[Symptomatic lumbar incisional hernia after open nephrectomy: What are the risk factors?]. / Éventrations lombaires symptomatiques après néphrectomies par lombotomie: quels sont les facteurs de risque?

OBJECTIVE: Lumbar incisional hernias after open nephrectomy are rare but can lead to aesthetic disorder, discomfort or intestinal obstruction. The aim of the study is to highlight their risk factors. PATIENTS AND METHODS: The characteristics of patients who suffered from symptomatic and surgically treated lumbar incisionnal hernia after open nephrectomy (study group "GE") were compared to those of patients who underwent open nephrectomy without postoperative incisional hernia (control group "GT") using the Student's t test and Mann-Whitney test (statistical significance P value<0.05). GT patients were randomly selected with a 1/4 ratio (1 lumbar incisionnal hernia vs 4 controls). RESULTS: From 2004 to 2014, 417 open nephrectomies were performed in one university hospital. Forty-five patients were included: 9 in GE and 36 in GT. There was no statistically significant difference between GT and GE for weight, height, body mass index (BMI), emergency, partial nephrectomy, laterality, rib resection, laparoscopic conversion to open surgery, postoperative complications, smoking, diabetes mellitus, cardiovascular history, obesity and sex, but there was a statistically significant difference for age, operative time, chronic obstructive pulmonary disease (COPD) and severe obesity (BMI>35) with, respectively, P=0.05, P=0.02, P=0.04 and P=0.02. CONCLUSION: Risk factors for lumbar incisional hernia after open nephrectomy are age, operative time, severe obesity and COPD. LEVEL OF EVIDENCE: 5.

[Systematization of proper lymphatic vessels of the diaphragm]. / Systematisation des voies lymphatiques propres du diaphragme.

The aim of this study was to demonstrate lymphatic vessels of the diaphragm, its connexions with mediastinum and abdominal cavity in order to better understand propagation of neoplasic or infectious processes. Diaphragmatic pleura of 30 adult cadavers and 12 fetuses, unscathed of any cardiopulmonary pathology, were injected with modified Gerota's medium to permit lymph vessels and nodes to be visualized and then dissected. Each stage of dissection was described and photographed. Diaphragmatic lymph vessels, their connexions with diaphragmatic lymph nodes, mediastinum and abdominal cavity have been so demonstrated. Diaphragm appear to be a very important lymphatic center, with its own lymphatic vessels, with connexions to the mediastinum and abdominal cavity. The propagation of infectious or neoplasic processes are so better understood.

An anatomical study of the vestibulocochlear anastomosis (anastomosis of Oort) in humans: preliminary results.

Von Oort first described the vestibulocochlear anastomosis in 1918, and there have been very few anatomical studies of it. It is located at the bottom of the internal auditory meatus and links the saccular nerve to the cochlear nerve. The aim of this study was to investigate the micro-anatomical characteristics of this anastomosis. We dissected 10 human temporal bones from five heads. We found the vestibulocochlear anastomosis in seven of the specimens, of which six were clearly visible. We were unable to uncover it in three specimens due to dissection problems. Its length was evaluated to be between 0.5 and 1 mm, with a diameter of 0.5 mm. The vestibulocochlear anastomosis could be the pathway for the nerve fibers of the cochlear efferent system, whose description remains incomplete. However, no anatomist, histologist or physiologist has demonstrated this function. From the results of this study, it seems likely that the vestibulocochlear anastomosis exists. Other studies are necessary to link it to the efferent system.

[Fistula between Wirsung and psoas muscle]. / Fistule wirsungopsoïque. A propos d'un cas.

We describe a rare case of fistula between the Wirsung duct and the right psoas muscle. The initial clinical presentation was localised in the thigh and successful treatment was achieved by exclusive mini-invasive techniques.

[Fundamentals of the anatomy of oculomotor behavior]. / Les bases anatomiques de l'oculomotricité.

The oculomotricity rests on complex anatomo-physiological bases and allows the binocular vision, which is a sensory function very completed in the human. After a short embryologic recall, the binocular vision is defined. The anatomical structures, which take part in the binocularity, are reviewed within three functional stages: an effector peripheral stage (eye ball, extrinsic muscles and their nerves), a sub cortical central stage, generator of the movements (oculomotor nuclei, reticularis formation...), and a central, cortical and subcortical stage, incitator of the movements (cortical areas, vestibular nuclei, cerebellum...). These anatomical bases make it possible to understand the many disorders observed in pathology.

Lymphatic drainage of the diaphragmatic pleura to the peritracheobronchial lymph nodes.

Non-small cell lung cancer invading the visceral pleura is characterized by a particular richness of mediastinal lymph node (LN) metastases. This may be due to subpleural lymphatic drainage of tumor cells. The aim of this study was to determine mediastinal LN lymphatic drainage from the diaphragmatic pleura. Subpleural lymphatics of 30 adult cadavers and 12 fetuses were injected with a modified Gerota's medium to permit lymph vessels and nodes to be visualized and then dissected. Each stage of the dissection was described and photographed. In 32 cadavers mediastinal visceral LN chains were injected, of which 29 originated from the mediolateral portion of the diaphragm. On the right, injections (n=16) demonstrated lymph vessels (n=20) ascending directly along the inferior pulmonary ligaments (n=8) or after having encircled the inferior vena cava (n=8), and lymph vessels passing between the pulmonary veins (n=4); all these lymphatics were connected to the intertracheobronchial nodes and some ascended along the tracheobronchial LN chains in the upper mediastinum. On the left, injections (n=13) demonstrated lymph vessels (n=16) ascending along the inferior pulmonary ligament (n=5) or along the esophagus (n=11) and connecting to the intertracheobronchial nodes, some of which ascended further in the upper mediastinum (left paratracheobronchial LN chain). These mediastinal LN chains are the same as those that receive lymph from the pulmonary segments. Lymphatic drainage of the diaphragmatic pleura may add to that of the lung involved in cancer and potentially increases lymphatic spread of tumor cells.

[Identification of recurrent inferior laryngeal nerve during a thyroid lobectomy]. / La recherche du nerf laryngé inférieur ou récurrent lors d'une lobectomie thyroïdienne.

Based an their findings during thyroid operations and pathological examination of 100 specimens, the authors report the principal steps for identification and dissection of recurrent nerve during a thyroid lobectomy.

[Laparoscopic diagnosis of stenosing eosinophilic jejuno-ileitis]. / Diagnostic coelioscopique d'une jéjuno-iléite sténosante à éosinophiles.

INTRODUCTION: Eosinophilic gastroenteritis of unknown origin could be isolated or integrated in idiopathic hypereosinophilic syndrome. Clinical expression is variable since the lesion may affect any area of the gastrointestinal tract and any layer of the wall. EXEGESIS: A 25-year-old male patient had digestive symptoms such as peritoneal, obstructive and diarrheal signs, associated with blood eosinophilia, giving evidence for eosinophilic jejuno-ileitis. Computer tomography revealed an extensive obstruction of the jejuno-ileum and thickening of the intestinal wall. The diagnosis was obtained using laparoscopy and controlled wedge biopsy, which showed a predominantly external infiltration of the intestinal wall by eosinophils. The disease evolution was favorable with corticosteroid therapy. CONCLUSION: Worrying and persistent digestive symptomatology, associated with blood eosinophilia, particularly when intestinal wall infiltration is revealed by computer tomography, should lead one to perform a laparoscopy to guide a surgical biopsy of the intestinal wall.

[Arterial blood supply and innervation of the rectus muscles of the eyeball]. / Vascularisation artérielle et innervation des muscles droits du bulbe de l'oeil.

UNLABELLED: The authors report on the arterial blood supply and the innervation of the rectus muscles of the eyeball from human orbital dissections. MATERIAL AND METHODS: Hundred human orbits were dissected using a superior approach after arterial injection with colored latex. The different arterial pedicles for each muscle were noted and the nervous supply was studied. RESULTS: The arterial blood supply of the rectus muscles comes from different branches of the ophthalmic artery, usually the inferior muscular artery, the lacrimal artery, the superior muscular artery when it exists, and by small branches arising from the ophthalmic artery. The superior rectus is supplied by branches of the ophthalmic artery and the lacrimal artery (1 to 5 pedicles). The medial rectus is supplied by branches of the ophthalmic artery and the inferior muscular artery (5 to 9 branches). The inferior muscle rectus is principally supplied by the inferior muscular artery (4 pedicles) and the lateral muscle is supplied by the lacrimal artery or the lateral muscular artery (3 to 6 branches). For innervation, the abducens nerve supplies the lateral rectus; the other muscles are supplied by the oculomotor nerve whose superior branch supplies the superior rectus and whose inferior branch, supplies the inferior and medial rectus. DISCUSSION: The arterial blood supply is variable. The arteries which lie near the rectus muscles usually supply one or more branches to the muscles. The arteries go into the muscles through their conal side. This arterial supply is at the posterior part of the muscle. Innervation, in contrast, is very constant and fixed. CONCLUSION: The arterial blood supply to the rectus muscles is variable but always substantial. The pedicles are numerous, often 3 to 5 for each muscle. Innervation is fixed and constant.

The inguinofemoral area from a laparoscopic standpoint. History, anatomy, and surgical applications.

No significant difference has been found between early and new diagrams of the posterior anatomy of the inguinofemoral area from a laparoscopic standpoint because anatomy is unique to each individual. But new dangers can arise from new approaches, even if the anatomic structures are well known, so anatomic research is still useful. It provides, relative to new surgical techniques, new vision of structures known for centuries.

The inguinal rings.

The inguinofemoral area constitutes the frontier between the abdomen and the lower limb. Because of the human standing position, the inguinal region is a zone supporting the abdominal thrust, and is weakened by the orifice of the inguinal and femoral passages. Peritoneal diverticula may externalize into these orifices, leading to the formation of hernias. This article reviews the anatomic constituents of the inguinofemoral region and the anatomic basis for the treatment of hernias.

Ampulla of Vater. Anatomic, embryologic, and surgical aspects.

The region of the ampulla of Vater constitutes a complex anatomic and functional entity, the biliopancreaticoduodenal confluence, of which the essentials of this rapid review are the: Variation in site of implantation of the greater duodenal papilla, whereas the relations between the common bile duct and the main pancreatic duct are relatively constant Presence at this site of a weak point in the duodenal wall, commonly the site of mucosal diverticula Interdependence of the parietal duodenal mucosa and the sphincteric system of Oddi Existence of an extramural zone of this sphincter, which should be the only one involved in sphincterotomy Danger of wide excisions of the papilla, which, apart from the risk for hemorrhage, cause a breach of the digestive barrier The ampulla of Vater corresponds to the dilated junction of the common bile duct and main pancreatic duct, if present. The ampulla is an extensive anatomic and functional region that includes not only the choledochopancreatic junction but also the sphincter of Oddi, the whole traversing the duodenal wall to open at the greater duodenal papilla. The chief anatomic features of this biliopancreaticoduodenal junction have been reviewed, forming the basis of techniques of surgical or endoscopic sphincterotomies and localized excisions of vaterian tumors.

Functional anatomy of the gastroesophageal junction.

The study of the functional anatomy of the gastroesophageal junction allows for the demonstration of a double mechanism that combats the conflict of pressures that tends to lead to gastroesophageal reflux. On one hand, the LES, an intrinsic structure, is directly related to the muscle fibers of the organ and responds to a neurohormonal physiologic command. On the other hand is an anatomic entity, centered by the crura of the diaphragm, closely related to the movements of respiration. These structures constitute a second, extrinsic sphincter that gives rise to the zone of high pressure in the terminal esophagus. This role is difficult to assess, and its importance is underestimated. The proper functioning of these two mechanisms implies that the gastroesophageal junction remains in place within the diaphragmatic channel of the esophagus. Also important are the postural phenomena associated with the sloping position of the fundus. In patients with gastroesophageal reflux, the decrease of the pressure measured in the terminal esophagus accounts for the occurrence of reflux. Investigators concede that, under the influence of abdominal straining, the gastroesophageal junction tends to ascend into the diaphragmatic channel. The results are twofold: (1) the muscle fibers of the lower esophagus relax, explaining the incompetence of the intrinsic sphincter, and (2) the sphincteric zone is withdrawn from its muscular diaphragmatic environment. Physicians should consider these structures as a whole in approaching the surgical treatment of reflux. The construction of a periesophageal valve has no anatomophysiologic basis. A gastropexy procedure must be added to replace the gastroesophageal junction in its anatomic setting and keep it there. This procedure also allows retightening of the muscle fibers of the esophageal wall, which is essential in long-term surgical correction.

Anatomic basis of hepatic surgery.

Modern hepatic surgery is based on precise anatomic foundations. The importance of this information applies to all levels of the diagnostic and therapeutic chain. Modern methods of imaging--CT scanning, MR imaging, and preoperative sonography--help physicians to detect variations and plan surgical excision.

Surgical anatomy and embryology of the adrenal glands.

Gross anatomy explains the different surgical approaches to adrenalectomy and the difficulties encountered by surgeons during this procedure. Development of the adrenal glands explains the location of the ectopic sites and excess hormone production by adrenal tumors. The choice of a surgical approach is sometimes difficult and is dependent on (1) the morphology of the body; (2) the volume of the tumor, which necessitates immediate vascular control; and (3) the type of disease, which may necessitate a complete exploration of the abdominal cavity.

[Rectal leiomyosarcoma. 4 new cases]. / Léiomyosarcome du rectum. Quatre nouvelles observations.

We report four cases of leiomyosarcoma of the rectum suspected by endoscopic ultrasonography. Three patients were treated by local excision and one by abdominoperineal resection. An excision of the mass via a Kraske's approach was used. Leiomyosarcoma confined to the rectum wall can be treated by local excision. Endosonography can provide exact estimation of the lesion and is of great value in selecting the appropriate treatment. The treatment is surgical excision with wide margins. The histological stage and the presence or absence of metastases determine the therapeutic. Two patients in our series underwent radiation therapy. Chemotherapeutic agents including doxorubicin have had beneficial effect on recurrence or survival, only for higher grade sarcomas.

Right nonrecurrent inferior laryngeal nerve and arteria lusoria: the diagnostic and therapeutic implications of an anatomic anomaly. Review of 17 cases.

The authors report 17 cases of a right non-recurrent inferior laryngeal n. (NRILN) observed during 15 years of practice of thyroid and parathyroid surgery. In their last two cases, the existence of an aberrant right subclavian a., constantly associated with NRILN, was confirmed by MRI angiography. On the basis of the literature and their own experience, the authors review the incidence of this double anomaly, its embryologic explanation and its anatomic and surgical importance. They stress the diagnostic factors and the therapeutic implications, very different in children and adults, of a particular vascular anomaly whose outcome is little understood.

Neonatal hip: from anatomy to cost-effective sonography.

Therapeutic success in treating congenital dysplasia of the hip is associated with early diagnosis, but the specific neonatal anatomy makes screening difficult. The purpose of this study was to determine whether this specific neonatal anatomy is taken into account by current ultrasound (US) techniques. Anatomic studies were performed on 22 hips, US examinations on 7750 neonatal hips; 2370 untreated hips were reexamined at 1 month by US and at 3 months by X-ray. The transformation of the neonatal cartilaginous acetabulum into an osseous cavity is dependent on harmonious metaphyseal growth and a properly seated femoral head. Defects in the acetabular roof, together with displacement of the femoral head, cause an abnormal anatomical relationship which leads to further deformities. The described sonographic techniques give only partial information on these specific abnormalities. The sonographic monoplanar methods as used in Graf's technique, which relies largely on acetabular development, lead to difficulties in assessing posterior coverage of the femoral head and difficulties in assessing alignment of the metaphyseal weight-bearing surface with the femoral head. Combining Graf's morphological analysis with Novick's dynamic technique enables one to more accurately define the relationship of the femoral head and the acetabulum and increases the reliability and predictive value of the examination, while reducing the number of doubtful cases. This makes screening cost effective.