Cadaveric Study of Variations in the Course of Lateral Femoral Cutaneous Nerve: Insight to Prevent Injury.

Objective: A recent spurt in incidence of meralgia paresthetica to 0.1-81% due to minimally invasive anterior approach to hip joint has resulted in reinterest in anatomy of lateral femoral cutaneous nerve (LFCN). Familiarity with variations in the course of LFCN will reduce the morbidity associated with orthopedic procedures around the anterior superior iliac spine (ASIS) and inguinal ligament (IL). Methods: Twenty five adult human formalin embalmed cadavers were dissected. Course and relations of nerve to ASIS, IL and sartorius muscle was noted, distance of nerve from ASIS at IL was measured and statistically analyzed. Results: Mean distance of LFCN from ASIS at IL was 1.73±1.15 cm. Differences between two sides and sexes was statistically not significant (p=0.51 and p=0.96 respectively). Inferomedial to ASIS, 94% of LFCNs crossed IL with 92% of them present within 4 cm medial to ASIS. Majority of LFCNs (90%) exited pelvis and entered thigh posterior to IL. Out of these nerves 48% were single trunks on entry into thigh, then bifurcated into anterior and posterior branches. Remaining LFCNs bifurcated proximal to IL or at level of IL. Trifurcations were seen in 6% while a rare case of pentafication was observed. In 66% main trunk/branches were present in intermuscular cleft between sartorius muscle and tensor fascia lata. Conclusions: Care should be exercised by surgeons while dissecting around IL as more than half of nerves are liable to be injured during operative procedures. This would help in better anticipation of problem, acceptance and reducing litigation.

Abnormal Persistence of Embryonic Blood Supply of Liver: Anatomist's Delight, Surgeon's Nightmare.

The high incidence of hepato-biliary vascular anatomy variations necessitates its evaluation prior to performing liver transplantation, hepatobiliary, pancreatic, gastric and oesophageal surgeries. We report a unique case of persistence of embryonic arteries of the liver, wherein, the liver was supplied by five vessels. In addition to the usual right and left hepatic arteries from the hepatic artery proper, the liver received two accessory right hepatic arteries, one from the gastroduodenal artery, while another arising from superior mesenteric artery and an accessory left hepatic artery, from the left gastric artery. The origin of gastroduodenal artery was found to be unusually high and its abnormal anterior course over the common bile duct further added complexity to the hepatobiliary anatomy. The presence of these aberrant and accessory arteries predisposes to inadvertent injury leading to patient morbidity and sometimes mortality.

Anomalous Medial Branch of Radial Artery: A Rare Variant.

Radial artery is an important consistent vessel of the upper limb. It is a useful vascular access site for coronary procedures and its reliable anatomy has resulted in an elevation of radial forearm flaps for reconstructive surgeries of head and neck. Technical failures, in both the procedures, are mainly due to anatomical variations, such as radial loops, ectopic radial arteries or tortuosity in the vessel. We present a rare and a unique anomalous medial branch of the radial artery spiraling around the flexor carpi radialis muscle in the forearm with a high rising superficial palmar branch of radial artery. Developmentally it probably is a remanent of the normal pattern of capillary vessel maintenance and regression. Such a case is of importance for reconstructive surgeons and coronary interventionists, especially in view of its unique medial and deep course.

Unusual communications of the brachial plexus.

The knowledge of innervation of pectoral muscles is important to surgeons performing breast surgeries, axillary lymph node dissection, harvesting pectoralis major/minor for flaps, and during neurotization procedures where the pectoral nerves are particularly at risk. The present case describes the innervation of the pectoral muscles solely by a nerve trunk arising from the ansa pectoralis (AP) - the loop of medial and lateral pectoral nerves. Interestingly, there was also a communication between the AP and roots forming the median nerve. It is imperative for the operating surgeons to be aware of these rare variations in order to prevent denervation and subsequent atrophy of the pectoral musculature.

Retroportal proper hepatic artery with malrotated gut.

he celiac trunk is the artery supplying the upper abdominal organs, mainly the lower part of esophagus, stomach, parts of duodenum, liver, gallbladder, spleen and pancreas. It normally trifurcates into the left gastric artery (LGA), the common hepatic artery (CHA) and the splenic artery (SA) at the superior border of the pancreas. This 'normal variant' of the vessel has been observed in 89.8 % cadaveric dissections in the Japanese population by Chen et al. (2009). Prakash et al. (2012) reported a normally trifurcating celiac trunk in 86 % of the south Indian population. The CHA branches from the celiac trunk, forms the gastroduodenal artery (GDA) and a proper hepatic artery (PHA), which further divides distally into right and left hepatic arteries. This normal origin and branching of CHA has been observed in 52­80 % of individuals (Michels 1966; Nelson et al. 1988; Hiatt et al. 1994; Koops et al. 2004; Chen et al. 2009). In a large series of 604 selective celiac and superior mesenteric angiographies, aberrant or anomalous vasculature was reported in 20.9 % of individuals by Koops et al. (2004). This knowledge and recognition of anomalous/aberrant or accessory vasculature in the upper abdomen, occurring in about one-fifth of the population is of vital importance to the hepatico-biliary-pancreatic surgeon to avoid iatrogenic injuries and complications, as well as to the interventional radiologist performing trans-arterial chemo-ablative procedures.

'Porcelain kidney': case report and review of the literature.

A rare case of pan-subepithelial dystrophic calcium deposition and bone marrow formation in hydronephrosis secondary to obstructive urolithiasis is reported and discussed. An elderly gentleman presented with accelerated hypertension, a nonfunctioning left kidney secondary to obstructive nephrolithiasis with additional pancalyceal calcification. His left retroperitoneoscopic nephrectomy specimen revealed sterile hydronephrosis secondary to an impacted ureteropelvic junction stone and pan-subepithelial fibrocalcific lamellar deposition. Special stains confirmed end-stage renal disease with chronic pyelonephritis with subepithelial dystrophic calcium deposition and evidence of bone marrow formation.

Asymmetric bilateral variations in the musculocutaneous and median nerves with high branching of brachial artery.

Brachial Plexus is formed by the union of the anterior rami of cervical 5, 6, 7, 8 and thoracic 1 nerves. These nerves unite and divide to form the key nerves innervating the upper limb. Variations in the course of these nerves are clinically important to anesthetists, neurologists and orthopedicians. We report bilateral variations in the arterial and neural structures in the upper limb of a 65 year old cadaver. The muscles of the arm on one side were innervated by the median nerve with absence ofmusculocutaneous. While on the other side the musculocutaneous nerve contributed to the formation of the median nerve. There was a presence of high bifurcation of brachial artery on both sides. Knowledge of such variations in the innervations of muscles and the arterial supply of the limbs are important to remember before performing any reconstructive procedures or interventions on the limb.

Differential expression of potassium ion channels in human renal cell carcinoma.

PURPOSE: Ether-a-go-go (EAG) or EAG-related (ERG) voltage-gated potassium ion channels are involved in tumor generation and progression. Their over- and/or misexpression has been demonstrated in various tumors, and inhibition of these channels has suppressed proliferation of various cancer cells. We investigate and compare the pattern of expression of EAG and human ERG (HERG) channels in renal cell carcinoma and "normal" renal tissue. METHOD: Tissue samples, obtained at the time of radical nephrectomy from the tumor-bearing areas, and uninvolved renal tissue were preserved in 4% paraformaldehyde and cryosectioned at 20 mum. Immunohistochemical and Western blot analysis was performed on the tumor and uninvolved kidney parenchyma by incubating with polyclonal anti-HERG 1b (Alomone Lab, Israel), anti-EAG1, and anti-EAG2. Pattern of expression of EAG/HERG channels in normal renal tissue and carcinoma were noted and compared. RESULTS: The study was performed on 16 radical and four partial nephrectomy specimens (n = 20). All tumors in the cohort were clear cell renal carcinoma. Normal renal tissue was found to exhibit heterogeneous cytoplasmic positivity for EAG1 and focal HERG immunoreactivity (IR) in the proximal (PCT) and distal convoluted tubules (DCT). EAG2 IR was absent in the normal renal tissue. Clear cell RCC demonstrated a loss of HERG expression while diffuse overexpression of EAG1 and EAG2 was noted. Western blot analysis corroborated the immunohistochemical observations. CONCLUSIONS: In our study both EAG1 and EAG2 potassium channels were overexpressed in clear cell renal cancer. In contrast to other adenocarcinomas, there is loss of HERG expression in clear cell RCC, which may possibly explain its chemoresistance. These ion channels may provide a potential for targeted therapy.

Variations of Thoracic Splanchnic Nerves and its Clinical Implications / Variaciones de los Nervios Esplácnicos Torácicos y sus Implicancias Clínicas

The present study reports an anomalous branching pattern of the thoracic sympathetic chain. At the level of T3 ganglion, an anomalous branch i.e accessory sympathetic chain (ASC) descended anteromedial to the main sympathetic chain (MSC). The MSC and the ASC communicated with each other at the level of T9, T10 and T11 ganglion, indicating the absence of classical pattern of greater, lesser and least splanchnic nerves on the right side. However, on the left side, the sympathetic chain displayed normal branching pattern. We opine that the ASC may be representing a higher origin of greater splanchnic nerve at the level of T3 ganglion and the branches from MSC at T9, T10 and T11 ganglion may be the lesser and least splanchnic nerves, which further joined the ASC (i.e presumably the greater splanchnic nerve) to form a common trunk. This common trunk pierced the right crus of diaphragm to reach the right suprarenal plexus after giving few branches to the celiac plexus. Awareness and knowledge of such anatomical variants of thoracic sympathetic chain may be helpful to surgeons in avoiding any incomplete denervation or preventing any inadvertent injury during thoracic sympathectomy.

El presente estudio relata un patrón de ramos anómalos de la cadena simpática torácica. A nivel del ganglio de T3, un ramo anómalo denominado cadena simpática accesoria (CSA), descendió anteroedialmente a la cadena simpática principal (CSP). La CSP y la CSA comunicadas cada una con la otra a nivel de los ganglios de T9, T10 y T11, indicaban la ausencia de patrones clásicos de nervios esplácnicos mayor, menor y mínimo del lado derecho. Sin embargo, en el lado izquierdo, la cadena simpática estaba dispuesta en un de patrón normal. Nuestra opinión es que la CSA estaría representando un origen alto del nervio esplácnico mayor a nivel del ganglio de T3 y que los ramos de CSP de los ganglios T9, T10 y T11 podrían ser los nervios esplácnicos menor y mínimo, los cuales se unían lejos a la CSA (presumiblemente el nervio esplácnico mayor) para formar un tronco común. Este tronco común perforaba la cruz derecha del diafragma para alcanzar el plexo suprarrenal derecho, dando después pequeños ramos para el plexo celiaco. El conocimiento de tales variaciones de la cadena simpática torácica pueden ser de ayuda para los cirujanos, pudiendo ser evitada alguna denervación incompleta o prevenir algún daño involuntario durante la simpactectomía torácica.