Three-dimensional reconstruction of the upper limb from anatomical slices of the Korean visible human: simulation and educational application.

PURPOSE: Digital anatomy is a novel emerging discipline. Use of virtual reality brings a revolution in educational anatomy by improving retention and learning outcomes. Indeed, virtual dissection is a new learning tool for students and surgeons. Three-dimensional vectorial models of the human body can be created from anatomical slices obtained by lengthy series of cryosection from the visible human projects. The aim of this paper is to show how these mesh models could be embedded into an Acrobat® 3dpdf interface, to produce an easy-to-use fully interactive educational tool. METHODS: The learning of this method and its practical application were evaluated on a multicentric cohort of 86 people divided into 3 groups, according to the duration of their training (1, 2 or 3 days, respectively). Participants learned how to use the Mesh tool and how to model 3D structures from anatomical sections. At the end of the training, they were given a survey form. Participants were also asked to rate the training (Poor; Average; Good; Very Good; Excellent). RESULTS: Ninety four percent of the subjects rated the device as excellent and would continue to use digital anatomy in their practice. CONCLUSION: This result is the Diva3d® virtual dissection table, a powerful educational tool for anatomists and students. It could also be the basis of future simulation tools for hand surgeons training.

Descriptive anatomy of the inferior epigastric, subscapular and internal thoracic vascular pedicles in three domestic mammals: A comparative study.

The descriptive anatomy of the inferior epigastric, subscapular and internal thoracic vascular pedicles of domestic animals is not fully known. Improvement of our knowledge in this field could lead to better development of animal models for both pedagogical purposes and surgical experimentation. The objective of this comparative study was to describe the descriptive anatomy of the inferior epigastric, subscapular and internal thoracic pedicles in three domestic mammals commonly used as animal models for experimentation. Our study focuses on the anatomical description of these vascular pedicles in the rat (Rattus norvegicus) (n=1), the rabbit (Oryctolagus cuniculus) (n=1) and the pig (Sus scrofa domesticus) (n=1). A comparative and analytical study of these vessels (origin, path, caliber, termination) with those of humans was carried out. The superficial inferior epigastric vascular pedicles have been identified only in rats and pigs. The deep inferior epigastric, subscapular and internal thoracic pedicles were identified in the three mammals studied. No perforator vessels for the subcutaneous tissue and skin were identify from the deep inferior epigastric pedicles. The anatomical characteristics (origin, path, termination) of these vascular pedicles in rabbits seems to be the closest to that of humans. However the caliber of these vessels is around a millimeter compared to a 2.0-3.0mm in humans. This comparative study allowed us to identify and better characterize the morphological characteristics of these vascular pedicles in three domestic mammals, a step prior improving the development of animal models intended for pedagogical or experimental purposes in the field of microsurgical free flaps.

Three-dimensional reconstruction of the lower limb's venous system in human fetuses using the computer-assisted anatomical dissection (CAAD) technique.

OBJECTIVE: The aim of the present study was to show the feasibility and describe the first results of a 3D reconstruction of the venous network of the lower limbs in human fetus using the computer-assisted anatomical dissection (CAAD) technique. MATERIALS AND METHODS: We used limbs from two human fetuses, respectively, 14 and 15 weeks gestation old. Specimens were fixed in 10% formalin, embedded in paraffin wax and serially sectioned at 10 m. The histological slices were stained using HES and Masson Trichrome for soft tissues identification. Immunolabeling techniques using the Protein S-100 marker and the D2-40 marker were used to identify nerves and vessels, respectively. Stained slices were aligned manually, labeled and digitalized. The segmentation of all anatomical structures was achieved using the WinSurf(®) software after manual drawing. RESULTS: A 3D interactive vectorial model of the whole leg, including skin, bone, muscles, arteries, veins, and nerves was obtained. In all limbs, we observed the presence of a big axial vein traveling along the sciatic nerve. In addition, the femoral vein appeared as a small plexus. Although this is a common anatomical feature at the end of organogenesis, this feature is observed in only 9% of adults. Usually interpreted as an "anatomical variation of the femoral vein" it should be considered as a light truncular malformation. These observations bring further support to our proposed "angio-guiding nerves" hypothesis. CONCLUSION: This preliminary study shows that the CAAD technique provided an accurate 3D reconstruction of the fetal leg veins anatomy. It should bring a new insight for the understanding of the different steps of development of the human venous system.

[The dorsal nerve of the clitoris: surgical applications]. / Le nerf dorsal du clitoris : de l'anatomie à la chirurgie reconstructrice du clitoris.

OBJECTIVES: To describe the course of the dorsal nerve of the clitoris (DNC) to better define its anatomy in the human adult and to help surgeons to avoid iatrogenic injury during surgical procedures. METHOD: An extensive review of the current literature was done on Medline via PubMed by using the following keywords: "anatomie du clitoris", "anatomy of clitoris", "nerf dorsal du clitoris", "dorsal nerve of clitoris", "réparation clitoridienne", "transposition clitoridienne", "surgery of the clitoris", "clitoridoplasty". This review analyzed dissection, magnetic resonance imaging, 3-dimensional sectional anatomy reconstruction and immuno-histochemical studies. RESULTS: The DNC comes from the pudendal nerve. He travels from under the inferior pubis ramus to the posterosuperior edge of the clitoral crus. The DNC reappears under the pubic symphysis and enters the deep component of the suspensory ligament. He runs on the dorsal face of the clitoral body at 11 and 1 o'clock. Distally, he gives many nervous ramifications, runs along the tunica and enters the glans. CONCLUSION: The NDC might be surgically injured (i) under the pubic symphysis, at the union of the two crus of clitoris and (ii) on the dorsal surface of the clitoral body. The pathway of the DNC on the dorsal face of the clitoris permits to approach the ventral face of the clitoris without risk of iatrogenic injuries. The distance between the pubic symphysis and the DNC implies that the incision should be done just under the pubic symphysis. Distally, the dissection of the DNC next the glands appears as dangerous and impossible, considering that the DNC is too close to the glandular tissues.

[Practice uptake in France before and after the 2010 French guidelines on kidney cancer]. / Évolution des pratiques de la chirurgie rénale avant et après les recommandations de l'AFU de 2010.

INTRODUCTION AND OBJECTIVE: Compared to the 2007 edition, the 2010 French urological association onco-urology guidelines boarded the indications of partial nephrectomy (PN) as long as the procedure is technically feasible. The aim of this study was to assess national practice with respect to kidney surgery in the 2 years before and after current guidelines. MATERIALS AND METHODS: The national database of the Agence Technique de l'Information sur l'Hospitalisation (ATIH) was queried for procedures performed between 2009 and 2010 (era 1) and between 2011 and 2012 (era 2). The coding system of the Classification Commune des Actes Médicaux (CCAM) was used to extract kidney related procedures. For each era, procedures were sorted into partial versus radical nephrectomy (RN), laparoscopic/robotic versus open approach, and private versus public hospital. The two eras were then compared. RESULTS: Overall, 28,000 and 28,907 procedures were reported in era 1 and 2 with mean 14,000 and 14,450 procedures per year respectively. PN increased from 30% to 35% (P<0.0001) between the two eras. This uptake was similar in public and private hospitals. Accordingly, laparoscopic/robotic approach has significantly increased between the two eras (35% versus 39%, P<0.0001) and even more importantly in public hospitals (P=0.0017). There was a significant increase in laparoscopic/robotic PN as well as a decrease in open RN over the years of the study period. CONCLUSION: This study showed the development of PN and the minimally invasive approach. Over the study period, minimally invasive procedure uptake was higher in public hospitals.

Anatomical basis of laparoscopic medial-to-lateral mobilization of the descending colon.

In laparoscopic colorectal resection, the medial-to-lateral approach has been largely adopted. This approach can be initiated by the division of either the inferior mesenteric artery (IMA) or the inferior mesenteric vein (IMV). This cadaveric study aimed to establish the feasibility of IMV dissection as the initial landmark of medial-to-lateral left colonic mobilization for evaluating the size of the peritoneal window between the IMV at the lower part of the pancreas and the origin of the IMA (IMA-IMV distance) and the point of origin of the IMA compared to the lower edge of the third part of the duodenum (IMA-D3 distance). These distances were recorded on 30 fresh cadavers. The IMA-D3 distance was 0.4 ± 2.2 cm (mean ± SD). The IMA originated from the aorta at the level of or below the D3 in 21 cases (70%). The IMA-IMV distance was 5.5 ± 1.8 cm and was greater or equal to 5 cm (large window) in 21 cases (70%). IMA-IMV distance was correlated with IMA-D3 showing that a large window was inversely correlated with a low IMA origin (P < 0.001). IMA-D3 distance was not correlated with weight, height and sex. IMA-IMV distance was largerin male (6.7 ± 0.9 vs. 4.9 ± 1.8, P = 0.001) and correlated with weight, (r = 0.60, 95%CI = 0.03-0.10, P < 0.001) and height (r = 0.54, 95%CI = 0.05-0.21, P = 0.002). IMV can be used as the initial landmark for laparoscopic medial-to-lateral dissection in two-thirds of cases. A too-small window can require first IMA division. The choice between the two different medial-to-lateral approaches could be made by evaluating the anatomical relationship between IMA, IMV, and D3.

[Computerized three-dimensional reconstruction of the retrohepatic segment of inferior vena cava of a 20 mm human embryo]. / Reconstruction tridimensionnelle informatisée du segment rétrohépatique de la veine cave inférieure d'un embryon humain de 20mm.

The subdiaphragmatic venous drainage of the embryo is provided by the two caudal cardinal veins to which is added the subcardinal vein system, draining the mesonephros, the perispinal supracardinal veins and the umbilical and vitelline venous system. The anastomosis of certain segments of the embryonic venous structures and the disappearance of others are at the origin of the inferior vena cava. Since the 19th century, three-dimensional reconstruction of solid models from histological sections were developed. At present, the development of computerized three-dimensional reconstruction techniques allowed to operate a multitude of techniques of image processing and modeling in space. Three-dimensional reconstruction is a tool for teaching and research very useful in embryological studies because of the obvious difficulty of dissection and the necessity of introducing time as the fourth dimension in the study of organogenesis. This method represents a promising alternative compared to previous three-dimensional reconstruction techniques including Born technique. The aim of our work was to create a three-dimensional computer reconstruction of the retrohepatic segment of the inferior vena cava of a 20mm embryo from the embryo collection of Saints-Pères institute of anatomy (Paris Descartes university, Paris, France) to specify the path relative to the liver and initiate a series of computerized three-dimensional reconstruction that will follow the evolution of this segment of the inferior vena cava and this in a pedagogical and morphological research introducing the time as the fourth dimension.

High tie versus low tie vascular ligation of the inferior mesenteric artery in colorectal cancer surgery: impact on the gain in colon length and implications on the feasibility of anastomoses.

BACKGROUND: There is no demonstrated benefit of high-tie versus low-tie vascular transections in colorectal cancer surgery. OBJECTIVE: The aim of this study was to compare the effects of high-tie and low-tie vascular transections on colonic length after oncological sigmoidectomy, the theoretical feasibility of colorectal anastomosis at the sacral promontory, and straight or J-pouch coloanal anastomosis after rectal cancer surgery with total mesorectal excision. DESIGN: This study is an anatomical study on surgical techniques. SETTINGS: This study was conducted in a surgical anatomy research unit. PATIENTS: Thirty fresh nonembalmed cadavers were randomly assigned to high-tie and low-tie groups (n = 15). INTERVENTIONS: Oncological sigmoidectomy followed by total mesorectal excision was performed. MAIN OUTCOME MEASURES: The distances from the proximal colon limb to the lower edge of the pubis symphysis were recorded after each step of vascular division. RESULTS: The successive mean gains in length in high-tie vs low-tie vascular transections were 2.9±1.2 cm vs 3.1 ± 1.8 cm (p = 0.83) after inferior mesenteric artery division, 8.1 ± 3.1 cm vs 2.5 ± 1.2 cm (p = 0.0016) after inferior mesenteric vein division at the lower part of the pancreas, 8.1 ± 3.8 cm vs 3.3 ± 1.7 cm (p = 0.0016) after sigmoidectomy. The mean cumulative gain in length was significantly higher in high-tie vs low-tie vascular transections (19.1 ± 3.8 vs 8.8 ± 2.9 cm, p = 0.00089). After secondary left colic artery division, the gain in length was similar to that of the high-tie group (17 ± 3.1 vs 19.1 ± 3.8 cm) (p = 0.089). Colorectal anastomosis at the promontory and straight and J-pouch coloanal anastomosis feasibility rates were 100% in the high-tie group, 87%, 53%, and 33% in the low-tie group, but 100%, 100%, and 87% after secondary left colic artery division. LIMITATIONS: This anatomical study, based on cadavers rather than live patients, does not evaluate colon limb vascularization. CONCLUSIONS: The gain in colonic length is 10 cm greater for high-tie vascular transections. With low-tie vascular transections, high inferior mesenteric vein division produced a small additional gain in length, and secondary left colic artery division produced the same length gain as high-tie vascular transections.

[Transvaginal repair of genital prolapse using the Prolift technique: a prospective study]. / Traitement du prolapsus génital par renfort transvaginal Prolift: une étude prospective.

OBJECTIVE: To evaluate the efficacy and to report the follow-up of transvaginal repair of genital prolapse using a tension free vaginal mesh. PATIENTS AND METHODS: Twenty-eight women were treated for genital prolapse with the Prolift technique and followed prospectively. Preoperative prolapse treatment, associated treatment, complications were reported. Postoperatively, efficacy and complications were reported. Patients were examined at one, three, six and 12 months then yearly. Treatment failure defined as Pelvic Organ Prolapse Quantification (POP-Q) stage II or more. RESULTS: The mean age was 68 years. The median follow-up was 12 months. Ten (35%) and 14 (50%) patients had a stage II and III/IV cystocele respectively. Nineteen (67%) patients had stage II/III rectocele. We reported one bladder injury (3.5%) sutured during surgery and one haematoma (3.5%) requiring secondary management. Important buttock pain appeared in two patients (7%) treated with a total mesh on day 1 and 6 weeks after surgery respectively. They were both relieved after cutting one posterior arm of the mesh. De novo stress incontinence appeared in one (3.5%) patient and urgency in two (7%) patients. Mesh exposure occurred in one (3.5%) patient requiring a minimal surgical management. One patient (3.5%) declared dyspareunia. Success was reached in 96.5% patients. CONCLUSION: The transvaginal mesh was a safe and efficient technique to treat genital prolapse.

[Mini-invasive posterior sacrospinous ligament fixation using the CAPIO needle driver: an anatomical study]. / Sacrospinofixation mini-invasive avec le dispositif CAPIO : étude anatomique.

OBJECTIVE: To study anatomical risks after posterior sacrospinous ligament fixation using the CAPIO needle driver. SUBJECTS AND METHODS: A simplified bilateral posterior sacrospinous ligament fixation was performed on seven fresh female cadavers using the CAPIO needle driver. Cadavers were installed in gynaecologic position then dissected by the abdominal route. The posterior sacrospinous ligament fixation was performed after a posterior vaginal wall incision on the midline and a simplified dissection of both pararectal fossae. The abdominal dissection was focused on the sacrospinous ligament area. We measured the distance between the neurovascular elements adjacent to the sacrospinous ligament from the suture site. RESULTS: Thirteen sacrospinous ligaments were available for analysis. The mean length (+/-SD) of the ligament was 51+/-9.2 mm and the mean width at the level of fixation (+/-SD) was 23.5+/-5.7 mm. No rectal injury was observed. Fixations were in the deeper (ligament) and medium (muscle) part of the SSL in eight (61%) and five (39%) cases respectively. The ischial spine was 21.6 mm (range: 13-30). The mean distances between fixation and pudendal nerve and artery were 16.1 mm (range: 4-32) and 20 mm (range: 12-37) respectively. CONCLUSION: Mini-invasive posterior sacrospinous ligament fixation using the CAPIO needle driver seemed to be reproducible with low anatomical risks. However, the fixation should be at least at 20 mm medially to the ischial spine in order to reduce neurological risks.

Bypassing melanocyte senescence by beta-catenin: a novel way to promote melanoma.

The Wnt/beta-catenin signaling pathway plays a key role in several cellular functions during embryonic development and adult homeostasis. The deregulation of this pathway may lead to the development of cancer, including melanoma. Deregulation of the Wnt/beta-catenin pathway occurs through either the induction/repression of, or specific mutations in, various members of this signaling pathway; this results in the stabilization of beta-catenin and its translocation from the cytoplasm to the nucleus, where it regulates transcription. Although nuclear beta-catenin is clearly involved in malignant transformation, the mechanism by which it exerts its effects remains elusive. This review focuses on the molecular and cellular mechanisms that are driven by beta-catenin and lead to melanocyte transformation. In particular, we describe how beta-catenin induces melanocyte immortalization, a novel activity of this multifunction protein. Finally, we discuss how beta-catenin-induced immortalization can cooperate with MAPKinase pathways to produce melanoma.

[Are dissections still needed in the faculty of medicine ?]. / Faut-il encore des dissections en faculté de médecine ?

The relevance of anatomical dissection is questioned in France by some authors who think that it is an archaic method in the time of virtual-anatomy softwares. In our opinion, anatomic dissection keeps a unique interest in medical students learning both in the first years of medicine and in the surgery learning and the techniques used in medical specialities. The research of new surgical techniques, anatomical variations as for example of peripheric nerves, also has a strong need of dissections.

[The meshes in the cure of cystocele by vaginal way]. / Cystocèle: place des implants de renforcement par voie vaginale.

The advantages of vaginal way in the treatment of cystocele are simplicity, rapidity, peritoneal security. Raphy is subject to recidive. The meshes replace the weak fascia in its role of hammock (Delancey) for the bladder. The mesh covers the central and lateral fascial defects. The procedure consists in a short vertical colpotomy, vesicovaginal dissection, uterine preservation (if uterus is not pathologic), no vaginal excision. The mesh can be spread without fixation, fixed or anchored by arms in the obturator foramen. The results show a significative improvement in the risk of redux cystocele. Complications become less frequent with the expertise and quality of new meshes. Implants are a new vaginal evolving surgery: it must be evaluated by experts and practiced by experienced in vaginal approach surgeons.

[Treatment of genitourinary prolapse]. / Prise en charge des prolapsus génito-urinaires.

Surgical treatment of genitourinary prolapse has changed considerably over the last few years. Now numerous surgical options are available offering efficient therapeutic solutions to treat different clinical situations. The type of surgical treatment depends on the precise analysis of the functional complaint and of anatomical pelvic lesions. The proposed treatment must take all aspects of the pathology into account. However, a review of existing research shows that there are still improvements to be made when it comes to comparing different techniques with one another.

[Update on the epidemiology of genital prolapse]. / Etat des lieux de l'épidémiologie des prolapsus génitaux.

The prevalence of pelvic organ prolapse (POP) varies between 2.9 and 11.4% in questionnaire-based studies and from 31.8 to 97.7% according to the ICS Pelvic Organ Prolapse Classification (POPQ) anatomical classifications. The cumulative incidence of surgery for POP is as high as 70% in women more than 70-year-old. Aging is significantly associated with the prevalence and severity of POP. Pelvic disorders are a health economic challenge for the future due to the longer life expectancy of women and to an increasing demand for a better quality of life. Identification of risk factors will be critical in order to develop strategies to prevent the disease and limitate the need for surgical intervention.

[Functional anatomy of the pelvic floor]. / Anatomie fonctionnelle du plancher pelvien.

The pelvic floor is the support of the pelvic visceras. The levator ani muscle (LA) with its two bundles (pubo- and ilio-coccygeus) is the major component of this pelvic floor. LA is formed essentially by type I fibers (with high oxidative capability and presence of slow myosin) as in postural muscles. The aerobic metabolism makes LA susceptible to injury caused by excentric contraction and mitochondrial dysfunction. The innervation of the pelvic floor comes from the 2nd, 3rd, 4th anterior sacral roots; denervation affects pelvic dynamism. Perineum includes the musculofascial structures under the LA: ventrally the striated urethral sphincter and the ischio-cavernous and bulbospongious, caudally the fatty tissue filling the ischioanal fossa. Pelvic fascia covers the muscles; it presents reinforcements: the uterosacral and cardinal ligaments, the arcus tendineus fascia pelvis (ATFP) and the arcus tendineus levator ani (ATLA). The pelvis statics is supported by the combined action of all this anatomical structures anteriorly forming the perineal "hammock", medially the uterosacral and cardinal ligaments, posteriorly the rectovaginal fascia and the perineal body. The angles formed by the pelvic visceras with their evacuation ducts participate to the pelvic statics. During the pelvic dynamics the modification of these angles expresses the action of the musculofascial structures.

[Physiopathology of genitourinary prolapse]. / Physiopathologie des prolapsus génito-urinaires.

The physiopathology of urogenital prolapse is multifactorial, a combination of the interaction between constitutional and acquired factors resulting in the weakening of perineal support. Genetic modifications contribute to the occurrence of prolapse (proof level 2). Differences relating to types of collagen and their proportions, the construction of smooth muscle fibres and nervous structures, have been described between women with and without prolapse. But the relationship of cause and effect is not always clear. It would appear that the reduction in the expression of the elastine gene and the perturbation of metabolism may be at the origin of the cause of a prolapse. However, the intense activity of tissue remodeling is probably the consequence of biomechanical pressure born by the prolapse. Muscular or neuropathic lesions of the levator ani have been widely researched and documented. In the case of prolapse, these were isolated exceptions and most often associated with dehiscence of support tissue.

[Risk factors and prevention of genitourinary prolapse]. / Facteurs de risque et prévention des prolapsus génito-urinaires.

Numerous epidemiological studies in recent years have involved the search for the principal risk factors of genitourinary prolapse. Although it has been agreed for a long time that vaginal delivery increases the risk of prolapse (proof level 1), on the other hand, the Cesarian section cannot be considered a completely effective preventative method (proof level 2). The pregnancy itself is a risk factor for prolapse (proof level 2). Certain obstetrical conditions contribute to the alterations of the perineal floor muscle: a foetus weighing more than four kilos, the use of instruments at birth (proof level 3). If the risk of prolapse increases with age, intrication with hormonal factors is important (proof level 2). The role of hormonal replacement therapy remains controversial. Antecedent pelvic surgery has also been identified as a risk factor (proof level 2). Other varying acquired factors have been documented. Obesity (BMI and abdominal perimeter), professional activity and intense physical activity (proof level 3), as well as constipation, increase the risk of prolapse. More thorough research into these varying factors is necessary in order to be able to argue for measures of prevention, obstetrical techniques having already evolved to ensure minimal damage to the perineal structure.