The Use of 3D Printed Models for Surgical Simulation of Cranioplasty in Craniosynostosis as Training and Education.

BACKGROUND: The advance in imaging techniques is useful for 3D models and printing leading to a real revolution in many surgical specialties, in particular, neurosurgery. METHODS: We report on a clinical study on the use of 3D printed models to perform cranioplasty in patients with craniosynostosis. The participants were recruited from various medical institutions and were divided into two groups: Group A (n = 5) received traditional surgical education (including cadaveric specimens) but without using 3D printed models, while Group B (n = 5) received training using 3D printed models. RESULTS: Group B surgeons had the opportunity to plan different techniques and to simulate the cranioplasty. Group B surgeons reported that models provided a realistic and controlled environment for practicing surgical techniques, allowed for repetitive practice, and helped in visualizing the anatomy and pathology of craniosynostosis. CONCLUSION: 3D printed models can provide a realistic and controlled environment for neurosurgeons to develop their surgical skills in a safe and efficient manner. The ability to practice on 3D printed models before performing the actual surgery on patients may potentially improve the surgeons' confidence and competence in performing complex craniosynostosis surgeries.

The 2020 update of the CEAP classification system and reporting standards.

The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification is an internationally accepted standard for describing patients with chronic venous disorders and it has been used for reporting clinical research findings in scientific journals. Developed in 1993, updated in 1996, and revised in 2004, CEAP is a classification system based on clinical manifestations of chronic venous disorders, on current understanding of the etiology, the involved anatomy, and the underlying venous pathology. As the evidence related to these aspects of venous disorders, and specifically of chronic venous diseases (CVD, C2-C6) continue to develop, the CEAP classification needs periodic analysis and revisions. In May of 2017, the American Venous Forum created a CEAP Task Force and charged it to critically analyze the current classification system and recommend revisions, where needed. Guided by four basic principles (preservation of the reproducibility of CEAP, compatibility with prior versions, evidence-based, and practical for clinical use), the Task Force has adopted the revised Delphi process and made several changes. These changes include adding Corona phlebectatica as the C4c clinical subclass, introducing the modifier "r" for recurrent varicose veins and recurrent venous ulcers, and replacing numeric descriptions of the venous segments by their common abbreviations. This report describes all these revisions and the rationale for making these changes.

Modelado vectorial tridimensional del corazón y los vasos coronarios a partir de cortes anatómicos del proyecto Korean Visible Human / Visible Human Project: a new computarized virtual dissection table as a learning tool for students and anatomy teachers

La disección virtual es una herramienta educativa sumamente valiosa en anatomía. Es particularmente útil cuando hay escasez de cadáveres o en los casos en que la disección no sea posible por motivos religiosos o éticos. En este trabajo los autores presentan una reconstrucción 3D de un corazón masculino a partir de la información del proyecto Korean Visible Human, realizado en el marco de asociaciones de la cátedra de anatomía digital de la UNESCO creada recientemente en la Universidad Descartes. La segmentación manual de 1640 cortes anatómicos se logró a través del software Winsurf, produciendo un modelo vectorial 3D interactivo del corazón y la anatomía que lo rodea. Se reconstruyeron ochenta y cuatro estructuras, incluyendo el corazón y sus vasos (27 estructuras), tráquea, esófago, pulmones, cayado aórtico, vena cava inferior, riñones, sistema esquelético conformado por 58 estructuras, entre ellas: esternón, cartílagos costales, vértebras torácicas y discos intervertebrales, sacro, coxales y piel. El modelo vectorial 3D obtenido se exportó en formato PDF 3D produciendo una verdadera herramienta de disección virtual a través de la interfaz de Acrobat: las estructuras anatómicas pueden individualizarse y manipularse interactivamente como 84 objetos 3D separados. Además, se pueden agregar "etiquetas" con el nombre de cada elemento anatómico. Esta nueva mesa de disección virtual computarizada es una herramienta simple y poderosa tanto para alumnos como para docentes de anatomía. Además, resulta ser la base para futuras herramientas de simulación que contribuirán al entrenamiento de cirujanos

The virtual dissection is a remarkable learning tool in anatomy. It is particularly useful in the case of lack of cadavers or if anatomical dissection is impossible due to ethical or religious reasons. The authors present here a 3D reconstruction of the female's heart from the Visible Korean human data, made in the frame of the projects of the UNESCO chair of digital anatomy created recently at the Descartes University.The manual segmentation of 1640 anatomical slices was achieved with the Winsurf ® software producing an interactive 3D vectorial model of the heart and surrounding anatomy. Eighty four anatomical structures were reconstructed, including the heart and its vessels (27 structures), trachea, oesophagus, lungs, aortic arch, superior vena cava, azygos system, inferior vena cava, right and left kidneys, skeletal system (58) structures including: sternum, xiphoid process, clavicles, ribs, costal cartilage, thoracic vertebrae, intervertebrales discs, sacrum, hip bones, and femurs) and skin. The obtained 3D vectorial model was exported in 3D PDF format, producing a true virtual dissection tool through the Acrobat's interface: the anatomical structures can be individually and interactively manipulated as 84 separated 3D objects. 3D labels can be added with the name of each anatomical element. This new computerized virtual dissection table is a simple and powerful learning tool for students and anatomy teachers. It is also the basis of future simulation tools for surgeon's training

Three-Dimensional Modelization of the Female Human Inferior Hypogastric Plexus: Implications for Nerve-Sparing Radical Hysterectomy.

BACKGROUND/AIMS: This study aims to describe the autonomic nervous network of the female pelvis with a 3D model and to provide a safe plane of dissection during radical hysterectomy for cervical cancer. METHODS: Pelvises of 3 human female fetuses were studied by using the computer-assisted anatomic dissection. RESULTS: The superior hypogastric plexus (SHP) was located at the level of the aortic bifurcation in front of the sacral promontory and divided inferiorly and laterally into 2 hypogastric nerves (HN). HN ran postero-medially to the ureter and in the lateral part of the uterosacral ligament until the superior angle of the inferior hypogastric plexus (IHP). IHP extended from the anterolateral face of the rectum, laterally to the cervix and attempted to the base of the bladder. Vesical efferences merged from the crossing point of the ureter and the uterine artery and ran through the posterior layer of the vesico-uterine ligament. CONCLUSIONS: The SHP could be injured during paraaortic lymphadenectomy. Following the ureter and resecting the medial fibrous part of the uterosacral ligament may spare the HN. No dissection should be performed under the crossing point of the ureter and the uterine artery.

Anatomy of the lymph node venous networks of the groin and their investigation by ultrasonography.

OBJECTIVE: To describe the anatomy of the lymph node venous networks of the groin and their assessment by ultrasonography. MATERIAL AND METHODS: Anatomical dissection of 400 limbs in 200 fresh cadavers following latex injection as well as analysis of 100 CT venograms. Routine ultrasound examinations were done in patients with chronic venous disease. RESULTS: Lymph node venous networks were found in either normal subjects or chronic venous disease patients with no history of operation. These networks have three main characteristics: they cross the nodes, are connected to the femoral vein by direct perforators, and join the great saphenous vein and/or anterior accessory great saphenous vein. After groin surgery, lymph node venous networks are commonly seen as a dilated and refluxing network with a dystrophic aspect. We found dilated lymph node venous networks in about 15% of the dissected cadavers. CONCLUSION: It is likely that lymph node venous networks represent remodeling and dystrophic changes of a normal pre-existing network rather than neovessels related to angiogenic factors that occur as a result of an inflammatory response to surgery. The so-called neovascularization after surgery could, in a number of cases, actually be the onset of dystrophic lymph node venous networks.Lymph node venous networks are an ever-present anatomical finding in the groin area. Their dilatation as well as the presence of reflux should be ruled out by US examination of the venous system as they represent a contraindication to a groin approach, particularly in recurrent varicose veins after surgery patients. A refluxing lymph node venous network should be treated by echo-guided foam injection.

Anatomy and embryology of the small saphenous vein: nerve relationships and implications for treatment.

The aim of this paper is to describe the anatomical relations of the small saphenous vein (SSV) in order to define the high-risk zones for the treatment of chronic venous disease. The SSV runs in the saphenous compartment demarcated by two fascia layers: a muscular fascia and a membranous layer of subcutaneous tissue. The clinician should be keenly aware of the anatomical pitfalls related to the close proximity of nerves to the SSV in order to avoid their injury: At the ankle, the origin of the SSV is often plexiform, located deep below the fascia, and the nerve is really stuck to the vein. The apex of the calf is an area of high risk due to the confluence of nerves which perforate the aponeurosis. Moreover, the possible existence of a 'short saphenous artery' which poses a high risk for injection of a sclerosing agent due to a highly variable disposition of this artery surrounding the SSV trunk. For this reason, procedures under echo guidance in this area are mandatory. The popliteal fossa is probably a higher risk zone due to the vicinity of the nerves: the small saphenous arch is close to the tibial nerve, or sometimes the nerve of the medial head of the gastrocnemius muscle. In conclusion, before foam injection or surgery, a triple mapping of the small saphenous territory is mandatory: venous haemodynamical mapping verifying the anatomy that is highly variable, nerve mapping to avoid trauma of the nerves and arterial mapping. This anatomical study will help to define the main high-risk zones.

Clinical analysis of the corona phlebectatica.

BACKGROUND: The corona phlebectatica (CP) is classically described as the presence of abnormally visible cutaneous blood vessels at the ankle with four components: "venous cups," blue and red telangiectases, and capillary "stasis spots." Previous studies showed that the presence of CP is strongly related to the clinical severity of chronic venous disorders (CVD) and the presence of incompetent leg perforators. The aim of this study was to select the most informative components of the CP in the assessment of the clinical severity of CVD patients. METHODS: A multicentric series of 262 unselected patients (524 limbs) consulted for CVD were clinically evaluated using a standardized form to record the CEAP "C" items and the presence of the four CP components. Standard categorical and ordinal statistics were used to describe the external validity of the CP components as severity indexes, taking the "C" classes as reference. RESULTS: "Stasis spots" (P < .001; r = .44) and blue telangiectases (P < .01; r = .32) were linearly associated with the ascending order of "C" classes, whereas the relationship is less clear for the red telangiectases and the "venous cups." The association pattern of the four components showed that only the blue telangiectases and the "stasis spots" were consistent with each other. Blue telangiectases were found more sensitive (0.91 vs 0.75) but less specific (0.52 vs 0.80) than "stasis spots" for advanced venous insufficiency (CEAP "C4-6"). CONCLUSION: This study shows that only blue telangiectases and "stasis spots" provide valuable information in patients with CVD and deserve to be taken into account in the evaluation of such patients. Further studies are needed to show the reproducibility of this data, which we regard as essential for clinical use.

Anatomical variations of the femoral vein.

BACKGROUND: The venous anatomy is highly variable. This is due to possible venous malformations (minor truncular forms) occurring during the late development of the embryo that produce several anatomical variations in the number and caliber of the main venous femoral trunks at the thigh level. Our aim was to study the prevalence of the different anatomical variations of the femoral vein at the thigh level. METHODS: This study used 336 limbs of 118 fresh, nonembalmed cadavers. The technique included washing of the whole venous system, latex injection, anatomical dissection, and then painting of the veins. RESULTS: The modal anatomy of the femoral vein was found in 308 of 336 limbs (88%). Truncular malformations were found in 28 of 336 limbs (12%); unitruncular configurations in 3% (axo femoral trunk [1%] and deep femoral trunk [2%]). Bitruncular configurations were found in 9% (bifidity of the femoral vein [2%], femoral vein with axio-femoral trunk [5%], and femoral vein with deep femoral trunk [2%]). CONCLUSION: Truncular venous malformations of the femoral vein are not rare (12%). Their knowledge is important for the investigation of the venous network, particularly the venous mapping of patients with cardiovascular disease. It is also important to recognize a bitruncular configuration to avoid potential errors for the diagnosis of deep venous thrombosis of the femoral vein, in the case of an occluded duplicated trunk.

Tridimensional computer-assisted anatomic dissection of posterolateral prostatic neurovascular bundles.

BACKGROUND: Detailed knowledge of nerve distribution in the neurovascular bundle (NVB) is essential to preserve sexual function after prostatic surgery. OBJECTIVE: To identify the location as well as the type (adrenergic, cholinergic, and sensory) of nerve fibres within the NVB and to provide a three-dimensional (3D) representation of their structural relationship in the human male foetus. DESIGN, SETTING, AND PARTICIPANTS: Serial transverse sections were performed every 150-200 microm in the pelvic portion of six human male foetuses (15-20 wk of gestation). Sections were treated with histologic and immunohistochemical methods (hematin-eosin-safran, Luxol Fast Blue, immunolabelling of protein S100, vesicular acetylcholine transporter, tyrosine hydroxylase, calcitonin gene-related peptide, and substance P). The 3D pelvic reconstruction was obtained from digitised serial sections using WinSurf software. MEASUREMENTS: NVB nerve location and type were evaluated qualitatively. RESULTS AND LIMITATIONS: The 3D reconstruction allowed precise identification of pelvic organ innervation. Nerve fibres derived from the inferior hypogastric plexus followed two courses: posterior and lateral, providing cholinergic, adrenergic, and sensory innervation to seminal vesicles, vas deferens, prostate, and urethral sphincter. Cavernous nerve fibres did not strictly follow the NVB course; they were distributed at several levels, in a fanlike formation. The main limitations of this study were the limited number of specimens available due to legal restriction and the time-consuming nature of the manually performed stages in the method. CONCLUSIONS: The distribution of nerve fibres within the posterolateral prostatic NVB and the existence of mixed innervation in the posterior and lateral fibre courses at the level of the prostate and seminal vesicles give us an insight into how to minimise effects on sexual function during prostatic surgery. The 3D computer-assisted anatomic dissection represents an original method of applying anatomic knowledge to surgical technique to improve nerve preservation and decrease postoperative sexual complications.

Clinical and hemodynamic significance of corona phlebectatica in chronic venous disorders.

BACKGROUND: Corona phlebectatica (corona) is a clinical sign associated with chronic venous disorders but is not yet included in the CEAP classification. Our aim was to analyze the clinical and hemodynamic correlations of corona to determine its significance and potential usefulness in classification grading and systems such as the CEAP classification. METHODS: A full clinical and duplex ultrasound record of 287 patients was collected by 60 vascular physicians from 10 European countries. They used the same computer software. This was designed to improve the interobserver consistency of computer-assisted procedures for clinical data gathering. Corona was defined as fan-shaped intradermal telangiectases in the medial and sometimes lateral portions of the ankle and foot. This definition was further refined into three severity grades of light, moderate, and severe, according to reference pictures provided by the software. To avoid overpowering the statistical tests, only data from right lower limbs were analyzed. RESULTS: In this series of 287 unselected patients, a corona was detected in 96 right lower limbs (27.7%) and graded as light in 61 (21.1%), moderate in 24 (8.3%), and severe in 11 (3.8%). The presence of a corona and its severity grade were found significantly related to two risk factors of chronic venous disorders (age and personal history of deep vein thrombosis), the presence of so-called venous symptoms, including pain, pruritus, burning sensation, feeling of swelling, cramps, heavy legs; and most individual items of CEAP clinical classes (varicose veins, edema, all skin changes, C5; and open ulcers, C6). Furthermore, among the patients without skin changes (classes C1 to C3), the presence and grade of corona appeared to be significantly associated with the severity of the disease, with increasing CEAP (P < .05), disability (P < .03), and anatomic (P < .01) scores. The presence of a corona and its severity grade were also found significantly related to the CEAP clinical classes themselves (P < .001), the CEAP disability (P < .001) and clinical severity scores (P < .001), and the presence of superficial reflux in the saphenous and nonsaphenous territories (P = .05) and in the perforators (P < .001). The presence of a deep venous reflux was not found to be significant in this series. The relative risk of finding incompetent leg or calf perforators by duplex ultrasound is 4.4 times greater in patients with corona (P < .001). A comparison between the CEAP classification without corona and a modified classification including corona in C3 shows a better reliability coefficient of Cronbach. CONCLUSION: Corona strongly correlates with the clinical severity and hemodynamic disturbances of the disease. The inclusion of corona in the C3 class should probably improve the reliability of the CEAP clinical classes.

Appraisal of the information content of the C classes of CEAP clinical classification of chronic venous disorders: a multicenter evaluation of 872 patients.

OBJECTIVE: Clinical classifications attempt to summarize a large amount of information in a few indices. CEAP is the most comprehensive and widely used classification of chronic venous disorders. The objective was to evaluate, in a routine clinical setting, the information associated with each CEAP clinical class and their ascending severity and additivity. METHODS: This work was a multicenter evaluation of newly designed software dedicated to the management of venous diseases. Forty-nine angiologists from nine European countries entered a total of 872 full records of unselected patients. The data were analyzed to evaluate the informational value of each of the clinical classes and to test their ascending severity and additivity, with monovariate and multivariate statistical techniques with SPSS/PC software on the database of the 872 right lower limbs. RESULTS: The series consisted of 700 women (80.3%) and 172 men, aged 18 to 100 years (median, 53 years). The ascending severity of the classes was shown with the statistical association of higher severity C classes with the age of the patient, a history of previous deep vein thrombosis, the diameter class of the most dilated varicose vein, venous symptoms, and the presence of a corona phlebectatica. The additivity, as measured with the Cronbach alpha coefficient analysis, was satisfactory in highest classes but poorer within the first three classes, and factor analysis of correspondences showed the heterogeneity of the variables that make the classification. CONCLUSION: The information summarized with the CEAP clinical classes shows a good ascending severity but a poorer additivity. These limitations seem to be related to the heterogeneity of the information content, which suggests some refinements of this basic tool for clinical research in the field of chronic venous disorders.

Three-dimensional characterization of pathologic lesions in pulmonary langerhans cell histiocytosis.

The characteristic lesions of pulmonary Langerhans cell histiocytosis (LCH) associate destructive granulomas containing large numbers of Langerhans cells and cysts. The lesions are usually considered to develop around small airways, and cysts are thought to result from destruction of the bronchiolar wall by the granulomatous reaction. However, the extent to which the granulomatous reaction is truly bronchocentric remains unknown, and the mode of formation of the cysts has not been defined. By using serial sections, this study aimed to explore further the relationships between pulmonary LCH lesions and distal airways, and the development of cysts. The results demonstrated that the granulomatous process of pulmonary LCH affected exclusively small airways, in an acinar distribution. The lesions extended without interruption along the bronchiolar axis, forming a continuous sheath around distal airways. The granulomatous reaction seemed to progress along the bronchiolar axis over time, extending the abnormalities in both the proximal and distal directions. Cystic lesions resulted from the destruction of the bronchiolar wall and progressive dilatation of the lumen, subsequently circumscribed by fibrous tissue. Because pulmonary LCH lesions affect and progressively destroy distal airways, it may be proper to consider the disease a bronchiolitis rather than an interstitial lung disorder.