Cancer of bile duct with situs inversus.

We present a case of adenocarcinoma of the distal common bile duct in a 68-year-old woman with total situs inversus. Endoscopic retrograde cholangiopancreatography prior to surgery demonstrated segmental obstruction of the distal common bile duct. Obstructive jaundice was observed and the results of liver function studies were abnormal. All biopsy specimens obtained in the operating room were negative. The case met all the criteria of Child and Frey, but at the end of the procedure the tumor was found to involve the superior mesenteric vein, a factor not appreciated during the operative evaluation of the patient. The situs inversus did not produce any technical problems. The patient did not have any surgical complications, but she died 18 months later of the cancer.

Obturator hernia. Embryology, anatomy, and surgical applications.

Obturator hernia is a rare clinical entity. In most cases, it produces small bowel obstruction with high morbidity and mortality. The embryology, anatomy, clinical picture, diagnosis, and surgery are presented in detail.

The surgical anatomy and technique of the thoracoabdominal incision.

The thoracoabdominal incision provides excellent exposure of the thoracic, abdominal, and retroperitoneal compartments and can be safely performed in the vast majority of cases. To be more specific, the advantage of the left thoracoabdominal incision is excellent exposure of the lower esophagus, the gastroesophageal junction, the gastric cardia and stomach in toto, the left hemidiaphragm, the distal pancreas and spleen, the left kidney and adrenal gland, and the aorta. The advantage of the right thoracoabdominal incision is excellent exposure of the upper esophagus, the liver, the hepatic triad and inferior vena cava, the proximal pancreas, the right hemidiaphragm, the right kidney, and the adrenal gland. Several possible disadvantages should also be taken into consideration when contemplating this procedure. Morbidity and mortality may be increased with the opening of the two cavities. The surgeon must possess good detailed anatomic technique for opening and closure. This procedure is not advisable for children; it should be used only for good technical indications. Some of the more commonly encountered anatomic complications to be avoided include (1) splenic injury, occurring most often during division and resection of the diaphragm; (2) phrenic nerve injury, with subsequent diaphragmatic dysfunction; (3) ureteric injury during retroperitoneal dissection; (4) left first lumbar vein injury (located in the posterior aspect of the left renal vein) during left kidney mobilization; and (5) pain in the early postoperative period, which can occur secondary to transection of the cartilaginous costal arch. This may be minimized by secure fixation using No. 1 Prolene. Patients occasionally complain of a clicking sensation owing to nonunion of the costal cartilage.

The vagus nerve and its vagaries.

Without any further comments we advise the surgeon performing open or laparoscopic vagotomy to know the anatomy and the vagaries of the vagus nerve. In view of the demonstration that the nerves of the greater curvature, identified as a concern in achieving a "complete" PGV, are projected from up to 20% of the nerve cell bodies of the dorsal motor nucleus of the vagus nerve in the brain stem, we believe it is appropriate to adopt the technique of EHSV as a means of avoiding the high recurrence rates reported with conventional highly selective vagotomy or proximal gastric vagotomy. When pyloric stenosis or outlet obstruction is present, anterior hemipylorectomy provides a solution. If surgeons adopt a laparoscopic approach to EHSV, they must be cognizant of all sites of preganglionic innervation, and (ideally) attempt to verify the "completeness" of vagotomy by Congo red testing. We look forward, also, to the work of Andrus and Schneider, who are evaluating alternative methods of achieving complete vagotomy.

Embryologic and anatomic basis of duodenal surgery.

The following points should be remembered by surgeons (Table 1). In writing about the head of the pancreas, the common bile duct, and the duodenum in 1979, the authors stated that Embryologically, anatomically and surgically these three entities form an inseparable unit. Their relations and blood supply make it impossible for the surgeon to remove completely the head of the pancreas without removing the duodenum and the distal part of the common bile duct. Here embryology and anatomy conspire to produce some of the most difficult surgery of the abdominal cavity. The only alternative procedure, the so-called 95% pancreatectomy, leaves a rim of pancreas along the medial border of the duodenum to preserve the duodenal blood supply. The authors had several conversations with Child, one of the pioneers of this procedure, whose constant message was to always be careful with the blood supply of the duodenum (personal communication, 1970). Beger et al popularized duodenum-preserving resection of the pancreatic head, emphasizing preservation of endocrine pancreatic function. They reported that ampullectomy (removal of the papilla and ampulla of Vater) carries a mortality rate of less than 0.4% and a morbidity rate of less than 10.0%. Surgeons should not ligate the superior and inferior pancreaticoduodenal arteries because such ligation may cause necrosis of the head of the pancreas and of much of the duodenum. The accessory pancreatic duct of Santorini passes under the gastrointestinal artery. For safety, surgeons should ligate the artery away from the anterior medial duodenal wall, where the papilla is located, thereby avoiding injury to or ligation of the duct. "Water under the bridge" applies not only to the relationship of the uterine artery and ureter but also to the gastroduodenal artery and the accessory pancreatic duct. In 10% of cases, the duct of Santorini is the only duct draining the pancreas, so ligation of the gastroduodenal artery with accidental inclusion of the duct is catastrophic. With the Kocher maneuver, surgeons reconstruct the primitive mesoduodenum and achieve mobilization of the duodenum, which is useful for some surgical procedures. Surgeons should not skeletonize more than 2 cm of the first part of the duodenum. If more than 2 cm of skeletonization is done, a duodenostomy using a Foley catheter may be necessary to avoid blow-up of the stump secondary to poor blood supply. Proximal duodenojejunostomy is advised for the safe management of patients with difficult duodenal stumps. Roux-en-Y choledochojejunostomy and duodenojejunostomy divert bile and food in the treatment of the complicated duodenal diverticulum. The suspensory ligament may be transected with impunity. It should be ligated before being sectioned so that bleeding from small vessels contained within can be avoided. Failure to sever the suspensory muscle completely, which is possible if the insertion is multiple, fails to relieve the symptoms of vascular compression of the duodenum (Fig. 18). Mobilization, resection, and end-to-end anastomosis of the duodenal flexure have been performed as a uniform surgical procedure, avoiding the conventional gastrojejunostomy. With a large, penetrating posterior duodenal or pyloric ulcer, surgeons should remember that The proximal duodenum shortens because of the inflammatory process (duodenal shortening) The anatomic topography of the distal common bile duct and the opening of the duct of Santorini and the ampulla of Vater is distorted Leaving the ulcer in situ is wise Careful palpation for or visualization of the location of the ampulla of Vater or common bile duct exploration with a catheter insertion into the common bile duct and the duodenum are useful procedures In most cases, the common bile duct is located to the right of the gastroduodenal artery at the posterior wall of the first part of the duodenum. (ABSTRACT TRUNCATED)

Surgical embryology and anatomy of the pancreas.

Knowledge of the surgical embryology and surgical anatomy of the pancreas is vital to the general surgeon. This article discusses the entities related to pancreatic surgery. It also highlights some common embryologic anomalies of the pancreas.

Embryologic and anatomic basis of inguinal herniorrhaphy.

The embryology and surgical anatomy of the inguinal area is presented with emphasis on embryologic and anatomic entities related to surgery. We have presented the factors, such as patent processus vaginalis and defective posterior wall of the inguinal canal, that may be responsible for the genesis of congenital inguinofemoral herniation. These, together with impaired collagen synthesis and trauma, are responsible for the formation of the acquired inguinofemoral hernia. Still, we do not have all the answers for an ideal repair. Despite the latest successes in repair, we, to paraphrase Ritsos, are awaiting the triumphant return of Theseus.

Embryology, anatomy, and surgical applications of the preperitoneal space.

The preperitoneal space is presented from an embryologic, anatomic, and surgical standpoint in detail. Because this space is one of the most used areas for the repair of groin hernias, knowledge of its embryology and anatomy is essential.

The surgical anatomy of the spleen.

The surgical embryology and anatomy of the spleen are reported with emphasis given to ligaments, blood supply, and segmentation. The anatomic entities involved with splenic surgery are presented. Surgical applications are emphasized. Knowledge of splenic anatomy and technique, with efforts to save the organ if possible, is paramount for good results.

Testicular atrophy and neuropathy in herniorrhaphy.

This study is based upon our collective experience with more than 3000 open herniorrhaphies, dissection of 99 cadavers from the external approach, and 39 cadavers from open dissections, including 14 laparoscopic dissections. These observations may be of use in avoiding pitfalls in hernioplasty, either from the classic external surgical approaches or those from within, whether transperitoneal or preperitoneal.

Clinical considerations of hormonal receptors in breast cancer.

PIP: Focus is on the current concepts of hormone receptors in breast cancer and their significance to the practicing physician. Hormone receptor assays have proven to be valuable to physicians treating patients with breast cancer. About 2/3 of patients with estrogen receptor (ER+) tumors experience palliation of their symptoms after some type of hormonal manipulation. At this time it is believed that estrogen exerts the most powerful effect on the cancer. There are several methods of testing for estrogen receptors. The 1st method involves injection of tritiated hexesterol prior to surgery and subsequent checking for radioactive estrogens in the mammary tissue. More recently, methods are used in which the receptors can be quantified. 1 method uses a sucrose density gradient. Another and less expensive method is the Dextran-coated charcoal test (DCC). Estrogen receptors have been found in 73% of primary and 58% of metastatic breast cancers using the DCC test. The treatment of choice is always dependent on the patient involved. If the lesion is ER+, some type of hormone manipulation may be considered, which type depending on the menopausal status of the women.^ieng

The duodenum. Part 4: Surgery.

This is the last part of our efforts to present, if possible, the duodenum in toto as an anatomical and surgical entity. For all practical purposes, Part 4 is a short presentation of the anatomy involved in mobilization and exposure of the duodenum from a surgical standpoint with specific applications. A table with most of the anatomical complications of duodenal surgery is also included.

The duodenum. Part 3: Pathology.

Duodenal pathology includes various developmental malformations and acquired lesions. This report provides brief descriptions of various congenital anomalies of the duodenum, including stenosis and atresia, annular pancreas and ectopic duodenal pancreatic tissue, megaduodenum, duodenal diverticula, preduodenal portal vein, and paraduodenal fossae. Acquired lesions, such as duodenal ulcer, tumors, vascular compression, and duodenal trauma are also described.

The duodenum. Part 1: History, embryogenesis, and histologic and physiologic features.

Long before the Christian era, the duodenum was named and its function in controlling gastric emptying was conjectured. It received almost no further attention until the Eighteenth century when its relation to the bile and pancreatic ducts became know. The embryogenesis of the duodenum and the histological features of the organ are described as well as the gross movements that explain the mature relations of the duodenum to the surrounding structures. The "sphincters" of the duodenum are mentioned and evaluated.

The duodenum. Surgical anatomy.

The second part of this monograph on the duodenum describes the muscular and mucosal changes observed at the gastroduodenal junction. The structure of the duodenal wall and details of the intramural portion of the common bile and pancreatic ducts are described, together with the surgical anatomy of the four parts of the duodenum. The arterial supply, the venous and lymphatic drainage, and the innervations are described from the surgeon's point of view.

Malignant fibrous histiocytoma of the pancreas.

Malignant fibrous histiocytoma (MFH) is a well-recognized soft-tissue sarcoma; however, its presentation as a primary neoplasm of the pancreas is unusual. We report a rare case of primary MFH of the pancreas treated with wide local excision and postoperative chemotherapy. Three cases of MFH of the pancreas have previously been reported in the world literature. The natural history of MFH of the pancreas cannot be summarized due to the rarity of the tumor. It appears, however, that the behavior of this tumor parallels the behavior of retroperitoneal MFH in terms of aggressiveness and poor prognosis.

The carpal tunnel syndrome: Part III.

The carpal tunnel syndrome is a compression of the median nerve within the carpal tunnel with very specific signs and symptoms. Anatomical dissection of 156 wrists is presented and then the authors compare their findings with the findings of other investigators. The purpose of this article is not to present results but rather to discuss the anatomic entities involved with the syndrome and to present the open treatment modality.

The carpal tunnel syndrome: Part II.

The carpal tunnel syndrome is a compression of the median nerve within the carpal tunnel with very specific signs and symptoms. Anatomical dissection of 156 wrists is presented and then the authors compare their findings with the findings of other investigators. The purpose of this article is not to present results but rather to discuss the anatomic entities involved with the syndrome and to present the open treatment modality.

The carpal tunnel syndrome: Part I.

The carpal tunnel syndrome is a compression of the median nerve within the carpal tunnel with very specific signs and symptoms. Anatomical dissection of 156 wrists is presented and then the authors compare their findings with the findings of other investigators. The purpose of this article is not to present results but rather to discuss the anatomic entities involved with the syndrome and to present the open treatment modality.

Smooth muscle tumors of the appendix and colon: a collective review of the world literature.

In this collective review, we compiled all reported cases of smooth muscle tumors of the colon/appendix in the world literature from 1959 to 1989. Our goal was to make more accurate conclusions about these tumors based on our increased data pool.