The Ability to Sustain Facial Expressions.

To gain more insight into facial muscle function, imaging during action would be optimal. Magnetic resonance imaging is highly suitable for visualizing facial muscles. However, magnetic resonance imaging requires the individual to remain as still as possible for a while. Knowledge of the ability to sustain facial expressions is requisite before scanning individuals. This could help adapting the scanning protocol to obtain optimal quality of imaging the muscles in action. A study, including 10 healthy volunteers, was done to perceive the extent of movement while holding facial expressions of smiling and pouting. During 6 minutes, 3-dimensional photographs were taken every consecutive minute while the participants maintained their facial expressions as motionless as possible. The movement was objectified by creating distance maps between the 2 models and calculating the Root Mean Square using the software 3DMedX. The results showed that most movements occurred in the first minute, with a decrease of the intensity of the expression. After the first minute, the expression, although less intense, could be held stable. This implies that magnetic resonance imaging scanning during facial expression is possible, provided that the scanning starts after the first minute has elapsed. In addition, results demonstrated that more slackening of the muscles while smiling compared with pouting.

A novel anatomical description of the esophagus: the supracarinal mesoesophagus.

BACKGROUND: During thoracoscopic esophageal resection, while performing the supracarinal lymphadenectomy along the left recurrent laryngeal nerve (LRLN) from the aortic arch to the thoracic apex, we observed a not previously described bilayered fascia-like structure, serving as prolongation of the already known mesoesophagus. METHODS: We retrospectively evaluated 70 consecutively unedited videos of thoracoscopic interventions on esophageal resections for cancer, in order to determine the validity of this finding and to describe its utility for performing a systematic and more accurate dissection of the LRLN and its adequate lymphadenectomy. RESULTS: After mobilization of the upper esophagus from the trachea and tilting the esophagus by means of two ribbons, a bilayered fascia was observed between the esophagus and the left subclavian artery in 63 of the 70 patients included in this study. By opening the right layer, the left recurrent nerve became visualized and could be dissected free in its whole trajectory. Vessels and branches of the LRLN were divided between miniclips. Mobilizing the esophagus to the right, the base of this fascia could be found at the left subclavian artery. After dissecting and clipping the thoracic duct, complete lymphadenectomy of 2 and 4L stations could be performed. Mobilizing the esophagus in distal direction, the fascia continued at the level of the aortic arch, where it had to be divided in order to mobilize the esophagus from the left bronchus. Here, a lymphadenectomy of the aorta-pulmonary window lymph nodes (station 8) can be performed. It seems that from there the fascia continued without interruption with the previously described mesoesophagus between the thoracic aorta and the esophagus. CONCLUSIONS: Here we described the concept of the supracarinal mesoesophagus on the left side. Applying the description of the mesoesophagus will create a better understanding of the supracarinal anatomy, leading to a more adequate and reproducible surgery.

The clinical significance of the human vomeronasal organ.

OBJECTIVE: To find out whether the vomeronasal organ (VNO) can be identified in the nose as a mucosal pit in the anterior nasal septum, to elucidate its function in man and to determine whether it is important to preserve the VNO during septal surgery. METHODS: Literature review. RESULTS AND CONCLUSION: The VNO is histologically present in almost all humans, but a macroscopically visible septal pit does not necessarily correspond with the actual VNO. The human VNO is probably a vestigial organ with a non-operational sensory function. It is not necessary to take particular care not to damage the VNO during septal surgery.

A comparative anatomical and histological study on the presence of an apical splenic nerve in mice and humans.

The cranial pole of the mouse spleen is considered to be parasympathetically innervated by a macroscopic observable nerve referred to as the apical splenic nerve (ASN). Electrical stimulation of the ASN resulted in increased levels of splenic acetylcholine, decreased lipopolysaccharide-induced levels of systemic tumor necrosis factor alpha and mitigated clinical symptoms in a mouse model of rheumatoid arthritis. If such a discrete ASN would be present in humans, this structure is of interest as it might represent a relatively easily accessible electrical stimulation target to treat immune-mediated inflammatory diseases. So far, it is unknown if a human ASN equivalent exists. This study aimed to provide a detailed description of the location and course of the ASN in mice. Subsequently, this information was used for a guided exploration of an equivalent structure in humans. Microscopic techniques were applied to confirm nerve identity and compare ASN composition. Six mice and six human cadavers were used to study and compare the ASN, both macro- and microscopically. Macroscopic morphological characteristics of the ASN in both mice and humans were described and photographs were taken. ASN samples were resected, embedded in paraffin, cut in 5 µm thin sections where after adjacent sections were stained with a general, sympathetic and parasympathetic nerve marker, respectively. Neural identity and nerve fiber composition was then evaluated microscopically. Macroscopically, the ASN could be clearly identified in all mice and was running in the phrenicosplenic ligament connecting the diaphragm and apical pole of the spleen. If a phrenicosplenic ligament was present in humans, a similar configuration of potential neural structures was observed. Since the gastrosplenic ligament was a continuation of the phrenicosplenic ligament, this ligament was explored as well and contained white, potential discrete nerve-like structures as well which could represent an ANS equivalent. Microscopic evaluation of the ASN in mice and human showed that this structure did not represent a nerve, but most likely connective tissue strains. White nerve-like structures, which could represent the ASN, were macroscopically observed in the phrenicosplenic ligament in both mice and human and in the gastrosplenic ligament in humans. The microscopic investigation did not confirm their neural identity and therefore, this study disclaims the existence of a parasympathetic ASN in both mice and human.

Sympathetic nerve distribution in human lymph nodes.

Various lymph node functions are regulated by the sympathetic nervous system as shown in rodent studies. If human lymph nodes show a comparable neural regulation, their afferent nerves could represent a potential therapeutic target to treat, for example, infectious or autoimmune disease. Little information is available on human lymph node innervation and the aim of this study is to establish a comprehensive and accurate representation of the presence and location of sympathetic nerves in human lymph nodes. Since previous studies mention sympathetic paravascular nerves to occasionally extent into T cell-rich regions, the relation of these nerves with T cells was studied as well. A total number of 15 inguinal lymph nodes were resected from six donated human cadavers. Lymph node sections were stained with HE and a double T/B cell staining for evaluation of their morphology and to screen for general pathologies. A triple stain was used to identify blood vessels, sympathetic nerves and T cells, and, to study the presence and location of sympathetic nerves and their relation to T cells. To evaluate whether the observed nerves were en route to other structures or were involved in local processes, adjacent slides were stained with a marker for varicosities (synaptophysin), which presence is suggestive for synaptic activity. All lymph nodes contained sympathetic nerves, both as paravascular and discrete structures. In 15/15 lymph nodes, nerves were observed in their capsule, medulla and hilum, whereas only 13/15 lymph nodes contained nerves in their cortex. The amount of sympathetic nerves varied between compartments and between and within individuals. In general, if a lymph node contained more paravascular nerves in a specific compartment, more discrete nerves were observed as well. Occasionally, discrete nerves were observed in relation to T cells in lymphoid tissues of the cortex and medulla. Furthermore, discrete nerves were frequently present in the capsule and hilum. The presence of varicosities in a portion of these nerves, independently to their compartment, suggested a local regulatory function for these nerves. Human lymph nodes contain sympathetic nerves in their capsule, trabeculae, cortex, medulla and hilum, both as paravascular or as discrete structures. Discrete nerves were observed in relation to T cells and non-T cell-rich areas such as the hilar and capsular connective tissue. The presence of discrete structures suggests neural regulation of structures other than blood vessels, which was further supported by the presence of varicosities in a portion of these nerves. These observations are of relevance in further understanding neural regulation of lymph node immune responses and in the development of neuromodulatory immune therapies.

Surgical anatomy of the upper esophagus related to robot-assisted cervical esophagectomy.

Robot-assisted cervical esophagectomy (RACE) enables radical surgery for tumors of the middle and upper esophagus, avoiding a transthoracic approach. However, the cervical access, narrow working space, and complex topographic anatomy make this procedure particularly demanding. Our study offers a stepwise description of appropriate dissection planes and anatomical landmarks to facilitate RACE. Macroscopic dissections were performed on formaldehyde-fixed body donors (three females, three males), according to the surgical steps during RACE. The topographic anatomy and surgically relevant structures related to the cervical access route to the esophagus were described and illustrated, along with the complete mobilization of the cervical and upper thoracic segment. The carotid sheath, intercarotid fascia, and visceral fascia were identified as helpful landmarks, used as optimal dissection planes to approach the cervical esophagus and preserve the structures at risk (trachea, recurrent laryngeal nerves, thoracic duct, sympathetic trunk). While ventral dissection involved detachment of the esophagus from the tracheal cartilage and membranous part, the dorsal dissection plane comprised the prevertebral compartment harboring the thoracic duct and right intercosto-bronchial artery. On the left side, the esophagus was attached to the aortic arch by the aorto-esophageal ligament; on the right side, the esophagus was bordered by the azygos vein, right vagus nerve, and cardiac nerves. The stepwise, illustrated topographic anatomy addressed specific surgical demands and perspectives related to the left cervical approach and dissection of the esophagus, providing an anatomical basis to facilitate and safely implement the RACE procedure.

Splenic artery loops: Potential splenic plexus stimulation sites for neuroimmunomodulatory-based anti-inflammatory therapy?

INTRODUCTION: The splenic plexus might represent a novel neuroimmunomodulatory therapeutic target as electrical stimulation of this tissue has been shown to have beneficial anti-inflammatory effects. Tortuous splenic artery segments (splenic artery loops), including their surrounding nerve plexus, have been evaluated as potential stimulation sites in humans. At present, however, our understanding of these loops and their surrounding nerve plexus is incomplete. This study aims to characterize the dimensions of these loops and their surrounding nerve tissue. MATERIALS AND METHODS: Six formaldehyde fixed human cadavers were dissected and qualitative and quantitative macro- and microscopic data on splenic artery loops and their surrounding nerve plexus were collected. RESULTS: One or multiple loops were observed in 83% of the studied specimens. These loops, including their surrounding nerve plexus could be easily dissected free circumferentially thereby providing sufficient space for further surgical intervention. The splenic plexus surrounding the loops contained a significant amount of nerves that contained predominantly sympathetic fibers. CONCLUSION: The results of this study support that splenic artery loops could represent suitable electrical splenic plexus stimulation sites in humans. Dimensions with respect to loop height and width, provide sufficient space for introduction of surgical instruments and electrode implantation, and, the dissected neurovascular bundles contain a substantial amount of sympathetic nerve tissue. This knowledge may contribute to further development of surgical techniques and neuroelectrode interface design.

Histopathological characterization of intimal lesions and arterial wall calcification in the arteries of the leg of elderly cadavers.

INTRODUCTION: Although arteries of the leg have been studied in extensively diseased amputation specimens, little is known about the composition of vascular lesions present in the general population. The aim of this study was to describe the natural development of adaptive intimal thickening, atherosclerotic lesion development and vascular calcification in the leg of a general elderly population. MATERIALS AND METHODS: Two hundred and seventy postmortem samples from the popliteal and posterior tibial arteries of 14 elderly cadavers were studied histologically. RESULTS: Atherosclerotic lesions were more frequently observed in the popliteal (60%) than in the posterior tibial artery (34%; p < .0005). These atherosclerotic plaques were most often nonatheromatous (80% and 83% for popliteal and posterior tibial plaques, respectively). The atheroma's that were present were small (most <25% of plaque area). Atherosclerotic plaque calcification was observed more often in the popliteal (39%) than in the posterior tibial samples (17%; p < .0005). Medial arterial calcification was observed more often in the posterior tibial (62%) than in the popliteal samples (46%; p = .008). Plaque calcification and medial arterial calcification were not associated with lumen stenosis. CONCLUSIONS: In the leg of elderly cadavers, the presence of atherosclerotic plaque and intimal calcification decreases from the proximal popliteal artery to the more distal posterior tibial artery and most atherosclerotic lesions are of the fibrous nonatheromatous type. In contrast, the presence and severity of medial calcification increases from proximal to distal.

Clinical relevance of the anatomy of the long head bicipital groove, an evidence-based review.

Pathology in the bicipital groove can be a source of anterior shoulder pain. Many studies have compared treatment techniques for the long head biceps tendon (LHBT) without showing any clinically significant differences. As the LHBT is closely related to the bicipital groove, anatomical aspects of this groove could also be implicated in surgical outcomes. The aim of this review is to contribute to developing the optimal surgical treatment of LHBT pathology based on clinically relevant aspects of the bicipital groove. Medline/PubMed was systematically searched using key words "bicipital" and "groove" and combinations of their synonyms. Studies reporting on evolution, embryonic development, morphometry, vascularization, innervation, and surgical treatment of the LHBT and the bicipital groove were included. The length of the bicipital groove reported in the included studies ranged from 81.00 mm to 87.33 mm, width from 7.74 mm to 11.60 mm, and depth from 3.70 mm to 6.00 mm. The anatomy of the bicipital groove shows a bottleneck narrowing approximately two-thirds from superior. The transverse humeral ligament can constrain the bicipital groove and could be involved in anterior shoulder pain. When either LHBT tenotomy or tenodesis is performed, routinely releasing the transverse ligament could decrease postoperative anterior shoulder pain, which has frequently been reported in the literature. To avoid the bottle neck narrowing, a location below the bicipital groove may be preferred for biceps tenodesis over a more proximal tenodesis site. Level of evidence: IV.

Sympathetic nerve tissue in milky spots of the human greater omentum.

Omental milky spots (OMSs), small lymphoid structures positioned in the greater omentum, are involved in peritoneal immune homeostasis and the formation of omental metastases. Sympathetic nerve activity is known to regulate immune function in other lymphoid organs (e.g. spleen and lymph nodes) and to create a favourable microenvironment for various tumour types. However, it is still unknown whether OMSs receive sympathetic innervation. Therefore, the aim of this study was to establish whether OMSs of the adult human greater omentum receive sympathetic innervation. A total of 18 OMSs were isolated from five omenta, which were removed from 3% formaldehyde-perfused cadavers (with a median age of 84 years, ranging from 64 to 94). OMSs were embedded in paraffin, cut and stained with a general (PGP9.5) and sympathetic nerve marker (TH and DBH), and evaluated by bright field microscopy. A T-cell, B-cell, and macrophage staining was performed to confirm OMS identity. In 50% of the studied OMSs, sympathetic nerve fibres were observed at multiple levels of the same OMS. Nerve fibres were represented as dots or elongated structures and often observed in relation to small vessels and occasionally as individual structures residing between lymphoid cells. The current study shows that 50% of the investigated OMSs contain sympathetic nerve fibres. These findings may contribute to our understanding of neural regulation of peritoneal immune response and the involvement of OMSs in omental metastases.

Approaches of anatomy teaching for seriously resource-deprived countries: A literature review.

Background: Teaching anatomy is an important but expensive part of the medical curriculum, potentially more than many countries can afford. In the search for efficient methods, cost-effectiveness is of utmost importance for such countries. The aim of this contribution is to provide a review of the literature on anatomy teaching methods, evaluating these for feasibility in resource-deprived countries. Methods: A literature review was carried out to identify distinct approaches to anatomy teaching published in the period 2000-2014, using the databases of PubMed, Wiley Online Library, Elsevier, HINARI, Springer, and ERIC. The approaches found were compared against their conceptual, operational, technical, and economic feasibility and Mayer's principles of effective instruction. Results: Our search yielded 432 papers that met the inclusion criteria. We identified 14 methods of teaching anatomy. Based on their conceptual feasibility, dissection and technology enhanced learning approaches appeared to have more benefits than others. Dissection has, besides benefits, many specific drawbacks. Lectures and peer teaching showed better technical and economic feasibility. Educational platforms, radiological imaging, and lectures showed the highest operational feasibility. Dissection and surgery were found to be less feasible with regard to operational, technical, and economic characteristics. Discussion: Based on our findings, the most important recommendations for anatomy teaching in seriously resource-deprived countries include a combination of complementary strategies in 3 different moments, lecturing at the beginning, using virtual learning environment (for self-study), and at the end, using demonstration through prosected specimens and radiological imaging. This provides reasonable insights in anatomy through both dead and living human bodies and their virtual representations.

Chyluria and chylothorax after posterior selective fusion for adolescent idiopathic scoliosis.

PURPOSE: To describe and discuss the diagnostic and treatment complexity of lymphatic system complications after scoliosis surgery. METHODS: Surgery for adolescent idiopathic scoliosis is very commonly performed with posterior pedicle screw instrumentation. Complications of the anteriorly based lymphatic system are, therefore, rare. We present a case with complications related to the lymphatic system, which have not been reported before after this type of surgery. RESULTS: After standard Th3 to Th12 posterior spinal reduction and fusion of a moderate thoracic curve, chyluria and a chylothorax developed in an adolescent girl. This appeared to be caused by an obstruction of the thoracic duct. Thorax drainage and finally thoracoscopic intervention prevented further pulmonal impairment. The exact cause could not be identified and the persistent lymph drainage problems had to be treated with a medium chain triglyceride diet. CONCLUSION: With this report, we aim to create awareness of the lymphatic system in general and the possibility of severe complications, even after a posterior only approach of the vertebral column.

EUS-guided celiac ganglia neurolysis: a clinical and human cadaver study (with video).

BACKGROUND AND AIMS: There is little evidence that structures targeted during EUS-guided celiac ganglia neurolysis (EUS-CGN) are celiac ganglia and that selective ethanol injection into ganglia is feasible. We aimed to visualize celiac ganglia, confirm that these structures are ganglia, and visualize ethanol spread after EUS-CGN and EUS-guided celiac plexus neurolysis (EUS-CPN). METHODS: First, celiac ganglia were sought during 97 consecutive EUS procedures. Second, ganglia were identified in a prosected human cadaver by placing a linear echoendoscope next to the celiac trunk and removing the underlying tissue for histology. Finally, various EUS-CGN and EUS-CPN techniques were performed in human cadavers; EUS-CGN was performed with 1 mL ethanol in 1 ganglion, 1 mL per ganglion (both low volume), and 4 mL per ganglion (high volume). EUS-CPN was performed with a central (20 mL) and a bilateral (2*10 mL) approach. Transverse sections (75 µm) were obtained and photographed to allow visualization of the spread of ethanol. RESULTS: A total of 204 ganglia were detected in 83 patients. Mean (± standard deviation) size of the long axis was 8.1 mm (± 7.4 mm). Histology of the removed region in the cadaver showed only nerve cell bodies. After low-volume EUS-CGN in cadavers, ethanol spread well beyond the targeted ganglion. After high-volume EUS-CGN in cadavers, a larger ethanol spread was seen, which also reached unidentified ganglia; the spread was comparable to the spread after EUS-CPN. CONCLUSIONS: Specific EUS-CGN is not feasible because ethanol spreads well beyond the targeted ganglion. Unidentified celiac ganglia are better reached with high-volume EUS-CGN, and this would likely result in a more thorough neurolysis. High-volume EUS-CGN should be preferred to low-volume EUS-CGN.

The virtual dissecting room: Creating highly detailed anatomy models for educational purposes.

INTRODUCTION: Virtual 3D models are powerful tools for teaching anatomy. At the present day, there are a lot of different digital anatomy models, most of these commercial applications are based on a 3D model of a human body reconstructed from images with a 1mm intervals. The use of even smaller intervals may result in more details and more realistic appearances of 3D anatomy models. The aim of this study was to create a realistic and highly detailed 3D model of the hand and wrist based on small interval cross-sectional images, suitable for undergraduate and postgraduate teaching purposes with the possibility to perform a virtual dissection in an educational application. METHODS: In 115 transverse cross-sections from a human hand and wrist, segmentation was done by manually delineating 90 different structures. With the use of Amira the segments were imported and a surface model/polygon model was created, followed by smoothening of the surfaces in Mudbox. In 3D Coat software the smoothed polygon models were automatically retopologied into a quadrilaterals formation and a UV map was added. In Mudbox, the textures from 90 structures were depicted in a realistic way by using photos from real tissue and afterwards height maps, gloss and specular maps were created to add more level of detail and realistic lightning on every structure. Unity was used to build a new software program that would support all the extra map features together with a preferred user interface. CONCLUSION: A 3D hand model has been created, containing 100 structures (90 at start and 10 extra structures added along the way). The model can be used interactively by changing the transparency, manipulating single or grouped structures and thereby simulating a virtual dissection. This model can be used for a variety of teaching purposes, ranging from undergraduate medical students to residents of hand surgery. Studying the hand and wrist anatomy using this model is cost-effective and not hampered by the limited access to real dissecting facilities.

Surgical anatomy of the supracarinal esophagus based on a minimally invasive approach: vascular and nervous anatomy and technical steps to resection and lymphadenectomy.

BACKGROUND: During esophageal dissection and lymphadenectomy of the upper mediastinum by thoracoscopy in prone position, we observed a complex anatomy in which we had to resect the esophagus, dissect vessels and nerves, and take down some of these in order to perform a complete lymphadenectomy. In order to improve the quality of the dissection and standardization of the procedure, we describe the surgical anatomy and steps involved in this procedure. METHODS: We retrospectively evaluated twenty consecutive and unedited videos of thoracoscopic esophageal resections. We recorded the vascular anatomy of the supracarinal esophagus, lymph node stations and the steps taken in this procedure. The resulting concept was validated in a prospective study including five patients. RESULTS: Seventy percent of patients in the retrospective study had one right bronchial artery (RBA) and two left bronchial arteries (LBA). The RBA was divided at both sides of the esophagus in 18 patients, with preservation of one LBA or at least one esophageal branch in all cases. Both recurrent laryngeal nerves were identified in 18 patients. All patients in the prospective study had one RBA and two LBA, and in four patients the RBA was divided at both sides of the esophagus and preserved one of the LBA. Lymphadenectomy was performed of stations 4R, 4L, 2R and 2L, with a median of 11 resected lymph nodes. Both recurrent laryngeal nerves were identified in four patients. In three patients, only the left recurrent nerve could be identified. Two patients showed palsy of the left recurrent laryngeal nerve, and one showed neuropraxia of the left vocal cord. CONCLUSIONS: Knowledge of the surgical anatomy of the upper mediastinum and its anatomical variations is important for standardization of an adequate esophageal resection and paratracheal lymphadenectomy with preservation of any vascularization of the trachea, bronchi and the recurrent laryngeal nerves.

Injection of tennis elbow: Hit and miss? A cadaveric study of injection accuracy.

PURPOSE: Different injection therapies are used in the treatment of lateral epicondylitis (LE). Usually, the extensor carpi radialis brevis (ECRB) tendon is affected. Therefore, an injection should be aimed at the origin of this tendon. This study demonstrates the accuracy of manual injections in the treatment of LE. METHODS: Ten surgeons have injected a cadaver elbow with acrylic paint, using the same injection technique (i.e. number of perforations, amount of injected fluid) that they in daily practice would use in the treatment of LE. After the injection, an arthroscopy and dissection of the elbow were performed. The injection technique and localization of acrylic paint were reported. RESULTS: Only a third of the injections were (partially) localized in the ECRB tendon; 60 % were localized intra-articular. CONCLUSION: Injections carried out manually for the treatment of LE are not accurate, resulting in the majority being localized intra-articular. For future research to the effect of injection therapy in the treatment of LE, it is important that injections should be performed in a reproducible and standardized way.

Predominance of Nonatherosclerotic Internal Elastic Lamina Calcification in the Intracranial Internal Carotid Artery.

BACKGROUND AND PURPOSE: Calcification of the intracranial internal carotid artery (iICA) is an independent risk factor for stroke. These calcifications are generally seen as manifestation of atherosclerosis, but histological investigations are limited. The aim of this study is to determine whether calcifications in the iICA are present in atherosclerotic plaques, or in other parts of the arterial wall. METHODS: Thirty-nine iICAs were histologically assessed, using digital microscopy to quantify the amount of calcification in the different layers of the arterial wall. RESULTS: Calcifications were found in the intima, around the internal elastic lamina and in the medial layer of the arterial wall. In 71% of the arteries, internal elastic lamina calcification contributed most to the total calcified cross-sectional surface area. Internal elastic lamina calcification was unrelated to the occurrence of atherosclerotic intimal lesions. Intimal calcifications were most often associated with atherosclerotic lesions, but also many noncalcified atherosclerotic lesions were found. CONCLUSIONS: In the iICA, calcifications are predominantly present around the internal elastic lamina, suggesting that this nonatherosclerotic type of calcification contributes to the previously observed increased risk of stroke in patients with iICA calcifications.

Architecture of the Corpus Spongiosum: An Anatomical Study.

PURPOSE: Urethral reconstruction is performed for urethral stricture or hypospadias correction. Research on urethral tissue engineering is increasing. Because the corpus spongiosum is important to support the urethra, urethral tissue engineering should ideally be combined with reconstruction of a corpus spongiosum. We describe a method to visualize and measure the architecture of the corpus spongiosum, which is needed for scaffold design. MATERIALS AND METHODS: The penis was dissected from 2 unembalmed male cadavers. One penis was flaccid and the other was erect, as induced by saline infusion. Both were frozen in ice. At 6 sites sections were obtained in the transverse and frontal directions. After digitalizing the stained sections the images were edited, area measurements were taken and a 3-dimensional reconstruction was made. RESULTS: In transverse sections the mean area of the vascular lumen was 60% and 77% in the flaccid and the erect corpus spongiosum, and in frontal sections it was 53% and 74%, respectively. This indicated a 129% transverse increase and a 140% longitudinal increase in erection. Section sites did not essentially differ except in the glans penis. Frontal sections showed larger vascular cavities and more incomplete septae than transverse sections. CONCLUSIONS: This study provides what is to our knowledge novel information on corpus spongiosum architecture, which is relevant for scaffold design in tissue engineering. The study protocol can be used in future research with a larger number of specimens and more extensive analyses.

Preserving the pulmonary vagus nerve branches during thoracoscopic esophagectomy.

BACKGROUND: Pulmonary vagus branches are transected as part of a transthoracic esophagectomy and lymphadenectomy for cancer. This may contribute to the development of postoperative pulmonary complications. Studies in which sparing of the pulmonary vagus nerve branches during thoracoscopic esophagectomy is investigated are lacking. Therefore, this study aimed to determine the feasibility and pitfalls of sparing pulmonary vagus nerve branches during thoracoscopic esophagectomy. METHODS: In 10 human cadavers, a thoracoscopic esophagectomy was performed while sparing the pulmonary vagus nerve branches. The number of intact nerve branches, their distribution over the lung lobes and the number and location of the remaining lymph nodes in the relevant esophageal lymph node stations (7, 10R and 10L) were recorded during microscopic dissection. RESULTS: A median of 9 (range 5-16) right pulmonary vagus nerve branches were spared, of which 4 (0-12) coursed to the right middle/inferior lung lobe. On the left side, 10 (3-12) vagus nerve branches were spared, of which 4 (2-10) coursed to the inferior lobe. In 8 cases, lymph nodes were left behind, at stations 10R and 10L while sparing the vagus nerve branches. Lymph nodes at station 7 were always removed. CONCLUSIONS: Sparing of pulmonary vagus nerve branches during thoracoscopic esophagectomy is feasible. Extra care should be given to the dissection of peribronchial lymph nodes, station 10R and 10L.

Clinical relevance of distal biceps insertional and footprint anatomy.

PURPOSE: The aim of this review was to present an overview, based on a literature search, of surgical anatomy for distal biceps tendon repairs, based on the current literature. METHODS: A narrative review was performed using Pubmed/Medline using key words: Search terms were distal biceps, insertional, and anatomy. RESULTS: Last decade, the interest in both reconstruction techniques, as well as surgical anatomy of the distal biceps tendon, has increased. The insights into various aspects of distal biceps tendon anatomy (two tendons, bicipital tuberosity, lacertus fibrosis, bicipital-radial bursa, posterior interosseous nerve, and lateral antebrachial cutaneous nerve) have evolved significantly in the last years. CONCLUSION: Thorough knowledge of the anatomy is essential for the surgeon in order to understand the biomechanics of rupture and reconstruction of the distal biceps tendon and to avoid injuries of the nerves. Some tips and tricks are provided, and some pitfalls were described to avoid complications and optimize surgical outcome. LEVEL OF EVIDENCE: IV.