[Reappraisal of the lateral rectal structure].

Colorectal surgeons have focused on the lateral structure of rectum for a long time and lateral ligament is the common term to depict this structure. A better understanding of lateral rectal structure could be beneficial to performing the total mesorectum excision (TME) procedure and protecting patients' urinary, sexual and defecation function. The main controversies focus on two aspects: (1) Does the lateral ligament exist? (2) What dose it contain? Does the middle rectal artery exist? Up to now, anatomic studies have failed to reach consensus on the lateral rectal structure. However, surgeons do find the lateral rectal ligament during surgery and it may be the pathway for lateral lymph node metastasis in rectal cancer. The lateral rectal structure contains the middle rectal artery, nerve branches, lymphatics and adipose fibrous tissue around them. We summarize our clinical experience and conclude that the middle rectal artery appears in lateral ligament constantly but some of them are too small to be easily observed. Therefore, regarding the perspective of membrane anatomy, embryology and surgery, this structure may be more appropriate to be called the "lateral mesorectum". We propose this new term based on the previous literature and our own experience for the readers' reference.

[A 51-year-old woman with upper abdominal pain]. / Een 51-jarige vrouw met pijn in de bovenbuik.

A 51-year-old woman presented to the emergency room with upper abdominal pain and elevated infection parameters. No abnormalities were found during gastroscopy. A CT scan demonstrated perigastricappendagitis. Perigastricappendagitis is a rare infarction of a fatty appendix of the perigastric ligaments. It is a benign and self-limiting disease.

Falciform ligament appendagitis after Roux-en-Y bypass surgery mimicking acute cholecystitis.

Fatty falciform ligament appendage torsion (F-FLAT) is a rare type of intraperitoneal focal fat infarction that involves torsion of a fatty appendage of the falciform ligament. It may cause severe pain, mimicking an acute abdomen, but is typically self-limited and does not require hospitalisation or surgery. As a type of intraperitoneal focal fat infarction, it shares many of the same physiological, clinical and radiological features of epiploic appendagitis. To our knowledge, F-FLAT has not previously been reported in a patient following a laparoscopic Roux-en-Y gastric bypass surgery. Identifying falciform ligament appendagitis is critical because it can prevent unnecessary hospitalisation, follow-up studies and surgery.

Anatomy of Ankle Syndesmotic Ligaments: A Systematic Review of Cadaveric Studies.

Diagnosis and management of isolated syndesmotic injuries are controversial and highly debated. Hence, the aim of this study is to explore and gain the current understanding pertaining to detailed anatomy of syndesmotic ligaments through a systematic review of published cadaveric studies. A systematic review was conducted online for literature published in English using PubMed and Google Scholar, as per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, up to April 30, 2019. Predefined eligibility criteria were applied, and the data thus compiled was analyzed. Study quality was assessed based on Quality Appraisal for Cadaveric Studies (QUACS) scale. A total of 12 studies reporting 365 ankles were included in this review. Considerable inconsistency in the naming and description of syndesmotic ligaments was observed, with only 2 studies reporting the vasculature of the ligaments. Hence further investigation of the anatomy of the syndesmotic ligaments is recommended so as to better inform clinical practice, as awareness of anatomy is critical for assessment, healing, and successful surgical management.Levels of Evidence: Level III: Systematic review of anatomical dissections.

Carpal tunnel ultrasound: is the "safe zone" on the ulnar side of the median nerve really avascular?

INTRODUCTION: Numerous publications have studied the regional anatomy of the carpal tunnel to define a "safe zone" to reduce the risk of perioperative neurovascular complications. This zone, located between the ulnar neurovascular bundle and the median nerve, is considered to be safe mainly because of the absence of vascular structures. This study aims to assess the presence of arterioles within this area using superb microvascular imaging (SMI). MATERIALS AND METHODS: The images from patients who underwent a bilateral routine wrist ultrasound with SMI, between January 28 and February 28, 2019, were retrospectively reviewed by two radiologists to evaluate the presence and location of arterioles in the safe zone. In addition, cadaveric wrists injected with intra-arterial red latex underwent dissection of the carpal tunnel. RESULTS: The images from 27 patients (54 wrists) were reviewed. In the safe zone, arterioles were seen superficial to the retinaculum in 36 wrists (36/54; 66.7%) and deep to the retinaculum in 21 wrists (21/54; 38.9%). The arterioles located deep to the retinaculum were more frequently found close to the median nerve (21/54; 38.9%) than to the ulnar artery (9/54; 16.7%). In five cadaveric wrists, arterioles were detected superficial to the retinaculum in 3 wrists (3/5; 60%) and deep to the retinaculum in 2 wrists (2/5; 40%). CONCLUSION: Arterioles can be seen in the safe zone both superficial and deep to the flexor retinaculum. Deep to the retinaculum, they are mainly observed in the proximal aspect of the carpal tunnel and more frequently close to the median nerve. KEY POINTS: • Superb microvascular imaging (SMI) enables the visualization of arterioles within the "safe zone" of the carpal tunnel (visible both superficial and deep to the flexor retinaculum). • Arterioles were more frequently observed in the proximal aspect of the carpal tunnel. • Deep to the retinaculum, arterioles were more frequently seen in proximity to the median nerve.

Neurovascular and lymphatic vessels distribution in uterine ligaments based on a 3D reconstruction of histological study: to determine the optimal plane for nerve-sparing radical hysterectomy.

OBJECTIVE: To present the distribution of neurovascular and lymphatic vessels in uterine ligaments using 3D models based on the pathological staining of serial 2D sections of postoperative specimens. METHODS: Serial transverse sections of fresh uterine ligaments from a patient with stage IB1 cervical squamous cell carcinoma were studied using the computer-assisted anatomic dissection (CAAD) technique. The sections were stained with hematoxylin and eosin, Weigert elastic fibers, D2-40 and immunostainings (sheep anti-tyrosine hydroxylase and rabbit anti-vasoactive intestinal peptide). The sections were then digitalized, registered and reconstructed three-dimensionally. Then, the 3D models were analyzed and measured. RESULTS: The 3D models of the neurovascular and lymphatic vessels in uterine ligaments were created, depicting their precise location and distribution. The vessels were primarily located in the upper part of the ligaments model, while the pelvic autonomic nerves were primarily in the lower part; the lymphatic vessels were scattered in the uterine ligaments, without obvious regularity. CONCLUSION: CAAD is an effective anatomical method to study the precise distribution of neurovascular and lymphatic vessels in uterine ligaments. It can present detailed anatomical information about female pelvic autonomic innervation and the spatial relationship between nerves and vessels and may provide a better understanding of nerve-sparing radical hysterectomy.

Arteries of the falciform ligament on C-arm CT hepatic arteriography: The hepatic falciform artery and the Sappey's superior artery.

BACKGROUND AND AIM: To investigate the prevalence, anatomy and distribution of the hepatic falciform artery (HFA) and Sappey's superior artery (SSA) using C-arm CT hepatic arteriography (C-arm CTHA). MATERIALS AND METHODS: From January 2011 to December 2012, 220 patients who underwent C-arm CTHA during initial transarterial treatment for hepatocellular carcinoma were included in this retrospective study. The HFAs and SSAs prevalence and origin were evaluated using axial images of C-arm CTHA. A 5-point scale for HFAs and a 4-point scale for SSAs were used to designate the radiologically conspicuous arteries. RESULTS: The prevalences of the total HFAs and SSAs were 95 % (n=209) and 22 % (n=49), while those of radiologically conspicuous HFAs and SSAs were 62 % (n=137) and 10 % (n=22), respectively. Thirty HFAs (22 % of radiologically conspicuous HFAs and 14 % of the total study population) were distributed in the subcutaneous layer of the anterior abdominal wall, while the majority of SSAs ran through the superior part of the falciform ligament in the left-anterior direction and anastomosed with left inferior phrenic artery. CONCLUSION: Our study using C-arm CTHA revealed that the prevalence of the HFA is higher than the existing knowledge and proved the existence of the SSA radiologically for the first time. KEY POINTS: • Prevalence of hepatic falciform artery is 95 %, higher than previously known. • 22 % of conspicious hepatic falciform arteries distributed in subcutaneous tissue around umbilicus. • The existence of Sappey's superior artery was proved with a radiological method.

Vascular anatomical relationships of the retropubic space and the sacrospinous ligament, using three-dimensional imaging.

INTRODUCTION AND HYPOTHESIS: Pelvic anatomy is complex and intimate knowledge of variabilities in anatomical relationships is critical for surgeons to safely perform surgical procedures. Three-dimensional Imaging provides the opportunity to analyze undisturbed anatomical relationships. The authors hypothesized that three-dimensional models created from pelvic computed tomography angiograms could be used to obtain vascular anatomical measurements, and that the measurements obtained from three-dimensional models would be similar to those from cadaver studies. METHODS: We included all pelvic computed tomography angiograms that were acquired in female patients older than 18 years at our institution within the previous 5 years. Three-dimensional models were created using the Invivo5 software based on the Digital Imaging and Communications in Medicine files. Structures of interest were virtually dissected and measured replicating previous cadaver studies. Statistical analysis of demographics and measurements was performed. RESULTS: The final analysis included 87 studies. The average age of the subjects was 66.9 years and their average BMI was 26.1 kg/m2. Of the 87 subjects, 12.6% had a history of hysterectomy, 2.3% a history of a continence procedure, and 1.1% a history of a prolapse procedure. The range of distance between the ischial spine and the pudendal artery was 3-17 mm. The closest vessels to the lower edge of the symphysis pubis were the obturator vessels. The aberrant corona mortis vessel was present in 27.9% of the subjects. Prior hysterectomy was associated with changes in the measurements of the obturator arteries with minimal changes in other measurements. CONCLUSIONS: Our results indicate that this technology provides similar measurements to those found in previous unembalmed cadaver studies. This technology offers a great opportunity to study anatomical relationships in a native undisturbed state.

Laparoscopic Nerve-Sparing Radical Hysterectomy for Cervical Carcinoma: Emphasis on Nerve Content in Removed Cardinal Ligaments.

OBJECTIVE: To evaluate the histopathology of autonomic nerve removal within the cardinal ligaments (CLs), patients' postoperative urinary function, and the feasibility and safety of laparoscopic nerve-sparing radical hysterectomy (LNSRH) for treatment of early-stage cervical cancer. METHODS: Perioperative and postoperative parameters were compared between patients with biopsy-proven, early-stage cervical carcinoma treated with LNSRH (n = 64) versus those treated with laparoscopic radical hysterectomy (LRH, n = 42) in a retrospective study. Nerves within CLs were identified by hematoxylin-eosin staining. Rates of the following complications were compared: bladder function, sexual dysfunction, and defecation problems. RESULTS: Duration of surgery, intraoperative blood loss, duration of hospitalization, and morbidity did not differ significantly between the LNSRH and LRH groups. Patients who underwent LNSRH had a significantly earlier return of bladder and bowel functions, with an average time to achieve residual urine of 50 mL or less of 10.22 days and a mean first defecation time of 3.58 days. Nerves were observed mainly in the CLs of the LRH group. Disease-free survival rate did not differ between the LNSRH (90.6%) and LRH (88.1%) groups (P = 0.643). CONCLUSIONS: The LNSRH is a safe, feasible, and easy procedure for trained laparoscopic surgeons. Patients who underwent LNSRH had a more satisfactory quality of life than patients who underwent LRH.

Remnant Repair-enhanced Polyethylene Terepthalate Artificial Ligament Graft Ligamentization.

The aim of this study was to investigate whether augmented remnant repair could enhance polyethylene terepthalate (PET) artificial ligament graft ligamentization. 12 female goats underwent ACL reconstruction with PET artificial ligament graft in the right knees. Right knees in 6 goats were reconstructed with augmented remnant repair (Remnant group), whereas the other 6 goats had no augmented remnant repair comprised the Control group. 3 goats in each group were randomly sacrificed at 6 months and 12 months respectively after surgery. The intra-articular parts of the reconstructed grafts were harvested for histological evaluation. Well-vascularized tissue ingrowth within the artificial ligament was observed in the remnant group at 12 months postoperatively. Collagen-I content of graft was significantly higher in the Remnant group than in the Control group at each time point (p<0.05). The relative expression of collagen-III positive area of the remnant-preserved group was significantly higher than that of the Control group at 12 months (p=0.005). The vascular endothelial growth factor (VEGF)-positive or CD31-positive area in the graft appeared higher in the Remnant group compared with the Control group at 6 months. Remnant repair enhanced the revascularization and remodeling of the PET artificial ligament in ACL reconstruction.

Allogeneic versus autologous derived cell sources for use in engineered bone-ligament-bone grafts in sheep anterior cruciate ligament repair.

The use of autografts versus allografts for anterior cruciate ligament (ACL) reconstruction is controversial. The current popular options for ACL reconstruction are patellar tendon or hamstring autografts, yet advances in allograft technologies have made allogeneic grafts a favorable option for repair tissue. Despite this, the mismatched biomechanical properties and risk of osteoarthritis resulting from the current graft technologies have prompted the investigation of new tissue sources for ACL reconstruction. Previous work by our lab has demonstrated that tissue-engineered bone-ligament-bone (BLB) constructs generated from an allogeneic cell source develop structural and functional properties similar to those of native ACL and vascular and neural structures that exceed those of autologous patellar tendon grafts. In this study, we investigated the effectiveness of our tissue-engineered ligament constructs fabricated from autologous versus allogeneic cell sources. Our preliminary results demonstrate that 6 months postimplantation, our tissue-engineered auto- and allogeneic BLB grafts show similar histological and mechanical outcomes indicating that the autologous grafts are a viable option for ACL reconstruction. These data indicate that our tissue-engineered autologous ligament graft could be used in clinical situations where immune rejection and disease transmission may preclude allograft use.

A historical perspective and evolution of our knowledge on the cardinal ligament.

AIMS: The objective of our review is to provide a critical appraisal of the literature on the anatomy, structure and roles of cardinal ligaments (CL) in pelvic organ support, in conjunction with the currently evolving evidence based mainly on imaging and biomechanical modeling studies. We aim to contribute to the understanding of the pathophysiology of pelvic organ prolapse (POP) and stimulate new insights in research and development of novel surgical approaches for POP. METHODS: PubMed, Embase, Scopus-Elsevier, and Cochrane Databases were searched in English and German. Studies from 1870 to 2012 were identified. The keywords used were "cardinal ligament," "transverse cervical ligament," "Mackenrodt ligament," "parametrium," and "paracervix." Cross check and Google search of the reference lists were used for missing articles. RESULTS: We identified 35 related articles. Located at the base of the broad ligament, the CL is a supportive structure that attaches the cervix and upper vagina to the pelvic wall. The ligament contains the uterine vessels and hypogastric plexus. It conducts most of the pelvic loading forces. On MRI, it appears as a web-like structure around the axis of the internal iliac vessels. Their clinical importance is based on the apical supportive role and lymphatic-rich structure, involved in dissemination of cervical cancer. CONCLUSIONS: The structure and role of the CL have been long studied, but remained unclear. Recent studies on imaging and biomechanics have improved our understanding and provide new insights which may enable the development of new techniques in prolapse surgery.

Microvasculature of the suspensory ligament of the forelimb of horses.

OBJECTIVE: To determine the microvascular anatomy of the suspensory ligament of the forelimb of horses. SAMPLE: 17 cadaveric forelimbs from 9 adult horses with no known history of forelimb lameness. PROCEDURES: The median artery of the forelimb was cannulated proximal to the antebrachiocarpal joint and injected with contrast medium for CT evaluation of the gross vasculature (n = 2) or India ink to evaluate the microvasculature (12). Routine histologic evaluation was performed on an additional 3 forelimbs to confirm the microvascular anatomy. RESULTS: The vascular supply of the suspensory ligament of the forelimb originated from branches of the medial and lateral palmar and palmar metacarpal vessels as well as the proximal and distal deep palmar arches. An abundant, longitudinally oriented microvascular supply was evident throughout the length of the suspensory ligament without distinct variation among the proximal, midbody, and distal regions. The intraligamentous blood supply originated from a periligamentous vascular plexus that surrounded the suspensory ligament throughout its length. Histologic findings indicated the presence of a periligamentous connective tissue plexus, which contained vessels that penetrated and anastomosed with an extensive network of intraligamentous vessels throughout the length of the suspensory ligament. CONCLUSIONS AND CLINICAL RELEVANCE: The suspensory ligament of the equine forelimb had an abundant intraligamentous microvascular supply throughout its entire length. The absence of an obvious hypovascular area suggested that regional variations in healing rates of the suspensory ligament are not associated with the microvascular anatomy.

Pseudolesions on clinical imaging caused by Sappey veins: a dynamic contrast magnetic resonance and Doppler study.

AIM: This study aimed to investigate the anatomy and mechanism of pseudolesions around falciform ligament, which appeared on dynamic contrast magnetic resonance (MR) imaging. METHODS: A total of 30 cases were included in the normal control group (group 1), and 30 cases were enrolled into the liver cirrhosis group (group 2). All cases underwent MR examination including in-phase and out-phase T1-weighted image, T2-weighted fat-suppressed image, and dynamic MR imaging enhancement scanning. The MR images were analyzed to detect pseudolesions, and results from the 2 groups were compared. An ultrasound examination was also performed in all cases to assess the abdominal umbilical vein blood flow. RESULTS: In group 1, MR images detected pseudolesions in 13 cases, and signal reduction did not appear in out-phase MR images compared with in-phase MR images. In 5 of these cases, the umbilical vein was observed to be connected with the hepatic IV segment, and direction flow was toward hepatic during Doppler ultrasound examination. In the 30 patients with liver cirrhosis, pseudolesions were not detected in any of the cases, dilation of the vena epigastricas was observed in 12 cases, and flow direction was from liver. The difference in the incidence of falciform ligament pseudolesions between group 1 and group 2 was statistically significant (P > 0.01). CONCLUSIONS: Pseudolesions around the falciform ligament are associated with the Sappey vein, and there is no significant relationship with fatty infiltration.

Ex vivo pharmacology of surgical samples of the uterosacral ligament. Part II: Effects of oxytocin and relaxin on arteries and vascular plexus.

AIMS: The uterosacral ligament (USL) contains prominent vessels, the function of which is unknown. Here we study the relationship between smooth muscle of the USL and the vascular bundles. METHODS: Native samples of arteries and vascular bundles were mounted in a perfusion chamber under the stereomicroscope. The effects of noradrenalin, carbachol, oxytocin, and relaxin were monitored by digital time-lapse video and quantified by image processing. RESULTS: Arteries were adrenergic and the smooth muscle in the adventitia cholinergic. Relaxin-2 shifted the dose response curve of noradrenalin to the right and widened the arterial lumen within 30 min. Oxytocin induced contraction of the adventitial smooth muscle leading to a slow opening of the artery. In a vascular bundle the differential pattern of both reactivities was demonstrated. CONCLUSIONS: In the USL the smooth muscle extends into the adventitial layer of blood vessels and forms a functional unit with the vascular plexus, which is regulated by relaxin and oxytocin.

Classical and nerve-sparing radical hysterectomy: an evaluation of the nerve trauma in cardinal ligament.

OBJECTIVES: This study evaluated histopathology and clinical outcome of autonomic nerve trauma and vessels removal within the cardinal ligament (CL) during nerve-sparing radical hysterectomy (NSRH) compared with radical hysterectomy (RH). METHODS: 25 women with FIGO stage Ib1-IIa cervical cancer underwent RH (n=13) or NSRH (n=12). Removed CLs lengths were measured. Biopsies were collected from the proximal, middle and distal segment of CLs and fixed. Different markers were used for immunohistochemisty analysis: tyrosine hydroxylase for sympathetic nerves; vasoactive intestinal polypeptide for parasympathetic nerves; CD34 for blood vessels; and D2-40 for lymphatic vessels. The volume density (Vv), a parameter of biological stereology, was used to quantitatively measure CL components, while post-operative functions, such as defecation, micturition and two-year disease free survival in RH and NSRH groups were compared. RESULTS: The nerves mainly existed in the middle and distal segments of CLs. The Vv was greater in RH compared with NSRH for both sympathetic and parasympathetic nerve markers (P<0.05), while the Vv of blood and lymphatic vessels were same in the two groups. Average time to achieve residual urine≤50ml and first defecation were shorter in NSRH than in RH (P<0.05). CONCLUSIONS: Less autonomic nerves within CL are transected in NSRH than in RH, while blood/lymphatic vessels are efficiently removed in both treatments. Compared to RH, NSRH decreases iatrogenic injury, which leads to reduced post-operative co-morbidities, with ensure the same radicality.

Vascular architecture in anomalous right-sided ligamentum teres: three-dimensional analyses in 35 patients.

BACKGROUND: Right-sided ligamentum teres (RSLT) is a congenital anomaly that is sometimes encountered during hepatobiliary surgeries. However, a valid protocol for describing the segmental anatomy of livers with RSLT has not been established, and confusions or anatomic misunderstandings have been a major problem. METHODS: The vascular architecture and morphological characteristics were investigated in 35 livers with RSLT using three-dimensional (3D) simulations. RESULTS: Couinaud's four sectors and three hepatic veins were clearly distinguished in the liver with RSLT using 3D simulations. The ligamentum teres was connected with the right paramedian portal pedicle, and the long axis of the cystic fossa was always observed on the left of the ligamentum teres in all 35 livers. However, when the main portal scissura was visualized using 3D simulation, the gallbladder was always located on the border of either side of the hemilivers, and the malposition of the gallbladder was not confirmed. CONCLUSIONS: Although the right-sided components of the livers are well developed as a result of the right-dominant distribution of the feeding vessels in livers with RSLT, the basic segmental structure defined by the four sectors and the three hepatic veins are as well preserved as those in the typical liver anatomy.

Chronic mesenteric ischemia in a 26-year-old man: multivessel median arcuate ligament compression syndrome.

BACKGROUND: Chronic mesenteric ischemia (CMI) is a rare diagnosis for patients in their third decade of life. Other conditions can mimic the signs and symptoms of CMI, including median arcuate ligament syndrome (MALS), primary arteritides, and congenital anomalies. Here, we present the case of a 26-year-old man who presented with CMI and multivessel mesenteric occlusive disease. METHODS: A 26-year-old man presented with a 6-month history of 40-pound weight loss, postprandial abdominal pain, and food fear. His physical examination showed a scaphoid abdomen with no tenderness. Findings from laboratory evaluation were normal. Computed tomography angiogram revealed celiac artery (CA) occlusion and >80% superior mesenteric artery (SMA) stenosis, with a large marginal artery of Drummond supplying collateral circulation. RESULTS: A retroperitoneal exposure of the perivisceral aorta was performed. Surgical exposure revealed compression of both CA and SMA by the MAL. The total distance of caudal arterial displacement was >3 cm. Both the CA and SMA were chronically stenotic/occluded secondary to this compression. After division of the MAL, a retrograde aortoceliac and aortomesenteric bypass was performed for mesenteric revascularization. The patient recovered uneventfully and was discharged home on the third day after surgery tolerating a full diet. CONCLUSIONS: MALS is a pathologic entity that can affect more than the CA. This case demonstrates multivessel, mesenteric arterial insufficiency secondary to MALS sufficient to promote IMA collateralization of the SMA circulation. In young patients with CMI, multivessel MALS must be considered. In addition to MAL release, arterial revascularization may be necessary owing to stenoses from chronic compression.

Attachment sites of the coracoclavicular ligaments are characterized by fibrocartilage differentiation: a study on human cadaveric tissue.

We analyzed the immunohistochemical labeling patterns of the extracellular matrix of the coracoclavicular ligaments (CCL) in order to relate the molecular composition of the attachment sites to their mechanical environment. Ligaments were exposed from 12 fresh-frozen human cadaveric samples (four males, mean age: 48.6 ± 12.1 years). Cryosection of methanol-fixed and decalcified tissue was cut and sections were labeled with a panel of monoclonal antibodies directed against collagens, proteoglycans and proteins of vascular components. Attachment sites of both ligaments showed characteristic fibrocartilaginous labeling of collagen type II, aggrecan and link protein in all samples. Labeling for type II collagen was most conspicuous at the insertion of the coracoid process. Morphometry of adjacent samples revealed a fibrocartilage zone of 10-15% in relationship with the ligament proper, where labeling for type II collagen, aggrecan and link protein was negative. The presence of fibrocartilage at both entheses of the trapezoid and conoid ligament suggests that the CCL complex is subject to shear/compression forces. A variable fibrocartilage differentiation at the entheses of both ligaments may be related to the marked change in loading and insertion angle that the ligaments undergo during shoulder movement.