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PubMed1988

Occult thyroid pathology in the young adult: an autopsy study of 138 patients without clinical thyroid disease.

Thyroid glands from autopsies on 138 adults, ages 20 to 40 years, with no known clinical or laboratory evidence of thyroid disease, were serially sectioned at 2 mm intervals and microscopically examined for occult thyroid disease and anatomic variations. Occult papillary carcinoma was found in 3% of the glands, along with a single case of medullary carcinoma. The prevalence of occult thyroid carcinoma in this group of young adults is significantly less than that reported in the literature in people over forty (P less than .001). The glands demonstrated a number of other morphologic changes of importance to surgical pathologists. The thyroid capsule was incomplete in 62% of the glands. Thyroid follicles were found in the capsule in 14% of cases and thyroid follicles or nodules were outside the gland in perithyroid connective tissue in 88% of cases. Thyroid follicles were identified in 7% of cases in perithyroid strap muscles attached to the pyramidal lobe. A number of other, less common anatomic variations were also seen.

Adenoma↗

PubMed1993

[Intraoperative cholangiography and ultrasound in laparoscopic cholecystectomy].

For years there has been a controversy as to whether or not a routine peroperative cholangiography is indicated during conventional cholecystectomy. With the introduction of the laparoscopic technique, the reasoning has changed, but the controversy persists. The surgeon of today has the choice between two diagnostic modalities, which are to be presented here. Peroperative cholangiography was the technique usually employed during conventional operation. Many surgeons are in favor of routine intraoperative cholangiography during laparoscopic cholecystectomy. The goal of the examination is no longer the detection of unsuspected common bile duct stones, but the visualization of anatomical variations of the bile ducts and hepatic arteries for prevention of bile duct injuries. A difference in number of bile duct injuries in patients examined routinely or selectively has not yet been proven, so selective use of intraoperative cholangiography is still a safe strategy. A multitude of different catheters and introducer-sets for the laparoscopic operation are commercially available. We feel that a catheter should facilitate insertion without requiring the introduction of an additional cannula. An exception are the patients with known bile duct calculi, where a laparoscopic bile duct exploration is planned and the additional cannula is needed for this procedure anyway. Intraoperative cholangiography detects bile duct stones with a sensitivity of 95 to 100%. The sensitivity for the demonstration of anatomical variations of the bile ducts is smaller and anomalies of the arteries can not be demonstrated at all.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholangiography↗

PubMed1997

Topographical anatomy of the penile arteries.

OBJECTIVE: To determine the relationship of the penile arteries to anatomical landmarks and thus ease their identification, so avoiding injury during surgery. MATERIALS AND METHODS: The penile arteries in 12 formalin-preserved adult male cadavers were dissected and the distances measured between the cavernosal arteries and both the endopelvic fascia and distal attachment of the crura to the ischial bones. The distance between the origins of both bulbar and cavernosal arteries, their length and the length of the cavernosal bodies and crural attachments were also measured. RESULTS: Several anatomical variations, e.g. accessory pudendal arteries, multiple cavernosal and bulbar arteries, irrigation of cavernosal bodies by contralateral branches, anastomosis of cavernosal arteries with accessory pudendal branches, dorsal artery or bulbar artery as main branches of accessory pudendal arteries, were observed in 13 of the 24 specimens. The mean distances between the anterior attachment of the crura to the ischial rami and the site on the tunica albuginea where the cavernosal arteries penetrated the cavernosal bodies were 1.26 cm on the right and 0.69 cm on the left. The corresponding measurements between the cavernosal arteries and the endopelvic fascia were 5.68 cm (right) and 4.85 cm (left). The mean extracavernosal lengths of the right and left cavernosal arteries were 2.47 and 2.2 cm, respectively. CONCLUSIONS: Multiple anatomical variations of the arterial penile anatomy occur frequently. Surgery at the penile hilum may easily damage the cavernosal arteries, which lie medially to the dorsal nerves and arteries of the penis, have an extracavernosal length of about 2.3 cm and perforate the tunica albuginea about 1 cm distally to the anterior attachment of the crura to the ischial ramus.

Adult↗

PubMed2003

Pyloric atresia: 15-year review from a single institution.

BACKGROUND: Pyloric atresia (PA) is a rare pathology. Calder presented the first pyloric atresia case in 1749 and Touroff, Sussman, Meltz, and their colleagues presented the first successful operation in 1940. PA has 3 types of anatomic variations: (1) type A, pyloric membrane or web; (2) type B, the pyloric channel is a solid cord; and (3) type C, in which there is a gap between the stomach and duodenum. Associated anomalies also have been described. Epidermolysis bullosa (EB) and intestinal anomalies occur most often with this condition. METHODS: Charts of 16 cases of congenital PA, aged 1 to 30 days and admitted to our department between 1986 and 2001, were studied retrospectively in regard to sex, prenatal diagnosis, presence of polyhydramnios, time of admission, pathology, type of operation, associated anomalies, and mortality rate. RESULTS: In the study group, the male to female ratio was 5:3, the mean birth weight was 2,312 g and the mean age of admission was 6.5 days. The distribution of the anatomic variations was type A in 9 (56.3%) and type B in 7 (43.7%) of cases. Associated anomalies were present in 7 cases (43.8%). Familial occurrence was a prominent feature of our series. Seven of 16 cases occurred in 3 families. We performed 9 web excisions together with Heineke Mikulicz (H-M) pyloroplasty, 5 atresia excisions and gastro-duodenostomy, and 2 H-M pyloroplasties alone. Stamm gastrostomy was supplemented in 3 cases. The overall mortality rate (n = 9) was 56.3%. CONCLUSIONS: Pyloric atresia can be managed successfully if it is diagnosed early. In this group of patients, congenital anomalies or septicemia are the main causes of mortality.

Abnormalities, Multiple↗

PubMed2001

[Percutaneous treatment of varicocele. 13-year experience with the transbrachial approach].

PURPOSE: To report our experience using the transbrachial approach, which is easily accepted by the patient, in the treatment of varicocele. MATERIAL AND METHODS: Between January 1986 and December 1998, 1490 patients with clinical or subclinical varicocele, but with seminal fluid alterations, underwent spermatic phlebography using the transbrachial approach. Since 1991 the procedure has also been adopted at the Unit of Pediatric Surgery of our hospital, which proposes it as a first choice treatment in adolescents with varicocele. The procedure consists in accessing the basilic vein at the elbow level percutaneously and using a hydrophile guidewire and multipurpose angiographic catheter to reach and catheterise the spermatic vein responsible for the varicocele. During the first years, we used sclerotherapy alone; subsequently, if the varicocele recurred or if the reflux was refractory to sclerotherapy or if the veins were large we adopted vein embolisation. Follow-up was one year and consisted of testicular ultrasound, Doppler flowmetry and/or color Doppler ultrasound at one, six and twelve months after the procedure. Patients were considered restored if they were free of symptoms, showed no venous reflux and/or had normal seminal fluid parameters and improved if they were free of symptoms but still presented venous reflux. Varicocele was considered persistent if the procedure failed to produce any beneficial effects, and recurrent if, although absent at the first follow up, it reappeared after the fifth month. RESULTS: We found 1296 (86.9%) cases of left varicocele, 25 of right varicocele and 169 (11.3%) of bilateral varicocele. In all cases, the symptoms disappeared after the percutaneous procedure. Duration of radioscopy was reduced to 3.5'; the procedure lasted 90' for the monolateral varicoceles and 120' for the bilateral forms. 313 diagnostic procedures were performed (20.7%). The procedure could not be completed in 104 patients (6.8%) due to basilic vein spasms, difficulties encountered in catheterizing the spermatic vein and, particularly in pediatric patients, anatomic variations. A total of 1195 (79.2%) procedures were completed: sclerotherapy alone in 642 patients and sclerotherapy followed by scleroembolisation in 527. Sclerotherapy alone was sufficient to restore 524 patients (86.6%), while 384 (78.5%) required scleroembolization. A small number of patients underwent scleroembolization alone, which brings the success rate for the two procedures to 82% and 84%, respectively. No serious side-effects were noted. DISCUSSION: The transbrachial approach in spermatic phlebography has proved to be a safe and effective technique for the treatment of both monolateral and bilateral varicocele. Furthermore, the procedure is well accepted by patients and can be performed in a day-care setting. In some cases, we only obtained partial results because of the large caliber of the spermatic vein; in other cases, we were unable to complete the procedure due to anatomic variations or to the spasm of the basilic vein. CONCLUSION: The safety and effectiveness of this procedure make it a valid alternative to traditional surgery, that should be considered as a possible first-choice treatment for varicocele in adolescents.

Adolescent↗

PubMedDate not supplied

SLAP lesions: a retrospective multicenter study.

A retrospective analysis of 530 glenohumeral arthroscopies performed by three independent Belgian arthroscopists revealed the presence of 32 SLAP lesions, which represents an incidence of 6%. Since this is exactly the same percentage as found by Snyder et al., we report our data in this article. We classified 23 of the SLAP lesions using Snyder's classification, 7 needed the additional classification of Maffet et al., and 2 lesions were considered to be anatomic variations; 53% of the lesions were of type II. Concerning the mechanism of injury, we found comparable percentages of traction (22%) and compression (28%) injury as reported by Snyder, but also a high number (25%) of overhead sports activities as described by Andrews et al. Associated lesions were in close accordance with Snyder's data, but a relatively low incidence of rotator cuff injuries (10%) was present. Comparison of treatment regimens showed that the same percentage of lesions (34%) was fixed arthroscopically in both series. Only SLAP II, IV, and V lesions must be considered as unstable and in need of fixation. We confirm that patients' complaints and clinical symptoms are vague and inconsistent. Imaging, using computed tomographic arthrography or magnetic resonance, was performed in a minority of cases. Advantages and pitfalls of both techniques are discussed. Anatomic variations causing an extra-large sublabral hole are shown, and we warn about potential diagnostic and therapeutic errors in these cases.

Adolescent↗

PubMed2000

Can three-dimensional helical CT cholangiography before laparoscopic cholecystectomy be a substitute study for endoscopic retrograde cholangiography?

The study investigated the usefulness of three-dimensional helical computed tomography (3D-CT) before laparoscopic cholecystectomy (LSC) when compared with that of endoscopic retrograde cholangiography (ERC). Forty-five patients referred for LSC, who had undergone 3D-CT cholangiography and ERC simultaneously, participated in the study. Endoscopic retrograde cholangiography and 3D-CT cholangiography were compared in each patient with regard to opacification of the biliary tree, stones, and anatomic variations. Three-dimensional helical CT cholangiography and ERC imaging for predicting operative difficulties in LSC also were compared. The common bile duct and cystic duct were shown in the patients by the images, but the gallbladder was shown in 43 patients (96%) with use of 3D-CT cholangiography and in 36 patients (80%) with use of ERC. A third or more peripheral branches were shown completely with use of 3D-CT cholangiography in 33 patients (73%) and in 32 patients (71%) with use of ERC. Cystic duct stones were found in two of three patients with use of 3D-CT cholangiography and ERC. Common bile duct stones in five of seven patients were detected with use of 3D-CT cholangiography, but all of the common bile duct stones were detected with use of ERC. Anatomic variations of the bile duct were shown in three of four patients by 3D-CT cholangiography and in all patients with use of ERC. No significant differences in findings of the angle of bifurcation and presence of Heister valves between operative easy and complex cases were shown by 3D-CT cholangiography and ERC, despite the more accurate assessment of the cystic duct anatomy with use of 3D-CT cholangiography than with use of ERC. Three-dimensional helical CT cholangiography is useful clinically in preoperative assessment of biliary anatomy, but it is not reliable in the detection of common bile duct stones, and it is not helpful in predicting technical difficulty during LSC.

Adult↗

PubMed2003

Intrahepatic segmental bile duct patterns in hepatolithiasis: a comparative cholangiographic study between Taiwan and Japan.

BACKGROUND/PURPOSE: We analyzed confluence patterns of intrahepatic segmental bile ducts, seeking to relate hepato-lithiasis to anatomic variation. The comparative study was completed patients with hepatolithiasis in Taiwan and Japan. METHODS: Direct cholangiography was performed in 103 hepatolithiasis patients in Taiwan and 77 in Japan. Segmental ducts patterns were classified as type I, normal configuration; type II, "triad" confluence; type III, posterior segmental duct joining left hepatic duct; or type IV, distal confluence of the right posterior segmental duct. RESULTS: Taiwanese patients had only calcium bilirubinate or black stones, and were mostly female. As overall analysis, types I, II, III, and IV were found in 61, 26, 13, and 3 patients, respectively. In Japanese, types I, II, III, and IV were found in 52, 10, 13, and 2, respectively. There was no difference between the two institutes. Since no patients in Taiwan had cholesterol calculi, Japanese patients were reanalyzed including only 58 patients with calcium bilirubinate or black stones. Differences in those populations remained insignificant. CONCLUSION: Anatomic variations in segmental ducts apparently do not contribute to pathogenesis of hepatolithiasis.

Adolescent↗

PubMed2001

Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset.

We have observed damage to the labrum as a result of repetitive acetabular impingement in non-dysplastic hips, in which the femoral neck appears to abut against the acetabular labrum and a non-spherical femoral head to press against the labrum and adjacent cartilage. In both mechanisms anatomical variations of the proximal femur may be a factor. We have measured the orientation of the femoral neck and the offset of the head at various circumferential positions, using MRI data from volunteers with no osteoarthritic changes on standard radiographs. Compared with the control subjects, paired for gender and age, patients showed a significant reduction in mean femoral anteversion and mean head-neck offset on the anterior aspect of the neck. This was consistent with the site of symptomatic impingement in flexion and internal rotation, and with lesions of the adjacent rim. Furthermore, when stratified for gender and age, and compared with the control group, the mean femoral head-neck offset was significantly reduced in the lateral-to-anterior aspect of the neck for young men, and in the anterolateral-to-anterior aspect of the neck for older women. For patients suspected of having impingement of the rim, anatomical variations in the proximal femur should be considered as a possible cause.

Acetabulum↗

PubMed1975

Some considerations concerning the deep femoral artery.

The great importance of the deep femoral artery as a collateral vessel in occlusion of the superficial femoral artery is a well-established fact. It has been found in the course of reconstructive operations of this artery that the origin of the two circumflex arteries varies considerably. A study of one hundred cadavers has given some idea of the frequency and nature of these anatomical variations. The importance of this vessel as a collateral is partially explained by the fact that the deep femoral artery has two groups of branches, both of them anastomosing with the branches of the popliteal artery. If the deep femoral artery is to function adequately as a collateral, it has to have a large caliber. An explanation for this may be found in comparative anatomy. In the phylogenetically farther advanced vertebrate animals, all of which have very strongly developed extensors in the posterior extremities, the deep femoral artery which supplies blood to this muscle group is a branch of the iliac artery, and accordingly, a pelvic artery. In man, this artery originates distal to the inguinal ligament from the common femoral artery and supplies blood to less well-developed muscle groups. In this way, phylogeny explains the large caliber of the deep femoral artery, which has originally been a pelvic artery and it also explains the numerous anatomical variations at the site of the bifurcation of the common femoral artery.

Adult↗

PubMed1996

The communicating branch of the lateral plantar nerve: a descriptive anatomic study.

Since the communicating branch of the lateral plantar nerve has been implicated as a factor in the etiology of Morton's neuroma, a painful perineurofibrosis of a common plantar digital nerve, this project was designed to investigate the anatomy of this communicating branch. Both feet of 40 embalmed human cadavers were dissected to show the frequency of occurrence and anatomical variation of the communicating branch. The communicating branch was present in 66.2% of the feet we studied with no large gender-based differences. Branches occurred bilaterally in 52.5% of cadavers, while 27.5% had branches unilaterally. The occurrence of this branch does not correlate well with the likelihood of development of Morton's neuroma. Differences in diameter of the communicating branch ranged from less than 0.5 mm to as large as the common plantar digital nerves themselves, about 2 mm. The presence or absence of the communicating branch made no qualitative difference in the diameters of the common plantar digital nerves. There were 60.4% of the communicating branches in this study that had a typically-described orientation, arising more proximally in the foot from the fourth common plantar digital nerve, while 39.6% of the branches had a reversed orientation, arising more proximally from the third common plantar digital nerve. These reversed branches had a more oblique orientation when compared to the classic branches. Other anatomical variations were noted, including accessory branches that attached to deeper structures in the foot. These data form a basis for further research into the etiology of Morton's neuroma and improved surgical techniques for correcting this condition.

Adult↗

PubMed2004

[The risk of biliary ductal injury during laparoscopic cholecystectomy].

The incidence of iatrogenic injuries of the bile ducts has increased significantly since laparascopic cholecystectomy became the "gold standard" in the treatment of cholelithiasis. The incidence of major biliary ductal injury ranges from 0.25% to 0.74%, and of minor injury from 0.28% to 1.7%. The cause of the injury is not always clearly identifiable. In more than half the cases, the injury occurs during maneuvers to isolate the cystic duct or to free the gallbladder from the common bile duct. These maneuvers may be more difficult and consequently more dangerous when there is significant inflammation as may be seen in acute cholecystitis, or in case of obesity, cirrhosis with portal hypertension, previous surgery with peritoneal adhesions, or anatomic variations of the hepatic pedicle. Pre-operative evaluation of clinical risk factors should be coupled with intra-operative caution and instrumental evaluation. The increase in frequency of iatrogenic biliary injuries can not be attributed simply to the inexperience of the surgeon or the learning curve as was initially suggested. Many injuries are due, rather, to the surgeon's failure to respect basic technical rules, long established for open cholecystectomy and which should not be modified for the laparoscopic technique. While routine cholangiography does not offer complete protection from iatrogenic ductal injuries, it is essential to visualize the biliary tract whenever a lesion of the ductal system is clearly identified or even suspected. In such cases, facility with the technique of intraoperative cholangiography and a knowledge of the radiological anatomy of the biliary tree are essential for an accurate and complete intraoperative evaluation of the biliary injury. Finally, in the presence of acute or chronic inflammation or other factors for technical difficulty (obesity, cirrhosis, previous surgery, anatomic variations, intraoperative bleeding), the surgeon must not hesitate to consider conversion to an open surgical approach. In such complicated cases, even the open approach is not a guarantee against biliary injury; there is no substitute for experience and caution in biliary surgery.

Bile Ducts↗

PubMed2005

Infralabyrinthine approach to the petrous apex.

This study measures the anatomical dimensions of the path to the petrous apex (PA) via the infralabyrinthine approach in temporal bones of adult Indian subjects, and studies the anatomical variation encountered in this approach. Forty-two temporal bones were dissected to gain access to the PA via the infralabyrinthine approach. The horizontal and vertical dimensions of the access window created as well as the length of the track to the PA from the vertical portion of facial nerve were measured with two-point calipers. Complete dissection was possible in only 21 bones (50%). In the remainder, after preliminary cortical mastoidectomy, an access window to the PA could not be created due to a high jugular bulb. The mean dimensions of the window in dissected bones were 4.60 mm vertically (SD = 0.94 mm) and 6.45 mm (SD = 1.44 mm) horizontally, and the depth of the track to the PA was 30.26 mm (SD = 3.62 mm). The infralabyrinthine approach to the PA provides wide access to lesions of the posterior and inferior PA. In up to 50% of temporal bones, as evidenced by this series, access may be limited by a high jugular bulb. The possibility of this anatomical variation should be considered when the surgical approach to a PA lesion via the infralabyrinthine approach is being planned.

Cadaver↗

PubMed2002

Laparoscopic renal biopsy in bilateral pelvic kidney with chronic glomerulonephritis.

Percutaneous needle biopsy under the guidance of ultrasound or computerized tomography is the most valuable method in the diagnosis of parenchymal kidney diseases. However, sometimes it can be difficult to perform in the presence of certain anomalies, anatomic variations, or medical problems. In the presence of bilateral pelvic kidney, which is a rare anomaly, laparoscopy can be used to obtain biopsy. Biopsy of kidney was planned in a 26-year-old woman who presented with a history of hypertension for 7 years and proteinuria with the diagnosis of nephrotic syndrome. For the biopsy, the laparoscopic approach was chosen since the patient had bilateral pelvic kidneys. Under general anesthesia, using three port sites, the right kidney was reached, which was located more anterior than the left one. Three biopsy specimens for histologic evaluation were taken with a Tru-Cut biopsy needle. No complications were encountered during or after the operation. The patient was ceased from urological follow-up after performing an ultrasound on the first postoperative day. This is the first case of pelvic kidney with chronic glomerulonephritis reported in the literature in which the histologic diagnosis was made with the help of laparoscopy. Laparoscopic kidney biopsy is a minimally invasive technique that can be done in cases with anatomic variations, making percutaneous needle biopsy impossible.

Adult↗

PubMed2005

Ultrasound imaging findings of femoral veins in patients with renal failure and its impact on vascular access.

BACKGROUND: Patients requiring dialysis due to acute or chronic renal failure frequently require temporary vascular access. Femoral vein catheterization is the easiest method for obtaining temporary vascular access in haemodialysis patients. The aim of this study was to utilize ultrasound imaging to describe femoral vein structures and to examine anatomical variations in uraemic patients. METHODS: We evaluated 114 (70 males, 44 females) renal failure patients. Femoral arteries were localized manually inferior to the femoral ligament, and ultrasonographic examination was performed from this location. Images of the vessels and demographic data of patients were recorded and analysed. Femoral veins were classified according to their diameter, patency and palpation status of the neighbouring femoral artery. RESULTS: Three patients had a history of prior femoral catheterization. In one of these, who had a history of bilateral catheterization, we detected bilateral femoral vein thrombosis. Overall, non-palpable femoral arteries or unsuitable femoral veins were found unilaterally in 16 patients (14.0%) and bilaterally in six patients (5.2%). The depth of femoral arteries (r = 0.54, P<0.001) and femoral veins (r = 0.59, P<0.001) was correlated with body mass index (BMI). Femoral arteries and femoral veins were located significantly deeper in overweight (BMI >25) patients compared with normal weight patients (20.7+/-6.5 vs 14.6+/-5.1 mm, P<0.001 and 26.1+/-6.7 vs 18.9+/-5.5 mm, P<0.001). CONCLUSIONS: Bilateral anatomical variations of femoral veins were relatively rare. However, ultrasound surveys should be performed in obese patients or when the femoral artery is not palpable.

Acute Kidney Injury↗

PubMed1986

Technique of right lymphatic duct cannulation for pulmonary lymph collection in an acute porcine model.

The pig is an increasingly preferred model for biomedical research, including studies for pulmonary pathophysiology. However, in piglets, the technique for cannulating the right lymphatic duct, which is subject to more anatomical variations and technically more demanding than that in dogs, has not been described. Our technique evolved to enable this collection of porcine lung lymph in acute experiments. The lymphatic ampulla is cannulated via one of the cervical lymphatics. The right lymphatic duct is invariably dorsal to the cranial vena cava and classically leads to the lymphatic ampulla. Yet in 18% of our pigs, cannulation was difficult or not feasible because the lymphatic duct either drained directly into the cranial vena cava at a distance from the lymphatic ampulla, or into the axillary lymph node of the first rib or the caudal deep cervical lymph nodes. Gently squeezing back regurgitated blood in the lymphatic ampulla before tying the suture and frequently withdrawing lymph with a syringe when the flow is small enabled us to collect clear lymph, usually immediately after completing the cannulation. The rate of lymph flow varied widely (1.7 +/- 0.6 ml/hr) and increased when the left atrial pressure was raised. The lymph protein was 2.8 +/- 0.2 g% with lymph/plasma protein ratio at 0.55 +/- 0.04. The anatomical variations encountered in our 34 dissections, as well as the technical maneuvers found to be useful in the successful cannulation and collection of the porcine lung lymph, are described in detail.

Animals↗

PubMed1994

[The superior gluteal nerve. Anatomical study of its extrapelvic portion and surgical resolution by trans-gluteal approach].

INTRODUCTION: The Transgluteal approach (TGa) to the hip, proposed by BAUER, and often used for total arthroplasties, could be responsible, according to some authors for bad clinical results, due to injury of the nervus gluteus superius (NGS). The aim of this study was to verify the nerve's anatomical condition and evaluate the risks of injury during TGa. MATERIAL AND METHODS: Thirty three dissections of fresh corpses in the lateral position (preceded by a TGa) permitted the estimation of the risk and the measurement of the distances between the nerve and the trochanter major (TM). The NGS was sought in the area of the foramen ischiaticum at the proximal side of the piriformis muscle after cutting the vessels and the fat. It was possible to follow it's branches to the end, but we had to lift the m. gluteus medius (mGM), or to cut it transversally. RESULTS: Many anatomical variations were found concerning the point of the nerve's division into 2 branches, nearer or farther from the foramen ischiaticum. The upper branch followed the proximal side of the gluteus minimus (GMin) then innervated the GM and the m. tensor fasciae latae (TFL). the lower branch showed a variable distribution of the strings to the three muscles (GM, GMin and TFL). The TFL's branch ended at upper side of the TM. A safe area, over the TM, without any nerve branches could be determined 7 cm above and behind the TM, 5 cm above it's posterior angle and 3 cm above it's anterior angle. During anterior TGa we noted that the coxofemoral dislocation could tear the GM's proximal fibers and threatened the "inter" or intramuscular nerve filaments. The acetabular exposition by retractors, could compress the more frontal branches. On the contrary using the posterior TGa, neither the dislocation nor the exposition seemed to threaten the nerve, which was farther away and more posterior. DISCUSSION: In this study we confirmed the existence of numerous anatomical variations of the NGS and classified them into 4 categories which include those already described in previous publications, of which the first category seems to be the most common. Our distances measured from the nerve to the TM are similar to those previously published, but our safe area is more restrictive than that proposed by Jacobs and Buxton. Respecting the limits of this area reduces the risk of nerve injuries. During the anterior TGa, the nerve is nearer to the TM and more exposed. The muscular mass innervated is large and the functional consequences of frontal injury must not be neglected. During acetabular exposition, the retractors should exert moderate muscular pressure, to avoid crushing them. The respect of the GMin, ensures adequate protection for the nerves situated between the muscles. To avoid muscular tearing during the anterior dislocation it is better to cut the collum femoris in place. The posterior approach seemed to be less dangerous for the nerves and muscles which are farther away. CONCLUSION: Strictly remaining within the limits of the safe area and carefully separating the muscles, should allow to decrease the risk of NGS injuries during TGa which seems to be more important in the anterior than in the posterior approaches.

Buttocks↗

PubMed2000

Still photography versus videotaping for documentation of cecal intubation: a prospective study.

BACKGROUND: Documentation of cecal intubation is important for credentialing and continuous quality improvement. However, convincing cecal photographs can be difficult to obtain. The aims of the study were to determine (1) the anatomic variations and photographic factors associated with convincing cecal photographs; (2) whether a prospective attempt to capture specific features resulted in more convincing photographs; and (3) how a prospective attempt at capturing convincing cecal features during still photography compares with videotaping as a method of documenting cecal intubation. METHODS: A single examiner evaluating 165 consecutive patients photographed the entire cecum from just distal to the ileocecal valve, the appendiceal orifice, the ileocecal valve orifice, and in the last 110 consecutive cases, the terminal ileum, if it could be intubated. The photographs were then scored by 8 experts according to how convinced they were that cecal intubation had occurred. Features associated with high and low scores were determined, and 50 additional consecutive patients were photographed with a specific effort to capture these features, along with videotaping of the cecum. These photographs and videotapes were then scored by 7 of the 8 experts on a scale of 1 to 5, with 5 representing "definitely the cecum." RESULTS: There was marked variation in scores of still photographs among reviewers. A combination of photographs produced the highest mean score and the highest percentage of scores that were either "probably" or "definitely" of the cecum. The photograph of the cecum from just distal to the ileocecal valve was most convincing and the terminal ileum photograph was least convincing. In the 50 cases in which an attempt was made to capture specific features, mean scores improved for the overall cecal photograph by 0.10, the appendiceal orifice by 0.23, the ileocecal valve lips by 0.20, and the terminal ileum by 0. 19. The cecum, appendiceal orifice, valve lips, and terminal ileum photographs for the last 50 patients were scored higher than those from the first 165 patients by 4, 4, 4, and 5 reviewers, respectively. Videotapes were consistently convincing (overall mean score 4.78 out of 5) and were scored more convincing than the combination of still photos from the final 50 cases by 6 of 7 reviewers. CONCLUSIONS: Still photography of the cecum can be improved somewhat by attempting to capture specific cecal features. However, because of anatomic variation among normal individuals, still photography remains inconsistently convincing. A combination of photographs is most convincing. Videotaping of the cecum is consistently convincing and would appear to serve effectively as a means of documenting cecal intubation rates for the purposes of continuous quality improvement and credentialing.

Cecum↗