Is inguinal hernia a risk factor for varicocele in the young male population? / ¿Es la hernia inguinal un factor de riesgo para varicocele en el varón joven?

OBJECTIVES: The aim of this study is to investigate the role of the inguinal hernia over the development of varicocele, in cases with accompanying inguinal hernia. METHODS: The continuous variables were calculated from mean and standard deviation, and intermittent variables were calculated over percentage and frequency. Normality testing was performed on continuous variables using the Kolmogorov-Smirnov test. Univariate analyses were performed using the unpaired Mann-Whitney U test and Chi-squared test was used for proportions. Kendall's tau-b correlation coefficient was used for correlition coefficient. Logistic regression modeling were used to identify the impact of inguinal hernias on selected cases. The data were analyzed with SPSS™ for Windows 22 (SPSS,Chicago, IL). RESULTS: Twelve cases (23.1%) in the inguinal hernia group also had varicocele, which was relatively high, whereas 12 cases with inguinal hernia in the varicocele group corresponded to only were 4.02% (12/52 (23.1%) vs 12/298 (4.02%) ). On the other hand, as a result of the binary logistic regression, we found statistically significant difference in the probability of being diagnosed varicocele among the patients with inguinal hernia as 1.94 times. CONCLUSIONS: We think that in addition to the direct compression of some of the inguinal hernias on testicular veins, the potential for a combination of common enzymatic and biochemical disorders in some of the cases involving these two disorders may be play role.

OBJETIVOS: La finalidad de este estudio es investigar el rol de la hernia inguinal respecto al desarrollo de varicocele, en casos con acompañamiento de hernia inguinal.MÉTODOS: Las variables continuas fueron calculadas a partir de media y desviación standard, y las variables discontinuas se calcularon con porcentaje y frecuencia. Se desarrollaron pruebas de normalidad para variables continuas utilizando el test de Kolmogorov-Smirnov. Se realizó análisis univariante usando el test U de Mann-Whitney sin emparejamiento y para proporciones y utilizó el test de Chi cuadrado. Se aplicó el coeficiente de correlación tau-b de Kendall para los coeficientes de correlación. Se usaron modelos de regresión logística para identificar el impacto de la hernia inguinal en casos seleccionados. La información fue analizada con SPSS™ 22 para Windows (SPSS, Chicago, IL). RESULTADOS: Doce casos (23,1%) en el grupo de hernia inguinal tenían también varicocele, incidencia relativamente alta, mientras que solo había 12 casos con hernia inguinal en el grupo de varicocele, que correspondían a un 4,02 % [12/52 (23,1%) vs 12/298 (4,02%)]. Por otro lado, como resultado de la regresión logística binaria, descubrimos una diferencia estadísticamente significativa en la probabilidad de ser diagnosticado varicocele en los pacientes con hernia inguinal (1,94 veces). CONCLUSIONES: Pensamos que además de la compresión directa de algunas de las hernias inguinales de las venas testiculares, el potencial para una combinación de alteraciones comunes enzimáticas y bioquímicas en algunos de los casos, implicando estas dos anomalías, podría desempeñar un papel importante/clave.

The peroneus brevis tendon at its insertion site on fifth metatarsal bone.

BACKGROUND: The differences at the attachment site of peroneus brevis (PB) to the fifth metatarsal bone is important in terms of the forces exerted on the bone and hence the mechanism of fractures involving this structure. In this study, we investigated the anatomical properties of PB at the insertion site to the base of fifth metatarsal bone, its possible intertendinous connections with peroneus tertius (PT) and their possible effects on the fracture occurrence at the bony attachment site. METHODS: The length and the width of PB tendons at their mid- and end-points were measured and classified according to the insertion types. Besides, the length and the width of the base of fifth metatarsal bone were assessed. The slips extending from the PB tendons and their relationship with PT were also evaluated. The data was compared statistically with each other and between the right and left sides. RESULTS: The length of PB tendon was measured 79.57±15.40mm on the right side; 81.48±14.31mm on the left. The width of PB tendon at the mid-point was 4.46±0.80mm on the right side; 4.42±0.94mm on the left. The width of the tendon at its insertion point was measured 14.85±3.40mm and 15.16±3.42mm on the right and left sides respectively. PB was divided into three types according to its attachment to base of fifth metatarsal bone (5thMB). Type I, Type II and Type III were observed at the rates of 59.5%, 28.6% and 11.5% respectively. It was observed that the slips to the bone were extending more commonly from PB than from PT and that the large majority of them were single having their insertions on the base of the proximal phalanx of the fifth toe. CONCLUSIONS: Knowing the width and insertional types of PB aids in understanding the mechanism of fractures at the site of bony attachment. The existence of slips may help the surgeon in the procedures involving PB or the lateral side of the forefoot.

A new perforator flap from distal medial arm: a cadaveric study.

BACKGROUND: In this study, a new fasciocutaneous perforator flap raised from inner medial surface of the distal medial arm has been described for soft tissue coverage. METHODS: The blood supply of this flap comes directly from the distal brachial artery. Fourteen limbs of 7 formalinized cadavers were dissected to study the origin and the course of perforator vessel. RESULTS: The average size of the flap was 10.7 cm × 5.6 cm in the distal medial arm region. The constant main perforator was measured within a circle of 2.76-cm diameter, the center of which was 11.5 cm above and 1.3 cm medial to the medial epicondyle of humerus. The mean length and diameter of the distal brachial perforator artery were 3.3 cm and 0.95 mm, respectively. CONCLUSION: We think that this flap may be a useful option for the reconstruction of soft tissue defect of elbow.

A Morphometric Study of the Maxillary Artery and Lingula in Relation to Mandibular Ramus Osteotomies and TMJ Surgery.

OBJECTIVES: Mandibular osteotomies and resection of the temporomandibular joint (TMJ) ankylosis are the mostly performed surgical procedures in the infratemporal fossa, which is in close proximity with the main trunk of the maxillary artery (MA). It is imperative to avoid the trunk or branches of the maxillary artery, otherwise, massive intraoperative or postoperative hemorrhage may develop. The goal of the study was to investigate the position of the maxillary artery in the infratemporal fossa and the lingula of the mandible. METHODS: Significant landmarks were selected on the mandibles of formalin fixed cadavers, and the distances were measured between the maxillary artery and the bony landmarks with a digital caliper. RESULTS: The average distances between the MA and the articular eminence, the medial cortex of the mandibular ramus, the inferior border of the pterygoid fovea and the mandibular notch were 1.67+/-0.48 mm, 5.38+/-2.47 mm, 16.84+/-1.74 mm, 2.94+/-0.52 mm, respectively. Course pattern of the MA at the subcondylar level was also mapped. In order to determine the position of the lingula, the average distances between the tip of the lingula and the mandibular notch, the inferior border of the ramus, the anterior margin of the ramus and posterior margin of the ramus were measured and found as 15.4+/-2.1 mm, 49.5+/-4.3 mm, 18.1+/-2.7 mm, 16.6+/-2.5 mm, respectively. No significant differences were found between the right and left sides, for all parameters. CONCLUSIONS: The studied parameters will assist and navigate clinicians to determine the anatomic proximity to the maxillary artery, and, minimize the risk of damaging the vessel.

Accessory levator muscle slips of the levator palpebrae superioris muscle.

BACKGROUND: Accessory levator muscle slips may be associated with congenital eyelid retraction or blepharoptosis. Nevertheless, congenital retraction of the upper eyelid is a poorly defined entity about which little is known. Because of the clinical importance of the accessory levator muscle slip of the levator palpebrae superioris muscle, this study aimed to describe the morphological appearance of this variation in human adult orbits. METHODS: This study was undertaken in 60 orbits of 30 embalmed adult human cadavers, 17 men and 13 women, between the ages of 38 and 87 years at death. All cadavers were embalmed in 4% formalin solution. RESULTS: Three accessory levator muscle slips of the levator palpebrae superioris muscle were identified. One of these arose laterally from the origin of the levator palpebrae superioris muscle. At its anterior end, it divided into two parts, the main superior and a smaller inferior accessory. The second had an accessory levator fibromuscular slip. It arose medially from the origin of the levator palpebrae superioris and lost its muscular character after a short course. The third arose from the origin of the levator palpebrae superioris as a thin flat muscle. CONCLUSIONS: Although many variations of the levator palpebrae superioris muscle have been reported in fetuses, investigation and demonstration of these may be more important in children and adults for ophthalmic surgery. We believe that detailed knowledge regarding the morphological appearance of an accessory levator muscle slip of the levator palpebrae superioris muscle may be useful for successful outcomes in ophthalmic surgery.

The course and branching pattern of the deep branch of the radial nerve in relation to the supinator muscle in fetus elbow.

We aimed to make first demonstration of the course and branching pattern of deep branch of the radial nerve (DBRN) in relation to the supinator muscle in the forearms of fetuses and make morphological measurements in both fetuses and adults. We carried out dissection on 80 radial nerves from 20 adult cadavers (16 males and 4 females), ranging from 30 to 56 years old and 20 formalin-fixed, spontaneously aborted fetuses (10 males and 10 females) without detectable malformations, ranging from 20 to 37 weeks of gestation. There were three different branching patterns of the DBRN in fetuses. It divided its terminal branches at entrance of the supinator in 2 (5%), after entry of the supinator in 4 (10%) and after the supinator in 34 (85%) forearms. The course was bilaterally same in fetuses. Dividing pattern at the entrance of the supinator was not seen in adults. Only 4 (10%) were seen at after entering to the supinator and 36 (90%) were seen at after the supinator. We saw in fetuses neither fibrous band deep from the extensor carpi radialis longus nor upper border of the supinator. We assume that these fibrous structures appear after birth, perhaps favored by physical exercise, such as repeated pronation-supination movements. We think that it is one of the reasons why DBRN compression has never been reported in children. This is the first fetal study about the course and branching pattern of the DBRN and there is a constant ratio (mean 4.3) between the measurements of the fetuses and adults.

Anatomical assessment of bile ducts of Luschka in human fetuses.

Bile ducts of Luschka (also called subvesical or supravesicular ducts) can cause bile leakage during laparoscopic cholecystectomy, especially if surgery is carried out in ignorance of such variations. The aim of this study was to clarify the clinical anatomy of these ducts in human fetuses and frequency of the ducts locating near gallbladder fossa. Thirty-two fetal cadaver livers were dissected and the gallbladders were separated from the livers and ducts were investigated under a surgical microscope. All observed ducts were examined microscopically and connective tissue cords were excluded. Bile ducts of Luschka locating near cystic fossa were found in 7 of 32 fetuses (21.9%). Three of the seven ducts ran towards to liver segment 5 (S5); three ducts were found in the gallbladder fossa; and one duct ran towards to liver segment 4 (S4). Also it was found that three of the seven ducts drained into the subsegmental duct of S5, two ducts drained into the right hepatic duct, one duct drained into the right anterior branch bile duct, and one duct drained into the subsegmental duct of S4. Subvesical ducts running along the gallbladder fossa between the gallbladder and the liver parenchyma were found in a relatively high incidence in fetuses than adults. Awareness and knowledge about incidence of such ducts alerts the surgeon during laparoscopic cholecystectomy. Therefore morbidity due to bile leaks can be reduced.

An unnamed branch of the lingual nerve: gingival branch.

Our main aim was to study the mylohyoid nerve, but during cadaveric dissections an unnamed branch of the lingual nerve was encountered incidentally. Dissections of sublingual and pterygomandibular spaces on 13 cadavers preserved in formalin showed an unnamed branch present bilaterally in 11 specimens, which had not been identified before in any of the anatomical textbooks. The branch extended horizontally from the medial mandibular cortex at the level of the retromolar pad to mesial of the lower first molars-second premolars. It was supplying the lingual periosteum, gingiva, and mucosa that were overlying the medial alveolar process. The mean (SD) diameter of the left and right branches was 0.66 (0.1) mm at the branching side. The mean (SD) length of the right and left sides was 28.7 (4.4) mm. The mean (SD) distance from the alveolar crest was 5.8 (0. 9) mm. The lingual nerve supplies the lingual soft tissues; however, none of the anatomical textbooks mention such a subdivision or a branch supplying that part of the oral cavity. We describe the site and the morphological characteristics of this unnamed branch, and recommend that it be named "the gingival branch of the lingual nerve".

The course and branching pattern of pudendal nerve in fetus.

The pudendal nerve is a considerably large branch of the sacral plexus. There are many articles in the literature concerning the pudendal nerve in adults, but as far as we know, there is none on the branching pattern and variations in pudendal nerve anatomy in fetus. This study investigates the pudendal nerve trunking with respect to the piriformis muscle in 25 formalin-fixed fetuses (50 sides of pelves, 15 females, 10 males), ranging from 20 to 37 weeks of gestation. We investigate pudendal nerve trunking in four types: Type I-a is defined as single-trunk with the inferior rectal nerve branching proximal to the dorsal nerve of penis/clitoris (38%), Type I-b is also single-trunk with the dorsal nerve of penis/clitoris branching proximal to the inferior rectal nerve (24%), Type II is double-trunk with medial trunk as an inferior rectal nerve (34%), and Type III is triple-trunk (4%). We measured the average diameter of the main trunk of pudendal nerve in Type I-a and I-b groups to be 0.98 +/- 0.33 mm. We also measured the average length of the pudendal nerve trunks before the dorsal nerve of penis/clitoris branch to be 7.35 +/- 3.50 mm. There was no significant statistical difference in the average length, diameter, number of trunks, and pudendal nerve variations between male and female and also right and left sides of the pelves. This first and detailed fetal study of pudendal nerve trunking with respect to the piriformis muscle would be useful for educational anatomy dissections and anatomical landmark definitions for relevant clinical procedures.

Extralaryngeal division of the recurrent laryngeal nerve: a new description for the inferior laryngeal nerve.

Extralaryngeal division of the recurrent laryngeal nerve was contradictory in the literature. We aimed to investigate extralaryngeal division of the nerve, and also propose a new description for the inferior laryngeal nerve. Sixty specimens (120 sides) were examined for this project, including 41 men and 19 women cadavers between the ages of 40 and 89 years at death. In one right side, terminal segment of the nerve gave off many small branches surrounding the inferior thyroid artery then reaching the larynx, trachea, thyroid gland and esophagus. In eight sides, terminal segment of the nerve had no extralaryngeal division and entered the larynx as a single trunk. In 110 sides, the nerve had extralaryngeal division. One hundred and three nerves had two laryngeal and one to three extralaryngeal branches. Two types were described in this group. In type I (66 nerves), both branches arose from the same level of nerve. Type I had two subtypes: type Ia, the origin of the branches was just below the inferior constrictor muscle; type Ib, the origin of the branches was 15-35 mm below the muscle. In type II (37 nerves), the laryngeal branches arose just 3-5 mm above the extralaryngeal branches. We observed that the laryngeal and extralaryngeal branches arose generally from the same point of the recurrent laryngeal nerve. The inferior laryngeal nerve is thus very short, or even nonexistent. Therefore, we suggest that if the term "superior laryngeal nerve" is a given, standard, and accepted term, then the term "inferior laryngeal nerve" should also be accepted instead of the term "recurrent laryngeal nerve."

Unusual origin and course of the testicular arteries.

BACKGROUND: The testicular arteries usually arise from the anterolateral aspect of the abdominal aorta just inferior to the renal arteries at the level of the second lumbar vertebra. However, they may also originate from the renal artery, middle suprarenal artery, one of the lumbar arteries, common or internal iliac artery, or the superior epigastric artery. METHODS: An unusual origin of the right testicular artery and an unusual course of the left one were observed during routine dissection of the retroperitoneal space of a 43-year-old male cadaver. RESULTS: The right testicular artery originated from the inferior segmental branch of the right renal artery. After the left testicular artery originated from the anterolateral surface of the abdominal aorta just inferior to the left renal artery it was located between the left renal vein and the left renal artery and descended anterior to the renal vein. Thereafter it coursed on its normal route distally with the testicular vein. CONCLUSIONS: Awareness of variations of the testicular arteries, such as that shown in this case, is important during surgical and radiological procedures pertaining to kidney.

Relationship between the Zuckerkandl's tubercle and entrance point of the inferior laryngeal nerve.

The Zuckerkandl's tubercle (ZT) is a lateral or posterior projection from the lateral thyroid lobe. It has been used as an anatomical landmark for location of the inferior laryngeal nerve (ILN). Because most nerve injuries occurred just below that point where the ILN passed under the inferior constrictor muscle, we aimed to investigate the relationship between the ZT and entrance point (EP) of the ILN. Forty-five specimens taken from 26 male and 19 female cadavers were dissected. We found Grade 2 and Grade 3 ZTs in 58 sides (64% of 90 sides). The ZT was situated at the middle third of lateral lobe of the thyroid gland in 48 sides (82.7% of 58 sides). This group had three subgroups: (I) the ZTs indicated EPs of the ILN or the anterior laryngeal branch, (II) the ZTs covered the EPs of the ILN or the laryngeal branches or only the anterior laryngeal branch, and (III) the ZTs were below or above the EPs of the laryngeal branches. In conclusion, the ZTs pointed the EPs of the ILN or the laryngeal branches in 32 of 58 sides (55.2%). For this reason, we imagine that the ZT may be used as a landmark by surgeon to locate the EPs of the ILN or the laryngeal branches.

Relationship between Zuckerkandl's tubercle and the inferior laryngeal nerve including the laryngeal branches.

PURPOSE: Zuckerkandl's tubercle (ZT) is the most posterior extension of the lateral lobes of the thyroid gland in the area of the ligament of Berry. We investigated the relationship between ZT and the inferior laryngeal nerve (ILN), including the laryngeal branches. METHODS: We examined 40 specimens (80 sides) from 24 male and 16 female cadavers aged between 40 and 89 years at the time of death. The ZTs were graded according to Pelizzo as grade 0, unrecognizable; grade 1, only a thickening of the lateral lobe; grade 2, smaller than 1 cm; or grade 3, larger than 1 cm. RESULTS: First, we classified ZT into three groups according to its location, and then we investigated the relationship between ZT and the ILN, including the laryngeal branches. Zuckerkandl's tubercle was located in the middle third of the thyroid gland in 46 of 52 sides defined as grade 2 or 3. We observed that some of the tubercles passed over the ILN, some passed over the laryngeal branches, and some passed over only the anterior laryngeal branch. ZT also indicated the ILN or only the anterior laryngeal branch. CONCLUSIONS: Zuckerkandl's tubercle indicated or passed over the ILN and the laryngeal branches. These findings suggest that an identifiable ZT could be used as a landmark to expose the ILN and the laryngeal branches.

Variations of the nutrient artery of the fibula.

In this study the authors aimed to show variations of the nutrient artery of the fibula, which is important for more effective vascularized fibular grafts. Thirty intact legs were examined to determine the number, location, and diameter of the nutrient arteries in the shaft. In 27 of these specimens (90%) there was single nutrient artery; two legs (6.6%) had double nutrient artery. In one leg (3.3%) no nutrient artery was observed. The number of nutrient arteries found on each of the surfaces was summarized as follows. Most of the nutrient arteries pierced the fibula at its medial crest, while only one entered from the posterior surface. Most nutrient arteries were near the middle third of the fibula. The most frequent diameter of the nutrient artery was 0.9-1.5 mm. The authors think that their results about the variations of the nutrient artery supplying the fibula will contribute to the clinical and vascular anatomy knowledge.