New anterior controllable antedisplacement and fusion surgery for cervical ossification of the posterior longitudinal ligament: a biomechanical study.

OBJECTIVE: The traditional anterior approach for multilevel severe cervical ossification of the posterior longitudinal ligament (OPLL) is demanding and risky. Recently, a novel surgical procedure-anterior controllable antedisplacement and fusion (ACAF)-was introduced by the authors to deal with these problems and achieve better clinical outcomes. However, to the authors' knowledge, the immediate and long-term biomechanical stability obtained after this procedure has never been evaluated. Therefore, the authors compared the postoperative biomechanical stability of ACAF with those of more traditional approaches: anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF). METHODS: To determine and assess pre- and postsurgical range of motion (ROM) (2 Nm torque) in flexion-extension, lateral bending, and axial rotation in the cervical spine, the authors collected cervical areas (C1-T1) from 18 cadaveric spines. The cyclic fatigue loading test was set up with a 3-Nm cycled load (2 Hz, 3000 cycles). All samples used in this study were randomly divided into three groups according to surgical procedures: ACDF, ACAF, and ACCF. The spines were tested under the following conditions: 1) intact state flexibility test; 2) postoperative model (ACDF, ACAF, ACCF) flexibility test; 3) cyclic loading (n = 3000); and 4) fatigue model flexibility test. RESULTS: After operations were performed on the cadaveric spines, the segmental and total postoperative ROM values in all directions showed significant reductions for all groups. Then, the ROMs tended to increase during the fatigue test. No significant crossover effect was detected between evaluation time and operation method. Therefore, segmental and total ROM change trends were parallel among the three groups. However, the postoperative and fatigue ROMs in the ACCF group tended to be larger in all directions. No significant differences between these ROMs were detected in the ACDF and ACAF groups. CONCLUSIONS: This in vitro biomechanical study demonstrated that the biomechanical stability levels for ACAF and ACDF were similar and were both significantly greater than that of ACCF. The clinical superiority of ACAF combined with our current results showed that this procedure is likely to be an acceptable alternative method for multilevel cervical OPLL treatment.

Anatomical Evaluation of Spinal Nerve and Cervical Intervertebral Foramina in Anterior Controllable Antedisplacement and Fusion Surgery: A Cadaveric and Radiologic Study.

OBJECTIVE: To achieve the anatomical evaluation of spinal nerve and cervical intervertebral foramina in anterior controllable antedisplacement and fusion (ACAF) surgery, a novel surgical technique with the wider decompression, through a cadaveric and radiologic study. METHODS: Radiographic data of consecutive 47 patients (21 by ACAF and 26 by anterior cervical corpectomy and fusion [ACCF]) who have accepted surgery for treatment of cervical ossification of the posterior longitudinal ligament(OPLL) and stenosis from March 2017 to March 2018 were retrospectively reviewed and compared between an ACAF group and ACCF group. Three postoperative radiographic parameters were evaluated: the decompression width and the satisfaction rate of decompression at the entrance zone of intervertebral foramina on computed tomography (CT), and the transverse diameter of spinal cord in the decompression levels on magnetic resonance imaging (MRI). In the anatomic study, three fresh cadaveric spines (death within 3 months) undergoing ACAF surgery were also studied. Four anatomic parameters were evaluated: the width of groove, the distance between the bilateral origins of ventral rootlets, the length of ventral rootlet from their origin to the intervertebral foramina, the descending angle of ventral rootlet. RESULTS: The groove created in ACAF surgery included the bilateral origins of ventral rootlets. The rootlets tended to be vertical from the rostral to the caudal direction as their takeoff points from the central thecal sac became higher and farther away from their corresponding intervertebral foramina gradually. No differences were identified between left and right in terms of the length of ventral rootlet from the origin to the intervertebral foramina and the descending angle of ventral rootlet. The decompression width was significantly greater in ACAF group (19.2 ± 1.2 vs 14.7 ± 1.2, 21.3 ± 2.2 vs 15.4 ± 0.9, 21.5 ± 2.1 vs 15.7 ± 1.0, 21.9 ± 1.6 vs 15.9 ± 0.8, from C3 to C6 ). The satisfactory rate of decompression at the entrance zone of intervertebral foramina tended to be better in the left side in ACAF group (significant differences were identified in the left side at C3/4 , C4/5 , C6/7 level, and in the right side at C4/5 level when compared with ACCF). And decompression width was significantly greater than the transverse diameter of spinal cord in ACAF group. Comparatively, there existed no significant difference in the ACCF group besides the C5 level. CONCLUSION: ACAF can decompress the entrance zone of intervertebral foramina effectively and its decompression width includes the origins and massive running part of bilateral ventral rootlets. Due to its wider decompression range, ACAF can be used as a revision strategy for the patients with failed ACCF.

Chronic Lymphocytic Leukemia Prognostic Index: A New Integrated Scoring System to Predict the Time to First Treatment in Chinese Patients with Chronic Lymphocytic Leukemia.

BACKGROUND: The established clinical staging systems (Rai/Binet) of chronic lymphocytic leukemia (CLL) cannot accurately predict the appropriate treatment of patients in the earlier stages. In the past two decades, several prognostic factors have been identified to predict the outcome of patients with CLL, but only a few studies investigated more markers together. To predict the time to first treatment (TTFT) in patients of early stages, we evaluated the prognostic role of conventional markers as well as cytogenetic abnormalities and combined them together in a new prognostic scoring system, the CLL prognostic index (CLL-PI). METHODS: Taking advantage of a population of 406 untreated Chinese patients with CLL at early and advanced stage of disease, we identified the strongest prognostic markers of TTFT and, subsequently, in a cohort of 173 patients who had complete data for all 3 variables, we integrated the data of traditional staging system, cytogenetic aberrations, and mutational status of immunoglobulin heavy chain variable region (IGHV) in CLL-PI. The median follow-up time was 45 months and the end point was TTFT. RESULTS: The median TTFT was 38 months and the 5-year overall survival was 80%. According to univariate analysis, patients of advanced Rai stages (P < 0.001) or with 11q- (P = 0.002), 17p- (P < 0.001), unmutated IGHV (P < 0.001), negative 13q- (P = 0.007) and elevated lactate dehydrogenase levels (P = 0.001) tended to have a significantly shorter TTFT. And subsequently, based on multivariate Cox regression analysis, three independent factors for TTFT were identified: advanced clinical stage (P = 0.002), 17p- (P = 0.050) and unmutated IGHV (P = 0.049). Applying weighted grading of these independent factors, a CLL-PI was constructed based on regression parameters, which could categorize four different risk groups (low risk [score 0], intermediate low [score 1], intermediate high [score 2] and high risk [score 3-6]) with significantly different TTFT (median TTFT of not reached (NR), 65.0 months, 36.0 months and 19.0 months, respectively, P < 0.001). CONCLUSIONS: This study developed a weighted, integrated CLL-PI prognostic system of CLL patients which combines the critical genetic prognostic markers with traditional clinical stage. This novel modified PI system could be used to discriminate among groups and may help predict the TTFT and prognosis of patients with CLL.

A Comparison between Three-Dimensional Visualization Guided Hepatectomy and Ultrasonography Guided Radiofrequency Ablation in the Treatment of Small Hepatocellular Carcinoma within the Milan Criteria.

Background. Treatment selection for small hepatocellular carcinoma (sHCC) is controversial. We aimed to compare the outcomes of medical imaging three-dimensional visualization system (MI-3DVS) guided surgical resection (SR) and ultrasonography guided radiofrequency ablation (RFA) for sHCC. Methods. In total, 194 patients who underwent SR or RFA in our hospital between January 2006 and May 2010 were retrospectively enrolled. Overall survival (OS), recurrence-free survival (RFS), and postoperative complications were compared. Cox regression was used to estimate the benefits of MI-3DVS-guided SR on OS and RFS. Results. Ninety-two patients underwent SR and 102 underwent RFA. The SR group experienced more complications (41.3% versus 19.6%) and longer hospital stay (18.04 ± 7.11 versus 13.06 ± 5.59) (both p < 0.05). The 1-, 2-, 3-, 4-, and 5-year OS was 96.7%, 95.7%, 93.5%, 83.5%, and 61.1% in the SR group and 95.0%, 88.1%, 72.7%, 56.9%, and 39.5% in the RFA group. Corresponding RFS was 95.7%, 94.6%, 84.7%, 59.8%, and 40.2% in SR group and 91.2%, 80.3%, 60.5%, 32.3%, and 22.3% in RFA group. The 5-year OS and RFS were higher in SR group (both p < 0.001). Interestingly, there was no significance in OS and RFS among subgroups aged >60 years. Independent predictors of OS and RFS, respectively, were intervention (HR, 2.769 and 1.933), tumor number (HR, 5.128 and 3.903), and serum alpha-fetoprotein (AFP) (HR, 1.871 and 1.474) (all p < 0.05). Conclusions. MI-3DVS based hepatectomy should be considered primary treatment while RFA can be treated as alternative therapy for older patients. Intervention, tumor number, and AFP are independent predictors for both survival and recurrence.

Computer-aided rigid choledochoscopy lithotripsy for hepatolithiasis.

BACKGROUND: Hepatolithiasis is challenging for surgeons to treat especially in patients with previous hepatobiliary surgery. The aim of the study was to report our experience of rigid choledochoscopy lithotripsy in targeted treatment of hepatolithiasis under the guidance of a medical image three-dimensional visualization system, which we developed and patented (software copyright no: 2008SR18 798) by comparing it with hepatectomy without a three-dimensional (3D) reconstruction technique. METHODS: Between December 2007 and March 2013, 64 patients underwent rigid choledochoscopy lithotripsy based on 3D visualization technology conducted by a medical image three-dimensional visualization system for hepatolithiasis (group A). During the same period, 61 patients with hepatolithiasis were selected for hepatectomy (group B). Comparative analysis was made of demographic and perioperative characteristics of the two groups. RESULTS: 3D visualization was instructive for surgeons on how the stones were distributed and what the spatial relationship was between stones and the intrahepatic vascular system. Compared with patients in group B, those in group A had a significantly lower intermediate residual stone rate, a faster operating time, a lower intraoperative blood loss and intraoperative blood transfusion, a shorter postoperative hospital stay, less postoperative complications, and more liver function reserved (P < 0.05 for all). Final residual stone rate, stone recurrence rate, and recurrent cholangitis rate were similar. CONCLUSIONS: 3D visualization technology provides an important reference and a valuable planning for rigid choledochoscopy lithotripsy, which is a feasible and effective method for management of hepatolithiasis.

Correlation of lymphovascular invasion with clinicopathological factors in invasive breast cancer: a meta-analysis.

OBJECTIVES: Lymphovascular invasion (LVI) has been associated with a poor outcome in patients with breast cancer, but it is not included in international TNM staging system and molecular subtype criterion. The current studies have reported the relation between LVI and the tumor size (T), the status of axillary lymph node (ALN), age, histological grade in invasive breast cancer, but the results were debatable. So the meta-analysis was conducted to confirm the relation between LVI and the four clinicopathological factors. METHODS: Literature was searched by entering the terms: breast AND (neoplasm OR cancer OR carcinoma) AND (lymphovascular OR "lymphatic vessel" OR "vascular vessel" OR "blood vessel" OR "lymph vessel") AND (invasion OR "carcinoma embolus") AND (lymph node OR grade OR size OR clinicopathological) in PubMed, The merged odds ratio (OR) and 95% confidence interval (CI) were estimated using fixed-effect or random-effect model, RevMan 5.3 was used to analyze the relation between LVI and tumor size, status of ALN, age, histological grade in invasive breast cancer respectively. The fail-safe number was used to estimate publication bias. RESULTS: The analysis included 6 studies, LVI positive rate was significant lower in T≤2 cm, ALN negative, age >50 y and histological grade 1 groups statistically. The OR and 95% CI were 0.53 [0.46, 0.61], 0.23 [0.15, 0.35], 1.62 [1.42, 1.85], 0.36 [0.17, 0.77] respectively. CONCLUSIONS: LVI was significantly correlated with the expression status of the tumor size, status of ALN, age, histological grade in invasive breast cancer, and was consistent with adverse features of the four factors.

Management complicated hepatolithiasis with operative rigid choledochoscope guided by computed tomography (CT)-based 3D reconstruction technique.

BACKGROUND: Treatment of complicated hepatolithiasis is complex and difficult. In this report, we present a novel approach to manage complicated hepatolithiasis using the rigid choledochoscope guided by CT-based 3D reconstruction technique with or without hepatectomy. METHODS: Between February 2012 to December 2013, 25 patients with complicated hepatolithiasis underwent rigid choledochoscope guided by CT-based 3D reconstruction technique combined with or without hepatectomy. 27 patients with complicated hepatolithiasis underwent a traditional operation (traditional method group) from June 2011 to January 2012. All operations were performed by the authors. RESULTS: The final stone clearance rate of the rigid choledochoscope group was 96%, whereas that of the traditional method group was 74.1% (P=0.032). There was no patient died of postoperative mortality in two groups. Moreover, the operative time in the traditional method group was significantly longer than that in the rigid choledochoscope group (P=0.010). Recurrent intrahepatic bile duct stones were not found during the follow-up period in the two groups. CONCLUSIONS: Operative rigid choledochoscope guided by CT-based 3D reconstruction technique combined with or without hepatectomy may be an effective and safe treatment for complicated hepatolithiasis.

New insights into autonomic nerve preservation in high ligation of the inferior mesenteric artery in laparoscopic surgery for colorectal cancer.

AIM: To take a deeper insight into the relationship between the root of the inferior mesenteric artery (IMA) and the autonomic nerve plexuses around it by cadaveric anatomy and explore anatomical evidence of autonomic nerve preservation in high ligation of the IMA in laparoscopic surgery for colorectal cancer. METHODS: Anatomical dissection was performed on 11 formalin-fixed cadavers and 12 fresh cadavers. Anatomical evidence-based autonomic nerve preservation in high ligation of the IMA was performed in 22 laparoscopic curative resections of colorectal cancer. RESULTS: As the upward continuation of the presacral nerves, the bilateral trunks of SHP had close but different relationships with the root of the IMA. The right trunk of SHP ran relatively far away from the root of IMA. When the apical lymph nodes were dissected close to the root of the IMA along the fascia space in front of the anterior renal fascia, the right trunk of SHP could be kept in suit under the anterior renal fascia. The left descending branches to SHP constituted a natural and constant anatomical landmark of the relationship between the root of IMA and the left autonomic nerves. Proximal to this, the left autonomic nerves surrounded the root of the IMA. Distally, the left trunk of the SHP departed from the root of IMA under the anterior renal fascia. When high ligation of the IMA was performed distal to it, the left trunk of SHP could be preserved. The distance between the left descending branches to SHP and the origin of IMA varied widely from 1.3 cm to 2.3 cm. CONCLUSIONS: The divergences of the bilateral autonomic nerve preservation around the root of the IMA may contribute to provide anatomical evidence for more precise evaluation of the optimal position of high ligation of the IMA in the future.

3D Reconstruction Aids Surgery For Complicated Hepatolithiasis.

BACKGROUND/AIMS: Three-dimensional (3D) imaging may improve surgical interventions for complicated hepatolithiasis. METHODOLOGY: Between July 2008 and December 2012 a total of 131 patients with complicated hepatolithiasis underwent surgical therapy in the Department of Hepatobiliary Surgery Zhujiang Hospital, Southern Medical University. 77 patients received preoperative planning using a computed tomography (CT)-based 3D reconstruction technique, and 54 received treatment based on preoperative planning with traditional imaging (CT, ultrasonography, magnetic resonance imaging/magnetic resonance cholangiography). Perioperative and long-term outcomes were analyzed. RESULTS: 3D reconstruction facilitated significantly more accurate diagnosis of pathological morphology than conventional imaging methods, as confirmed during surgery. Patients that received 3D reconstruction preoperative planning had significantly better clinical outcomes. The immediate stone clearance rates were 92.2% and 61.1%, respectively. Additional postoperative choledochoscopic lithotripsy raised the clearance rates to 94.8% and 81.5%, respectively. The hospital mortality rates were 0% and 1.9%, respectively, and the complication rates were 33.8% and 44.4%, respectively. With a median follow-up of 28 months (5-38 months), the long-term overall asymptomatic survival rates were 80.5% and 46.3%, respectively. 3D reconstruction preoperative planning was a significant prognostic protective factor of long-term asymptomatic survival for the patients with complicated hepatolithiasis (Cox regression analysis, RR = 0.348, 95% confidence interval 0.185-0.657, p = 0.001). CONCLUSION: Surgical therapy conducted following preoperative planning using 3D reconstruction achieved better clinical outcomes than conventional imaging techniques. Whilst conventional imaging techniques accurately identify intrahepatic stones, they are less capable of identifying bile duct stricture.

Digital three-dimensional model of lumbar region 4-5 and its adjacent structures based on a virtual Chinese human.

OBJECTIVE: To study the methods for constructing a digitized three-dimensional (3D) model of a virtual lumbar region and its adjacent structures in order to assist anatomical study and virtual surgery. METHODS: Images of DSCF5375-p1 to DSCF5745-p1 were taken from the database of the digitized Virtual Chinese human of Southern Medical University in Guangzhou. This region encompasses the superior facet joint of L4 to the inferior edge of the intervertebral body of L5. The regions of interest were interactively segmented from the images utilizing Adobe Photoshop software. The images were further processed using format conversion and segmentation. Finally, a 3D model of the L4-5 region and its neighboring structures was reconstructed with the assistance of Mimics 10.01 software. RESULTS: A digitized 3D model of this part of the virtual lumbar spine and its adjacent structures was reconstructed. This model allows all constructed structures to be displayed individually or jointly, moved or rotated arbitrarily, setting of different transparencies and convenient measurement of the diameters and angles of the reconstructed structures. The 3D model precisely displays the anatomical relationships between all structures and provides a reliable 3D model for a spinal endoscopic surgery simulation system. CONCLUSION: Visualization of the digitized 3D reconstruction of the virtual lower lumbar region displays this region and its adjacent structures stereoscopically and in actuality, thus providing morphological data concerning anatomy, image diagnosis and virtual operations in this region.

[Anatomical observation on surgical spaces related to laparoscopic right hemicolectomy].

OBJECTIVE: To explore regional anatomy of fasciae and spaces related to laparoscopic right hemicolectomy (LRC). METHODS: Seven cadavers and 49 patients undergoing LRC for cancer were observed. Computed tomography (CT) images of patients and healthy individuals were reviewed. RESULTS: Between ascending mesocolon and prerenal fascia (PRF), there was a right retrocolic space (RRCS), which communicated in all directions. Anterior, posterior, medial, lateral, cranial, and caudal boundaries of the RRCS were ascending mesocolon, PRF, superior mesenteric vein, peritoneal reflexion at right paracolic sulcus, inferior margin of transverse part of duodenum, and inferior margin of the mesentery root, respectively. Between transverse mesocolon and pancreas and duodenum, there was a transverse retrocolic space (TRCS), which was bounded cranially by root of transverse mesocolon. On CT images of healthy individuals, PRF was noted as slender line of middle density, continuing to transverse fascia, and the retrocolic spaces were unidentifiable. For patients with right colon cancer, PRF and right retrocolic space might be easier to be identified. CONCLUSIONS: The RRCS and the TRCS are natural surgical spaces. The PRF is natural surgical plane in LRC for cancer.

Anatomical variations of hepatic veins: three-dimensional computed tomography scans of 200 subjects.

BACKGROUND: The impact of hepatic venous anatomic variations on hepatic resection and transplantation is the least understood aspect of liver surgery. METHODS: A prospective three-dimensional computed tomography study was undertaken on 200 consecutive subjects with normal livers to determine the prevalence of surgically significant hepatic venous anatomic variations. RESULTS: The prevailing pattern of the three hepatic veins in these subjects was a right hepatic vein (RHV) and a common trunk for the middle (MHV) and left (LHV) hepatic veins (122/200, 61%). The remaining patients had the RHV, MHV, and LHV draining independently into the inferior vena cava (IVC). In 39% of patients, the RHV was small and was compensated by a large right inferior hepatic vein (21.0%), an accessory RHV (8.5%) or a well-developed MHV (6.5%). A segment 4 vein was seen in 51.5% of patients. This segment 4 vein joined the LHV (26%), the MHV (17.5%), or the IVC (8%). An umbilical vein and a segment 4 vein were seen in 3.5% of patients. These two veins joined either the LHV (2.0%) or the MHV (1.5%). CONCLUSIONS: Knowing the variations of hepatic veins before surgery is useful during both partial hepatectomy and donor operations for living related liver transplantation.

[Application of the medical image three-dimensional visualization system of abdomen in diagnosis and evaluating resectability of pancreatic tumors].

OBJECTIVE: To study the value and the clinical application of the Medical Image three-dimensional Visualization System of Abdomen (MI-3DVS) in diagnosis and evaluating resectability of pancreatic tumor. METHODS: Twelve patients with pancreatic tumor were tested with 64-slice helical CT (64-MSCT) angiography, and the CT data was reconstructed with MI-3DVS from November 2008 to August 2009. The 3D findings were adopted in diagnosis and evaluating resectability, and the results were compared with surgical operation and the pathological finding. There were 7 male and 5 female, aged from 14 to 83 years. Within the 12 cases, there were 4 cases with pancreatic carcinoma, 5 cases with pancreatic solid pseudopapillary tumor, 2 cases with pancreatic serous cystadenoma, 1 case with pancreatic cyst (ductal epithelial papillary hyperplasia). RESULTS: Nine tumors which had been regarded as removable pre-operatively with MI-3DVS were removed successfully. Three patients who were considered unresectable by other hospitals with CT were operated successfully with MI-3DVS. The other 3 patients' tumors were actually not able to be removed as pre-operative evaluation. CONCLUSION: MI-3DVS plays an important role in diagnosis and assessment of resectability of pancreatic tumor.

Biomechanical evaluation of stability and three-dimensional movements of the atlantoaxial joint after artificial atlanto-odontoid joint arthroplasty.

OBJECTIVE: To investigate the stability and three-dimensional movements of the atlantoaxial joint after artificial atlanto-odontoid joint (AAOJ) arthroplasty. METHOD: Ten sets of AAOJ implanted in bony specimens from 10 adults were used to test the pull-out strength of the atlas-axis components with a MTS858 Mini Bionix machine. Another twelve human cadaveric specimens including C(0)-C(4) were used to evaluate the three-dimensional movements of C(1)-C(2) under five different conditions in sequence, that is, the complete specimen, anterior decompression, posterior transarticular screws fixation, AAOJ arthroplasty and fatigue test. RESULT: There were significant differences between atlas and axis components in the maximum pull-out strength and trajectory length, however the yield length was not significantly different. The maximum pull-out strength of the atlas and axis was positively correlated with trajectory length (r(1)= 0.880, P < 0.05) and yield length (r(2)= 0.606, P < 0.05), respectively. After AAOJ arthroplasty, the range of movement (ROM) with respect to rotation and the neutral zone of the atlantoaxial joint were close to normal (P > 0.05), but the ROM in flexion-extension and lateral bending was significantly smaller compared with the specimens which underwent anterior decompression (P < 0.05). No abrasion and abnormal mobilization were observed after 2000 cycles of flexion, extension, lateral bending and axial rotation in the fatigue test. CONCLUSIONS: The self-designed AAOJ has excellent biomechanical performance, and AAOJ arthroplasty can restore excellent instant stability and preserve the movement of the atlantoaxial joint.

Clinical anatomy study of autonomic nerve with respective to the anterior approach lumbar surgery.

INTRODUCTION: Male genital dysfunction was recognized as a complication following anterior approach lumbar surgery. Disruption of efferent sympathetic pathways such as the abdominal aortic plexus (AAP) and superior hypogastric plexus (SHP) which lied pre-abdominal aorta and iliac artery had been thought as the main reason. Though there were some clinical reports of retrograde ejaculation, the applied anatomic study of the autonomic nerve anterior to the lumbar was little. The purpose was to find out a lumbar surgery approach which was ejaculation preservation through the detailed study of the anatomy and histology observation of the autonomic nerve anterior to the lumbar vertebrae. METHODS: The lumbar region of ten male cadavers was dissected and analyzed. We investigated the relationship between the peritoneum and abdominal aorta, iliac artery and sacral promontory fascia, as well as the trend and distribution of the autonomic nerve and SHP anterior to the L5-S1. We also observed the distribution of autonomic nerve at retroperitoneum through hematoxylin and eosin (HE)-stained tissues pre-aorta, para-aorta, and pre-vertebrae sacrales. RESULTS: Superior hypogastric plexus, which deviated to left, located in a triangle formed by the common iliac arteries and its bilateral branches, its truck sited anterior to the lumbarsacral space in seven cases (70%), and anterior to sacrum in three cases (30%); at the aortic bifurcation, SHP strided over left iliac artery from left-hand side, then located in front of sacrum in four cases (40%), and sifted to the left at the lumbar sacral promontory in six cases (60%); from both anatomic and histological view, the autonomic nerve plexus lying in an fascia layer of retroperitoneum. CONCLUSION: At the anterior approach lumbar surgery of trans-peritoneum, we should choose the right-hand side incision; the SHP should be pushed aside carefully from right to left along intervertebral disc. The accurate surgical plane was at the deeper layer of autonomical nerve fascia; we also could lift the complete autonomical nerve layer which lies behind the aorta and lumbar sacral promontory, so that the autonomic nerve could be preserved.

A new technique for lag screw placement in the dynamic hip screw fixation of intertrochanteric fractures: decreasing radiation time dramatically.

The goal of this study was to confirm the decrease in radiation time required for a new technique to place dynamic hip screws (DHS) in intertrochanteric fractures. Seventy-six patients were treated with DHS by either the new technique (NT) or the conventional technique (CT). The width of femoral shaft, the length of the hip screw to be implanted into the injured side, and the distance between the tip of the greater trochanter and the entry point of the guide wire were measured at the uninjured side on the anteroposterior pelvic radiograph preoperatively, and the actual width of the injured femoral shaft was measured intra-operatively. Finally, the entry point and the length of hip screw were obtained through an equation. Mean radiation time of the NT patients (24.57 +/- 7.80 s) was significantly shorter than the CT patients (54.2 +/- 18.26 s) (P < 0.001). The new technique decreased radiation time dramatically in DHS fixation.

[The clinic anatomy of lumbar plexus in the lumbar anterolaterally approach minimally invasive surgery].

OBJECTIVE: To provide anatomic data for reducing lumbar plexus nerve injury. METHODS: The applied anatomy of lumbar plexus was studied by 15 formaldehyde-preserved cadavers, two groups of sectional images of lumbar segment and three series of virtual chinese human dataset. RESULTS: Arrangement of the lumbar nerve was regular. From anterior view, lumbar plexus nerve arranged from lateral to medial from L2 to L5; from lateral view, lumbar nerve arrange from ventral to dorsal from L2 to L5. The angle degree between the lumbar nerve and lumbar increased from L1 to L5. The lumbar plexus nerve was revealed to be in close contact with transverse process. By sectional anatomy, all parts of the lumbar plexus nerve were located in the dorsal third of the psoas major. The safety zone of the psoas major to prevent nerve injuries was ventrally 2/3. CONCLUSIONS: Psoas major can be considered as surgery landmark when expose the lateral anterior of lumbar by incising the psoas muscle. Incising the psoas muscle ventral 2/3 can prevent lumbar plexus injury. Transverse process can be considered as landmark for the position of lumbar plexus in operation.

[Study on the three dimensional hepatic virtual operation based on the data of 64-slice helical CT scanning].

OBJECTIVE: To study the surgery plan and simulation effect of the three dimensional (3D) hepatic virtual operation based on the data of 64-slice helical CT scanning and to probe the feasibility of the virtual operation based on the FreeForm Modeling System. METHODS: The volunteer liver was scanned to collect two dimensional (2D) DICOM data of 64-slice helical CT scanning and the 3D hepatic and intrahepatic vessels model were reconstructed by MIMICS software. The reconstructed liver, the intrahepatic vessels model and the artificial tumor models were output into the FreeForm Modeling System in the STL format. The device PHANTOM with the characterization of dynamo-feedback was applied to make the operation on the 3D hepatic. RESULTS: The spatial relationship between the tumour and the intrahepatic vessels were clearly observed by rotation and enlargement of the target. According to the operation principle, the left lobe of liver resection was simulated by manipulating the device PHANToM. Through the liver transparence surface, the intrahepatic vessels were easily distinguished. The operation procedure was accord with the clinic hepatic surgery. Meanwhile, during the operation, by adjusting the incision objective intensity, the dynamo-feedback intensity was definitely touched. CONCLUSIONS: By using the FreeForm Modeling System,the hepatic operation procedure can be simulated ahead of time. The operation complication in the practical surgery can be anticipated and the individualization operation schema can be reasonable instituted.

Clinical anatomic study of the lower lumbar anterolateral vein: with respect to retroperitoneal endoscopic surgery.

OBJECTIVE: To study the anatomy of veins of the lower lumbar spine and provide the anatomic basement for laparoscopic lumbar surgery. METHODS: A total of 15 formaldehyde-preserved cadavers were studied with special attention to the variety and surrounding structure of ascending lumbar vein (ALV) and iliolumbar veins (ILV), and their relationship with lumbar plexus. RESULTS: ALV and ILV can be found on every sides, which have four variants including separate entry and common entry. The ascending vein and iliolumbar vein separately enter common iliac vein in 18 cases, and as a common stem enter the common iliac vein in 12 cases. Retracting common iliac vein medially both the ascending lumbar and the iliolumbar veins are always at risk of avulsion on exposure of the disc space. The injury of obturator nerve and lumbosacral trunk of lumbar plexus should be avoided. CONCLUSION: Awareness of these anatomic variation can prevent the hemorrhage and be helpful for the surgeon in performing a careful ligation of these veins before medial retraction of the common iliac vein. Our findings emphasize the need for proper dissection of ALV and ILV before ligature during exposure of the lower lumbar spine.