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Because of the anatomic variations of stricture or ectropion, the surgeon should master several of the techniques quoted here. These methods may have to be modified in selected patients, but all changes should be based on sound anorectal plastic principles.
Hepatic transplantation was pioneered by the work of Starzl and colleagues, first at the University of Colorado and later at the University of Pittsburgh. With the meeting of the National Institutes of Health (NIH) Consensus Development Conference in June of 1983, and their conclusion that liver transplantation was no longer experimental, orthotopic liver transplantation entered the "modern era." The release of cyclosporine by the US Food and Drug Administration (FDA) to transplant centers around the country, at the end of 1983, allowed for significant expansion of hepatic transplantation programs. Hepatic transplantation remains, however, the most difficult and complex of all solid organ transplants. A thorough grounding in the anatomic variations of hepatic segmental, arterial, venous, and ductal anatomy is only the first step in the successful completion of this challenging procedure.
Major biliary complications of laparoscopic cholecystectomy may be prevented by an understanding of extrahepatic biliary ductal and arterial anatomic relationships. The common patterns of anatomic variations important to the surgeon performing laparoscopic cholecystectomy are reviewed with respect to recently reported biliary injury during this procedure. Recommendations for delineating biliary anatomy and avoiding laparoscopic complications are reviewed.
The intimate anatomical relationship between the orbit and the paranasal sinuses places the orbit and its contents at risk of harm from primary pathologic processes of the sinuses. In the absence of ophthalmic signs or symptoms, ophthalmologists are not routinely involved in the management of patients with sinus disease. Occasionally, some patients may develop ophthalmic complaints after surgical intervention. The orbit, optic nerve, extraocular muscles, and lacrimal drainage system are susceptible to injury during endoscopic sinus surgery. The risk of injury is related to the skill of the sinus surgeon, history of previous surgery, extent and severity of disease, and anatomic variation. Furthermore, recent advances in endoscopic sinus surgery, in particular the use of powered cutting instruments, has resulted in a novel mechanism of injury to the ocular structures.
BACKGROUND: The aim of the study was to compare the clinical signs of patients with cervical and lumbar root affections. METHODS: From January 1994 to January 1995, we performed a prospective study on 395 patients. The study comprised 93 patients with a cervical and 302 patients with a lumbar root affection. 338 patients underwent surgery. General data, case histories, and neurological findings were analyzed. RESULTS: The patients with brachialgia had a nonradicular pain radiation in 67%, the patients with sciatica only in 35%. All other data showed no significant differences. The investigation also shows that a radicular pain radiation is significantly correlated with an unequivocal radicular deficit. In particular, the patients with a cervical radicular pain radiation had a highly significant incidence of a radicular neurological deficit. CONCLUSIONS: We could demonstrate in this prospective study that only about one third of the patients with a cervical root affection showed an unequivocal radicular pain radiation. This contradicts the traditional medical textbook concept of a cervical root compression syndrome. This difference in respect of the clinical signs of lumbar and cervical root compressions might be explained by the anatomical variations of cervical root anastomoses. To determine the affected cervical root level, further investigation of the myotomes is recommended.
OBJECTIVES: To determine whether a high versus a dependent ureteral insertion significantly affects the outcome of endopyelotomy for management of ureteropelvic junction (UPJ) obstruction. METHODS: Sixty patients with UPJ obstruction were treated with an endopyelotomy by way of either an antegrade percutaneous approach (n = 36) or a retrograde hot-wire balloon incision (n = 24). In these 60 patients, the ureteral insertion was high on the renal pelvis in 19 (32%), dependent in 25 (42%), and indeterminate in 16 (26%). Intravenous urography was performed 4 to 6 weeks after stent removal (8 to 12 weeks after endopyelotomy) and then at 6 to 12-month intervals. Success of the procedure was defined as resolution of symptoms and decrease in hydronephrosis compared with pre-endopyelotomy studies. RESULTS: With a follow-up range of 2 to 41 months (mean 10.3), the overall success rate was 80%. This rate was independent of whether the procedure was performed in an antegrade or retrograde fashion. A successful result was achieved in 15 (78.9%) of those with a high insertion, 19 (76%) of those with a dependent insertion, and 14 (87.5%) of those with an equivocal insertion; these differences were not statistically significant (P = 0.72). CONCLUSIONS: The type of ureteral insertion (ie, high versus dependent) had no significant impact on the outcome of endopyelotomy by way of either a percutaneous or retrograde approach. As such, these anatomic variations need not play a role in a decision-making algorithm for contemporary management of UPJ obstruction.
From the authors three-dimensional video analyses they had to learn that the advantages of a one-stage procedure is outweighed by far by the disadvantages. A three-stage concept to a one-stage procedure was preferred for the following reasons: 1. Safety of having a cross-face nerve graft to cover the distance from the healthy facial nerve to the nerve of the muscle transplant without problems and without the danger of tension on the nerve suture line because of shortage of the muscle nerve. 2. Independence of anatomical variations like a very proximal muscle hilus in the latissimus dorsi muscle e.g., resulting in a too short muscle nerve. 3. Only face-lift incisions are necessary without the need of an additional incision in the nasolabial fold while using a cross-face nerve graft. 4. Freedom of positioning the muscle graft on the paralyzed side with free choice of the position of the transplant hilus. 5. The superficial temporal vessels can be used for microvascular anastomoses. 6. Prevention of a scar in the submandibular region with its tendency of hypertrophy, especially if it is connected to the preauricular incision. Different functional territories of one muscle transplant for eye closure and for smile is only possible in combination with two cross-face nerve grafts. Further on the three-dimensional video analysis showed clearly that Final surgical corrections for improvement of the static and dynamic symmetry should be performed. when the muscle transplant or the transposed muscle have gained their final functional result, which is often not before one or one and a half year after muscle transplantation. Therefore a three-stage concept is needed for the majority of patients. Detailed analyses of the movements in the different regions and the comparison of both sides clarify preoperatively the indication for the operative techniques to be used, and describe exactly the improvement of the overall result. It is not only possible to show, eg, the better positioning of the alar of the nose by a nasolabial dermal suspension plasty on the paralyzed side in millimeter, but also the influence on the relation of all the different points in the face (Fig. 5). The comparison of the right and the left side gives exact data on the symmetry of the face on rest and during the different movements. Of course, also qualities of facial reanimation like prevention of mass movements or synkinesias are detected in the three-dimensional graphs of all the points at the same time or in the repeated reviews of the original movement in the original video sequence. In conclusion, three-dimensional video analysis of facial movements became an important tool for online planning of operative procedures for the individual patient, and an excellent tool for comparative studies of different operative concepts and alternative operative techniques within a standardized registry of one center treating facial palsy or within international multicenter studies.
Following a set of principles, free style free flaps may be harvested from any region of the body where a Doppler signal is heard. By using a retrograde dissection technique, the skin vessel is traced through its subfascial course (intramuscular or septocutaneous), until adequate length or vessel size is achieved. If a "free style free flap" is not originally planned, this approach can be usedwhen anatomic variations or unexpected events are encountered. The thigh, a region that is familiar to the surgical team at Chang Gung Memorial Hospital, was chosen as the site to begin exploring this style of flap harvest. Nine flaps were harvested as free style free flaps from the thigh and were used successfully for the reconstruction of complex defects.
Factors affecting the negotiability of MB2 canals were evaluated by studying 87 extracted maxillary molars that had undergone previous endodontic treatment in the endodontic technique laboratory. The mesiobuccal roots were resected and radiographed, after which a #08 file was used in an attempt to negotiate those roots with the potential for a second mesiobuccal canal. The file was then intentionally separated in the MB2 canals that could be negotiated. The roots were decalcified, cleared, and observed under a stereomicroscope. Several factors that could interfere with the total or partial negotiation of MB2 canals were identified and included accumulation of debris and sealer that blocked access to these canals, dentinal debris produced with the pathfinding instrument, the presence of anatomical variations, diffuse calcifications, and pulp stones.
BACKGROUND: Numerous associations to anatomic variation and systemic vascular disease have been made to anterior ischemic optic neuropathy (AION) but exogenous agents have not been emphasized. The authors studied the effect that smoking had in the development of AION. The relevance of other intraocular and systemic vascular disease to AION also is discussed. METHODS: Over a 10-year period (January 1980-May 1990), nonarteritic AION was diagnosed in 148 patients, 137 of whom were included in this analysis. FINDINGS: Of the 137 patients identified with nonarteritic AION, 28 smokers were statistically younger, at 51 years of age, compared with 83 nonsmokers whose mean age was 64 years (P = 0.005). CONCLUSIONS: Cigarette smoking is an important risk factor in the development of AION. Cessation of smoking appears to reduce the risk of AION to that of the nonsmoking population.
PURPOSE: To evaluate the position of the iris insertion into the ciliary body in persons with pigment dispersion syndrome (PDS) and control subjects. METHODS: Ultrasound biomicroscopy was performed on 19 eyes with PDS and on 21 eyes of control subjects. A radial, perpendicular image in the temporal meridian detailing Schwalbe line (SL), scleral spur (SS), and iris root insertion (IR) was obtained for each eye by a single examiner. The distances between these structures then was measured. RESULTS: There were no differences between the groups in refractive error (mean +/- standard error, -2.8 +/- 0.7 diopters for PDS eyes versus -2.2 +/- 0.6 for control subjects) (P=0.46), sex distribution (P=0.49), and trabecular meshwork height (SL to SS) (0.63 +/- 0.03 mm [PDS eyes] versus 0.59 +/- 0.03 [control eyes]; P = 0.24). The SS-to-IR distance was significantly greater in PDS eyes (0.04 +/- 0.04 mm) than in control eyes (0.28 +/- 0.04 mm) (P=0.01) as was the overall distance from SL to IR (0.98 +/- 0.04 mm versus +/- 0.04 mm) (P = 0.003). CONCLUSION: The insertion of the iris into the ciliary body is more posterior in PDS eyes than in control eyes. This anatomic variation places the iris pigment epithelium proximal to the zonular apparatus and may increase the likelihood of iridozonular contact and zonular pigment dispersion.
OBJECTIVE: The estimate frequency of anatomic variations in origin of the right coronary artery in a Turkish population. MATERIAL AND METHOD: The angiographic data of 5253 consecutive adults patients undergoing coronary angiography were analysed retrospectively for the diagnosis of anomalous origin of the right coronary artery. RESULTS: Among 5253 adults patients, five (0.09%) patients had anomalous origin of the right coronary. They had an isolated anomalous origin of the right coronary artery. The right coronary arose from the left coronary sinus of Valsalva (there was separate orificium for the right coronary artery and the left coronary artery) in two (0.03%) patients, from above the left coronary sinus of Valsalva in three (0.05%) patients. In all patients, the anomalous origin of right coronary artery from the left sinus of Valsalva and from above the left coronary sinus of Valsalva coursed between the aorta and the pulmonary artery. CONCLUSION: The anomalous origin of the right coronary artery is a rare congenital cardiac malformation. Most patients remain asymptomatic. However, there are cases of sudden cardiac death described in the literature, indicating a potentially malign course of the disease. The angiographic recognition of this vessel may be useful for physicians dealing with diagnosis and treatment of the anomaly of the right coronary artery.
BACKGROUND: Laser-assisted hair removal has become popularized using wavelengths in both the red and infrared regions of the electromagnetic spectrum. These photoepilation devices target follicular melanin or an exogenous pigment placed within the follicle resulting in thermal damage to the hair follicle and shaft. However, melanocytes and keratinocytes located within the superficial layers of the skin also absorb red and infrared laser radiation. This may result in unwanted epidermal injury during the hair removal process. OBJECTIVE: The purpose of this study was to examine a large patient population to determine the frequency of side effects using 3 different hair removal laser systems with various wavelengths, pulse durations, and treatment protocols. METHODS: A retrospective chart review and digital photographic analysis of the side effects resulting from 900 consecutive laser-assisted hair removal treatments delivered over a 24-month study period, by means of either a Q-switched Nd:YAG laser with pretreatment wax-epilation and topical carbon solution, a long-pulse ruby laser with a contact cooling tip, or a long-pulse alexandrite laser are reported. RESULTS: Treatment pain, erythema, edema, hypopigmentation and hyperpigmentation, blistering, crusting, erosions, purpura, and folliculitis were observed. The majority of undesirable tissue effects occurred on tanned skin or in Fitzpatrick skin phototypes III and higher. The ruby and alexandrite laser systems resulted in the majority of side effects seen. The effects of seasonal variations, anatomic treatment location, and sun exposure were striking within the ruby and alexandrite laser groups. No infections, scarring, or long-term complications occurred. CONCLUSION: Laser-assisted hair removal is a safe procedure when patient characteristics such as skin type, anatomic location, and sun-exposed or tanned skin are considered during selection of laser treatment parameters. Lasers emitting wavelengths with high melanin absorption capabilities should be used in a conservative manner when treating patients with dark skin phototypes or suntans. No long-term complications, infections, or scarring occurred in this study population.
The key to successful surgery in the frontal recess is a complete understanding of the anatomy. The frontal recess is behind the beak of the frontal bone between the lamina papyracea and superior portion of the middle turbinate. It is a hazardous and complex area with a range of anatomical configurations. This article describes the anatomy of the frontal recess as it relates to the agger nasi cell using this cell as the key around which the anatomy is built. The simplest anatomical configuration is explained first and this knowledge is built upon so that the more complex configurations can be better understood. The classification of frontal ethmoidal cells by Kuhn is incorporated into the anatomical description of the various configurations. The implication of each anatomical variation on the surgical approach to the frontal recess is discussed.
Although anatomic variations in the development of the nose and paranasal sinuses such as the Haller's cell do not themselves represent a disease state, in many cases they are responsible for the patient's symptoms. Particularly in the absence of extensive associated mucosal changes, these conditions may be easily overlooked unless specifically sought. Haller's cells may cause recurrent or chronic sinusitis and persistent sinugenic headache, without significant findings on physical examination including nasal endoscopy. The presence of Haller's cells on coronal CT in a patient with corresponding symptoms deserves consideration as the potential cause of the symptoms. When medical therapy is ineffective, such cases respond well to surgical therapy through the functional endoscopic approach.
This report calls attention to the increasingly common operative complication of injury to the medial antebrachial cutaneous nerve during surgery on the cubital tunnel. The anatomical variations of site of this nerve are described, as well as typical examples of injury seen clinically.
The relationship of Gantzer's muscle (the accessory head of flexor pollicis longus; FPL) to the median nerve and its anterior interosseous branch is debated. In an anatomical study of 25 limbs, the incidence, origin, insertion, nerve supply and relations of Gantzer's muscle have been documented. The muscle was found in 13 of the 25 (52%) limbs and was supplied by the anterior interosseous nerve. It arose from the medial humeral epicondyle in 85% and had a dual origin from the epicondyle and coronoid process in the rest. Its insertion was to the ulnar part of FPL and its tendon. Gantzer's muscle always lay posterior to both the median and anterior interosseous nerves. Anatomical variations in which Gantzer's muscle may contribute to median nerve compression in pronator syndrome are discussed.
Carpal tunnel syndrome is an exceedingly common orthopaedic problem in the United States. When conservative management is unsuccessful, most surgeons proceed to surgical treatment. Though the carpal tunnel release procedure is usually curative, many patients experience postoperative complications, such as scar sensitivity, pillar pain, recurrent symptoms, and grip weakness, regardless of whether the release was done through an open, mini-open, or endoscopic approach. The exact causes of these and other complications of carpal tunnel release remain unclear. Release of the carpal tunnel has an effect on carpal anatomy and biomechanics, including an increase in carpal arch width, carpal tunnel volume, and changes in muscle and tendon mechanics. We set out to review the morphological and biomechanical changes caused by carpal tunnel release with the goal of better understanding the root causes of postoperative complications. This article first reviews normal carpal tunnel anatomy and anatomic variations, then available surgical techniques for carpal tunnel release, and finally the literature on morphologic, physiologic and biomechanical alterations in the wrist after carpal tunnel release.