The clinical anatomy of cystic artery variations: a review of over 9800 cases.

PURPOSE: While laparoscopic cholecystectomy can be a routine procedure when biliary anatomy is normally located, cystic artery variations can easily disorientate the inexperienced surgeon to the anatomy of the hepatobiliary triangle. This study presents the clinically important anatomical variations of the cystic artery. METHODS: PubMed, Medline, Cochrane Database of Systematic Reviews, and Google Scholar databases were searched to conduct a review of the existing English literature on the clinically important cystic artery variations. An aberrant vessel was defined as a vessel that originated from an atypical source and/or one that was present in a specimen in addition to the normal vessel. RESULTS: The cystic artery originated typically from the right hepatic artery (79.02 %) and was found in the hepatobiliary triangle in only 5427 of 6661 (81.5 %) cases. Clinically important cystic artery variations are (1) the cystic artery located anterior to the common hepatic duct or common bile duct found in 485 of 2704 (17.9 %) and 228 of 4202 (5.4 %) of cases, respectively, (2) the cystic artery located inferior to the cystic duct found in 38 of 770 (4.9 %) of cases, (3) short cystic arteries found in 98 of 1037 (9.5 %) cases and (4) multiple cystic arteries found in (8.9 %) of cases. CONCLUSION: These variations are common in the general population and can lead to inadvertent ligation of biliary ducts or aberrant vessels. Therefore, it is important for the hepatobiliary surgeon to be aware of these vascular anomalies to avoid operative complications.

Continuous negative pressure wound therapy in the treatment of a gigantic trophic leg ulcer.

AIM: to present a therapeutic algorithm for chronic venous insufficiency complicated with ulceration, using etiologic treatment combined with local treatment by negative pressure wound therapy (NPWT) before and after skin grafting. MATERIAL AND METHOD: we are discussing a 59 years-old patient with a lower leg gigantic, circumferential trophic lesion. The aetiology was combined, post-traumatic and chronic venous insufficiency, with 30 years of evolution. RESULTS: the treatment was applied in two surgical steps. Initially the pathological refluxes were interrupted; secondarily a skin graft was applied, preceded and followed by NPWT until graft intake. The wound healed completely; patient developed secondary foot lymphoedema. CONCLUSIONS: 1. Case treatment particularity consists in using a combination of etiologic and local treatment, combined with adjuvant NPWT. 2. Secondary lymphoedema developed due to circumferential location of the lesion. 3. Continuous NPWT has proven its efficiency in chronic ulcer before and after skin grafting, reducing costs and duration of treatment.

A review of the tragal pointer: anatomy and its importance as a landmark in surgical procedures.

The tragal pointer has long been used as a surgical landmark for the identification of the facial nerve trunk and the maxillary artery in such procedures as parotidectomy, internal fixation of subcondylar and condylar fractures, mandibular osteotomy, temporomandibular joint arthroplasty, and percutaneous blocks of branches of the trigeminal nerve and pterygopalatine ganglion. Aside from its use as an external landmark, it has also been implicated as a contributor to crease formation in the presence of peripheral arterial disease. This article will review the available literature on the tragal pointer's use as an external landmark.

[Accessory renal allotransplantation with internal or external urinary drainage. An experimental model in pig]. / Allotransplantarea renala accesorie cu drenaj urinar intern sau extern. Model experimental la porc.

This study describes an experimental model of accessory renal allotransplantation in the big laboratory animal (pig). A total of 24 common-breed pigs were used. All allografts were transplanted in an accessory manner and revascularized at the level of the infrarenal abdominal aorta and inferior vena cava. The urinary drainage was performed either through a nexternal uretheroneostomy at the ipsilateral lumbar region (Group A--n=8) or by internal uretheroneocystostomy (Group B--n=8). All transplants were monitored for 8 days postoperatively using translumbar ultrasound-guided biopsies at 1, 4, 7 days. A total of 16 transplants were performed. 1 ectopic donor kidney was found and transplanted in the same fashion. Mean operative time was 125 minutes, immediate postoperative survival was 100% and at 72 hours, 87.5%. The onset of acute rejection was at day 4, by massive lymphocyte infiltration and was directly correlated with the abrupt decrease of the allograft diuresis in Group A, at day 3. At day 7, the rejection was complete. Both methods of urinary drainage are functional and can be employed. This experimental model is a useful tool for training of the transplant surgeons or for transplantation research. The surgical technique for accessory renal allotransplantation in pig is easy to learn and offers the possibility for allograft monitoring until complete rejection without influencing the receptor health condition.

Enteric nervous system development in cavitary viscera allocated to the celiac plexus.

Enteric nervous system (ENS) is a network made of neuronal cells and nervous fibers. There are two plexuses: myenteric of Auerbach and sub mucous of Meissner and Henle. Many substances are involved in neurotransmission at ENS level. ENS assures all gastrointestinal system functions: digestion, absorption, etc. Our study is made on 23 human fetal specimens at different ages of evolution with crown-rump lengths from 9 to 28 cm, and three new born human specimens. We used the Trichrome Masson stain technique and the argental impregnation Bielschowsky on block technique for microscopic evidence. Our study concerned the cavitary viscera allocated to the celiac plexus, involving all layers of each studied viscera.

[Surgical methods of covering head soft tissues defects]. / Modalitati chirurgicale de acoperire a defectelor de parti moi la nivelul capului.

Posttraumatic and post-excisional head soft tissue defects represent a challenge for the plastic surgeon due to the functional and esthetic impact of this body area. Choosing the simplest way of covering a defect is many times the most efficient way, but it must deliver a good tissue cover and their aspect and function must simulate the characteristics of that area. This article is proposing to be a brief description of all these procedures, informing and being necessary for every general surgeon. The methods of covering head soft tissues defects specific to plastic surgery will be presented in a ladder way from simple to complex, that means from the simple skin graft to island flaps and the tissues transfers. Choosing a right procedure refers to the etiopathogeny, and the length and width of the defect. We shall present advantages and disadvantages of each procedure, indications and their limits, giving specific clinical cases. We shall present the results for each type of procedure also, giving specific arguments for our option. We'll insist on the functional reconstruction of the lids, nose and cheek, as single defects and on the surgical limits which come upon very large soft tissue defects. Due to the complexity of the head structures, either single or complex, and to the functional and esthetic impact of these soft tissue defects, we consider this paper to be a real benefit. It is very important to choose the right procedure, considering all the factors who are implicated (sex, age, general condition, etiopathogeny, the length and width of the defect, previous treatments, patient wish, etc).

[Surgical management in complex trauma of the lower limb with soft tissue defects]. / Indicatia metodei chirurgicale în rezolvarea defectelor posttraumatice de parti moi la nivelul gambei.

This work is studying the treatment for the complex trauma of the lower limb, followed by soft tissue defects, with bones exposure, that necessitate immediate coverage with adequate tissues. The reconstructive method should be chosen according to the location and soft tissue requirement of the defect (local/regional flap, or free tissue transfer). Aggressive management of acute trauma of the lower limb provides good results. First condition for the intervention success is working together: plastic surgeon, orthopaedic surgeon, neurosurgeon, physiotherapist.

[Dupuytren disease. Experience at the Clinic of Plastic Surgery, Clinical Emergency Hospital "Bagdasar-Arseni"]. / Maladia dupuytren. Experienta sectiei de chirurgie plastica de la Spitalul Clinic de Urgenta "Bagdasar-Arseni".

This work is studying the pathogenic concepts about Dupuytren disease. A lot of theories and assumptions have been put forward around this disease, but none of them could explain the real etiopathogenic conditions. Doctor Chiotan (1999) was saying that if we don't have an objective, integrated concept, it doesn't mean that we don't have ideas, theories. We call this ideology. We want to present, by turn, the tumoral theories about Dupuytren disease, the healing and inflammatory theories, the neurovascular theory, the intrinsic and extrinsic theories.

[Therapeutic solutions in post-excision defects for plantar verrucous carcinoma]. / Modalitati de acoperire într-un caz de carcinom verucos plantar (Epithelioma cuniculatum).

Carcinoma verrucous--anatomoclinical entity histological high rate of differentiation of the spinocellular epithelioma, clinically associated with 3 types of lesion. We present the therapeutical solution of a plantar carcinoma verrucous case, a large post-excisional defect-free flap transfer of latissimus dorsi muscle using microsurgical techniques.

[Comparative electronmicroscopic research on normal palmar aponeurosis and adulterated palmar aponeurosis in Dupuytren disease]. / Studiu comparativ electronomicroscopic al aponevrozei palmare normale si modificate in maladia Dupuytren.

This article represents a comparative research between the normal palmar aponeurosis seen with the electron microscope and adulterated palmar aponeurosis in Dupuytren disease. For that reason, we harvested normal palmar aponeurosis from 5 patients hospitalised in emergency in our department with different posttraumatic hand lesions, and adulterated palmar aponeurosis from 15 patients with Dupuytren disease. The samples were prepared to obtain sections visualised with the electron microscope. Comparative research of these sections lead to the conclusion that in the normal palmar aponeurosis the fibroblast is visualised in its resting functional form (fibrocytes), and in the adulterated palmar aponeurosis in Dupuytren disease the fibroblast is visualised in its active, secretory, form. In Dupuytren disease we found an increased, anarchic, collagen production, clinically demonstrated by nodules and fibrous strips. This paper is just a preliminary stage of a research looking for alternative, noninvasive, therapeutical methods in Dupuytren disease (ex. : effects of electromagnetic field made by millimeter waves on the adulterated palmar aponeurosis cell structure).

Aspects of the thyroid gland vascularization in young organisms (a morphological and radioisotope-based study).

The thyroid gland vascularization has been studied on 58 pieces belonging to young organisms (human and animal) by means of both morphometric methods (macro- and microscopic) and injection of radioisotopes (86Rb). The statistical-mathematical study of the dimensional values characterizing the thyroid vascular branch at different levels assumed for study allowed to determine the thyroid central area as the best vascularized of the thyroid parenchyma. Estimating the specific activity and the absorption constant value of the 86Rb in the vascular wall and the glandular parenchyma, the radioisotope-based study attests the data obtained morphologically. By the simultaneous injection of 86Rb into strychnine, the pharmacodynamic study shows a more prominent reduction of the 86Rb absorption constant value in the distal area of the gland as compared to its central one and the blank batch.

The vascular morphometry of some brain stem parts.

With the view of following the vascular system of the cerebral trunk, there have been simultaneously injected coloured tracers combined with radio-opaque substances and radio-isotopes (32P, 22Ca) by intravital perfusion to 130 animals (dogs, rabbits and rats). The macro- and microscopical vasculature of the human brain stem was studied on 30 specimens of adults and children. The angioarchitecture of the diverse parts and sectors of the brain stem was studied as a whole in tetraline transparentised preparations and on histological section in comparison with the microradiographies and to incorporation of radioisotopes. A particular attention has been given to the irrigation of hypoglossal nuclei, the bulbar oliva, and the pontopeduncular region, all being zones with multiple sources of vascularization. The vascular morphometry has been macro- and microscopically performed, the data being worked out mathematically-statistically by computing some hemodynamical indices in order to estimate the circulation in different zones of the brain stem.