femoral triangle (femoral recurrence prevention); c) the lower mesh border fixation by a running suture, 2-3 cm laterally to the internal inguinal ring, together with the "locking" of the internal inguinal ring by two interrupted sutures, one fixing the superior mesh tail to the inferior one - cranial to the spermatic cord, 1-1,5 cm medially to the Poupart?s ligament, and the other fixing the lower border of the superior mesh tail and the lower border of the inferior mesh tail to the inferior part of the Poupart?s ligament, 1 cm cranially and laterally to the preceding suture, fully protecting the lateral triangle (indirect inguinal recurrence prevention). One thousand eighteen patients with 1236 (unilateral 800, bilateral 218) inguinal hernias were electively operated on by the modified Lichtenstein technique between January 2003 - January 2011. All operations were performed by a single surgeon. One hundred and thirty (10.5%) hernias were recurrent following one or more tension or tensionfree repairs, and 203 (16.4%) hernias had a > 5 cm hernial defect. In seven hundred and twentyfour (71.1%) patients, the operation was performed under local, in 271(26.6%) under general, and in 23(2.3%) under regional anesthesia, while 635(62.4%) patients were operated on an "out-patient" basis, and 383(37.6%) on an "in-patient" basis. The ASA score was: 388 ASA I, 450 ASA II, 153 ASA III, and 27 ASA IV. The mean stay at a day surgery unit was 2.5 (2-8) hours, and the mean hospital stay was 1.6 (1-10) days. During the mean follow-up of 37 (1-96) months, the rate of complications was: 23(1.86%) haematoma, 5(0.4%) seroma, 5 (0.4%) wound infections, 6(0.48%) ischaemic orcihitis, 2(0.16%) testicle atrophy, 1 (0.08%) disejaculation, 3(0.24%) hydrocoella, 21(1.7%) pain, and 2(0.16%) recurrence. There were 6 reoperations due to the complications. The modified Lichtenstein technique performed usually under local anesthesia as "a day-case" procedure is a good solution for challenging groin hernias.