The Story Retold: The Kocher Manoeuvre.

The Kocher manoeuvre is used for mobilization of the duodenum and head of the pancreas and bears the name of Theodor Kocher, who published it in 1903. We describe the embryology of the duodenum and pancreas, relating it to surgical anatomy applied during the procedure. Finally, we present the key points of the procedure, providing more insights into the anatomical structures that are mainly involved.

Anatomic Variations of the Deep Femoral Artery and Its Branches: Clinical Implications on Anterolateral Thigh Harvesting.

The deep femoral artery (DFA) is the largest branch of the common femoral artery (CFA), supplying with its branches, the medial circumflex femoral artery (MCFA) and lateral circumflex femoral artery (LCFA), the thigh muscles, the hip joint, and the femur. Their anatomical variations have a great impact on both interventional and surgical procedures. The anterolateral thigh (ALT) flap, a versatile soft tissue with highly increasing use in reconstructive surgery, is noticeably influenced by this variability. A total of 25 articles were incorporated into the review. Studies conducted after the year 2009 were included. After the assessment of all studies included, we concluded that the DFΑ arises from the CFA with a varying site of origin, the posterolateral being the prevalent one found in 51.32% of cases. Of all cases studied, the MCFA and the LCFA most often originated from the DFA in 63.125% and 74.92%, respectively, but the CFA constitutes another frequent source of origin in 27% and 12.12% of cases, respectively. The descending branch of the lateral circumflex femoral artery (dLCFA) is the prominent pedicle in the ALT flap, originating from the LCFA in 83.55% of cases. However, the presence of an oblique lateral circumflex femoral artery (oLCFA) branch with changeable origination was observed. Knowledge of the anatomical variants in the deep femoral artery is imperative both for interventional radiologists and surgeons. Especially in reconstructive surgery, the possibility for different sources supplying the skin and the pedicle compel surgeons to acquire an awareness of this subject.

Hypoglossal Nerve: Anatomy, Anatomical Variations Comorbidities and Clinical Significance.

We review the anatomical variations of the hypoglossal nerve and their surgical and clinical significance, and we report multiple diseases that affect function of the nerve leading to paresis, either unilateral or bilateral. The hypoglossal nerve is the 12th cranial nerve, and knowledge of the detailed anatomy and relationship with critical structures is of paramount importance in neurosurgery, head and neck surgery, and vascular surgery. Numerous studies have depicted conventional landmarks in the cervical part of the hypoglossal nerve, but their findings have not been consistent reliable. We analyze and review these critical landmarks used to identify and preserve the hypoglossal nerve during surgery and to minimize iatrogenic complications in head and neck, neurosurgical, and vascular procedures. We performed an online database search during January and February 2019 to pinpoint the diseases that affect function of the nerve. According to this literature review, apart from iatrogenic injury during surgery, the most frequently observed cause of paresis is pressure due to the presence of tumours and head injury. Furthermore, motor neuron degenerative conditions, such as amyotrophic lateral sclerosis, multiple sclerosis or tooth infection and presence of an aberrant vessel in the hypoglossal canal can affect the function of the nerve.

Uterus Transplantation as a Therapy Method in Mayer-Rokitansky-Küster-Hauser Syndrome.

The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is the most common cause of uterine aplasia (underdevelopment or absence) at a frequency estimated to be worldwide of 1/4500 births of new-born female infants. This is a literature review aiming to determine the sufficiency of the uterine transplantation (UTx) method as a therapeutic protocol for the MRKH syndrome. Online searches were carried out in PubMed, Embase, CINAHL and Google scholar databases, during January and February 2019. The search included a combination of the various terms (see key words) as well as a combination of these terms in Greek and English so as to identify and display articles that would be as close as possible to the subject of research. The online search yielded 95 articles. Eighty-five of these were considered as eligible and possible sources from the title and abstract presented but later were excluded, whereas 10 of them were selected to be included in the literature review. The literature review results showed that two therapeutic methods that are now successfully applied are the Vecchietti method and the Davydov method, which is the latest and less invasive technique but with equally if not improved immediate results. However, this treatment is not adequate to satisfy or provide a solution for the reproduction requirements of this patient group. The UTx proved sufficient. Although uterus transplant could be considered the ideal solution for the management of infertility and the satisfaction of the reproductive and sexual needs of women with MRKH syndrome, since the first successful pregnancy after uterine transplantation is a reality in the recent years, it is early days to be considered as a safe mode of management.

Variation of Marginal Mandibular Nerve in a Caucasian Male Cadaver: A Study Using the Anatomage Table.

Anatomage (Anatomage, Inc., San Jose, CA) is a modern method for studying anatomy. It is a state-of-the-art method used for the representation of the structure of the human body. In our study, we examined the seventh cranial nerve of a male Caucasian cadaver using an Anatomage Table in the Anatomy Department of the School of Medicine, National and Kapodistrian University, Athens, Greece. After exiting the skull from the stylomastoid foramen, the facial nerve divided into the temporofacial and cervicofacial main branches. The cervicofacial branch divided into its own branches, including the marginal mandibular nerve (MMN), which ran within the investing (superficial) layer of the deep cervical fascia. We found a variation of the course of the marginal mandibular branch of the facial nerve. In the area of the lower border of the mandible, where the MMN actually crossed the facial artery and vein, it appeared to run deeper than both of those vessels, rather than running superficially. This seemed to be a rare variation of the location of the MMN relative to the facial vessels, which suggested that extra care is essential in surgical approaches within this area.

Right or left thoracotomy for esophageal atresia and right aortic arch? Systematic review and surgicoanatomic justification.

INTRODUCTION: The optimal thoracotomy approach for the management of esophageal atresia and tracheoesophageal fistula (EA/TEF) with a right aortic arch (RAA) remains controversial. METHODS: Systematic review of complications and death rates between right- and left-sided repairs, including all studies on EA/TEF and RAA, apart from studies focusing on long-gap EA and thoracoscopic repairs. Review of right- and left-sided surgical anatomy in relation to reported complications. RESULTS: Although no significant differences were elicited between right- and left-sided repairs in complications (9/29 vs. 1/6, p = 0.64) and death rates (2/29 vs. 0/6, p = 0.57), unique anatomic complications - such as injury to the RAA covering the esophagus and intractable bleeding - associated with mortality were revealed in the right thoracotomy group. Left-sided repairs following failed repair through the right showed higher complications rate (3/3) than straightforward right- (9/29) or left-sided repairs (1/6) (p = 0.024). Right thoracotomies converted to left thoracotomies led to staged repairs more frequently (4/9) than straightforward right (5/38) or left thoracotomies (0/6) (p = 0.03). CONCLUSIONS: There is not enough evidence to support that right thoracotomy, characterized by unique surgicoanatomic difficulties, is equivalent to left thoracotomy for EA/TEF with RAA. Both approaches might be required, and, therefore, surgeons should be familiarized with surgical anatomy of mediastinum approached from right and left. Systematic review, Level of Evidence III.

A model of hemorrhagic shock and acute lung injury in Landrace-Large White Swine.

Traumatic injury is a leading cause of death worldwide for people between 5 and 44 y of age, and it accounts for 10% of all deaths. The incidence of acute lung injury, a life-threatening complication in severely injured trauma patients remains between 30% and 50%. This study describes an experimental protocol of volume-controlled hemorrhage in Landrace-Large White swine. The experimental approach simulated the clinical situation associated with hemorrhagic shock in the trauma patient while providing controlled conditions to maximize reproducibility. The duration of the protocol was 8 h and was divided into 5 distinct phases-stabilization, hemorrhage, maintenance, resuscitation, and observation-after which the swine were euthanized. Lung tissue samples were analyzed histologically. All swine survived the protocol. The hemodynamic responses accurately reflected those seen in humans, and the development of acute lung injury was consistent among all swine. This experimental protocol of hemorrhagic shock and fluid resuscitation in Landrace-Large White swine may be useful for future study of hemorrhagic shock and acute lung injury.

Anatomy of the lymphatics.

The lymphatic system is perhaps the most complicated system of Homo sapiens. An introduction to the anatomy, embryology, and anomalies of the lymphatics is presented. The overall anatomy and drainage of the lymphatic vessels in outlined. The topographic anatomy, relations, and variations of the principle vessels of the lymphatic system (the right lymphatic duct, the thoracic duct, and the cisterna chyli) are presented in detail.

Groin hernia: anatomical and surgical history.

The history of surgical repair of groin hernia is a lengthy record of assorted techniques in search of a cure for an ailment that comes in many sizes and shapes and that has plagued humanity for thousands of years. Although improvements are still being sought and found, for several decades surgeons have had the means to relieve most hernia sufferers. A remaining issue is whether the wide array of surgical procedures can or should be whittled down to a few "standard" operations that are safe, effective, and cost-efficient. The history of the anatomy of groin hernia shows how much there was to learn and how much remains to be learned. It also shows how important it is for the surgeon to know and understand both the anatomy of the area and the formation of groin hernia.

"To afford the wounded speedy assistance": Dominique Jean Larrey and Napoleon.

Dominique Jean Larrey (1766-1842) has been described as the father of modern military surgery and is considered even today as the model military surgeon. He developed a plan of rapid evacuation of wounded soldiers from the battlefield during combat, using flexible medical units which he named ambulances volantes ("flying ambulances"). He won the admiration of Napoleon Bonaparte (1769-1821), who was amazed by the results of Larrey's sanitary system. Larrey spent almost 18 years with Napoleon, accompanying him in 25 campaigns, 60 battles, and more than 400 engagements. Napoleon's enormous military success was due not only to his strategy and skill but also to the medical services provided by Larrey. The surgeon became a master of wound management and limb amputation. In his vivid battlefield journals, Larrey documented the course of tetanus, the pathophysiology of cold injury, the effective control of hemorrhage, the drainage of empyema and hemothorax, the aspiration of pericardial effusion or hemopericardium, and the packing of sucking chest wounds. Larrey established a categorical rule for the triage of war casualties, treating the wounded according to the observed gravity of their injuries and the urgency for medical care, regardless of their rank or nationality.

The monarch and the master: Peter the Great and Frederik Ruysch.

The extraordinary European journey of Tsar Peter the Great and his passage to Amsterdam, The Netherlands, allowed him to meet a great figure of medical history who offered insight into the mysteries surrounding the structure of the human body. The famous Dutch anatomist Frederik Ruysch, preeminent in dissection and anatomical preservation, impressed the emperor and inspired his love for anatomy and surgery. Peter the Great was fascinated by the study of the structure of the human body and spent many hours in the anatomical cabinet of Ruysch. This impressive collection of cadavers and anatomical specimens, described as "a perfect necropolis," was both a laboratory for teaching anatomy and a bizarre and unique form of art. The profound and enduring impression that the West made on the emperor also led him to modernize the medical services in his homeland, Russia.

Richter hernia: surgical anatomy and technique of repair.

Richter hernia (partial enterocele) is the protrusion and/or strangulation of only part of the circumference of the intestine's antimesenteric border through a rigid small defect of the abdominal wall. The first case was reported in 1606 by Fabricius Hildanus. The first definition of partial enterocele was given by August Gottlieb Richter in 1785. Sir Frederick Treves discriminated it from Littre hernia (hernia of the Meckel diverticulum). More often these hernias are diagnosed in the sixth and seventh decades of life. They comprise 10 per cent of strangulated hernias. Their common sites are the femoral ring, inguinal ring, and at incisional trauma. The most-often entrapped part of the bowel is the distal ileum, but any part of the intestinal tube may be incarcerated. These hernias progress more rapidly to gangrene than other strangulated hernias, and obstruction is less frequent. The gold standard technique for repair is the preperitoneal approach, followed by laparotomy and resection if perforation is suspected.

Littre hernia: surgical anatomy, embryology, and technique of repair.

Littre hernia is the protrusion of a Meckel diverticulum through a potential abdominal opening. Alexis de Littre (1700) reported ileal diverticula and attributed them to traction. August Gottlieb Richter (1785) defined them as preformed, and Johann Friedrich Meckel (1809) postulated their embryologic origin. Sir Frederic Treves (1897) distinguished between Littre and Richter hernia (partial enterocele). Embryologically, Meckel diverticulum is the persistent intestinal part of the omphaloenteric duct through which the midgut communicates with the umbilical vesicle until the fifth week. It is found at the antimesenteric border of the ileum, usually located 30 to 90 cm from the ileocecal valve, measuring 3 to 6 cm in length and 2 cm in diameter. Usual sites of Littre hernia are: inguinal (50%), umbilical (20%), and femoral (20%). Meckel diverticulum may be accompanied in the sac by the ileal loop to which it is attached; rarely, it may undergo incarceration or strangulation, necrosis, and perforation. In children, it is mostly found in umbilical hernias, and the diverticulum is more prone to adhere to the sac. Repair of Littre hernia consists of resection of the diverticulum and herniorraphy; in perforated cases, care must be taken to not contaminate the hernia field.

Transversalis, endoabdominal, endothoracic fascia: who's who?

In Terminologia Anatomica of 1998, the fasciae of the trunk are listed as parietal, extraserosal, and visceral. Parietal fascia is defined as the fascia located outside the parietal layer of a serosa (e.g., pleura, peritoneum) lining a body wall cavity. The parietal fascia of the thorax is endothoracic fascia, and that of the abdomen is endoabdominal fascia. According to Terminologia Anatomica, endoabdominal fascia comprises: 1) transversalis fascia and 2) investing abdominal fascia: deep, intermediate and superficial. Thus, transversalis fascia is the innermost layer of endoabdominal fascia and, consequently, not synonymous with it. We assert that transversalis fascia is the inner epimysium of transversus abdominis muscle; no separate deep investing fascia exists. Embryologically, deep, intermediate and superficial layers of investing fascia are produced as muscular primordia--originating from somites invading somatopleura--penetrate somatic wall connective tissue, and thus obtain epimysium on either side, which give layers of investing fascia. In the thoracic wall, muscle layers are not separated and no distinct investing fasciae are found on them. Furthermore, in the thorax extraserosal fascia does not exist. Therefore, only endothoracic fascia is found on the inner side of the innermost intercostal muscle, which is deprived of investing fascia, to separate this muscle from pleura.

Spigelian hernia: surgical anatomy, embryology, and technique of repair.

Spigelian hernia (1-2% of all hernias) is the protrusion of preperitoneal fat, peritoneal sac, or organ(s) through a congenital or acquired defect in the spigelian aponeurosis (i.e., the aponeurosis of the transverse abdominal muscle limited by the linea semilunaris laterally and the lateral edge of the rectus muscle medially). Mostly, these hernias lie in the "spigelian hernia belt," a transverse 6-cm-wide zone above the interspinal plane; lower hernias are rare and should be differentiated from direct inguinal or supravescical hernias. Although named after Adriaan van der Spieghel, he only described the semilunar line (linea Spigeli) in 1645. Josef Klinkosch in 1764 first defined the spigelian hernia as a defect in the semilunar line. Defects in the aponeurosis of transverse abdominal muscle (mainly under the arcuate line and more often in obese individuals) have been considered as the principal etiologic factor. Pediatric cases, especially neonates and infants, are mostly congenital. Embryologically, spigelian hernias may represent the clinical outcome of weak areas in the continuation of aponeuroses of layered abdominal muscles as they develop separately in the mesenchyme of the somatopleura, originating from the invading and fusing myotomes. Traditionally, repair consists of open anterior herniorraphy, using direct muscle approximation, mesh, and prostheses. Laparoscopy, preferably a totally extraperitoneal procedure, or intraperitoneal when other surgical repairs are planned within the same procedure, is currently employed as an adjunct to diagnosis and treatment of spigelian hernias. Care must be taken not to create iatrogenic spigelian hernias when using laparoscopy trocars or classic drains in the spigelian aponeurosis.

"Most brilliant in judgment": Alexander the Great and Aristotle.

From historical sources, it is evident that Alexander the Great was indebted to one of his teachers, Aristotle of Stagira. It was the teaching of Aristotle that evoked all the nascent talents of young Alexander and turned him into a great man. Alexander was extremely interested in the secrets of medicine and considered it an art. The medical knowledge he acquired from Aristotle may have saved his life and the lives of his troops on many occasions. If Alexander did not possess medical knowledge and if his everyday life had not been so greatly influenced by medicine, he might never have been able to create his empire.