Intra-abdominal laparoscopic pudendal canal decompression - a feasibility study.

BACKGROUND: Pudendal canal syndrome (PCS) is induced by the compression or the stretching of the pudendal nerve within Alcock's canal. METHODS: Considering the difficulty and possible complications involved in exposing the pudendal canal and nerve by either transperineal, transgluteal or transischiorectal approaches, an intra-abdominal laparoscopic pudendal canal decompression (ILPCD) was employed. For this technique, 30 male adult human cadavers were examined. RESULTS: Measurements revealed an adequate working space in 16 (80%) of the 20 cadavers, while in four specimens the ischiococcygeus muscle was too large to be mobilized sufficiently. The mean working space was 24 mm with a range of 18 to 31 mm. It was considered that a working space of less than 20 mm would not be sufficient for manipulation of the instruments. With regards to pudendal nerve compression, it was observed that 7 (35%) of the 20 cadavers exhibited anatomic signs of PCS. In five (25%) specimens, the compression was observed between the sacrospinous and sacrotuberous ligaments, while the other two (10%) exhibited a broader compression, by the falciform portion of the sacrotuberous ligament. Under the guidance of a laparoscope, the peritoneum was cut laterally to the bladder, and fascia pelvis was identified. The latter was split and the internal iliac vein was traced to the opening of the pudendal canal allowing clear visualization of its contents. Subsequently, either the sacrospinous or sacrotuberous ligament was cut. CONCLUSIONS: Considering that none of the surgical procedures currently used are known to completely improve all the symptoms of PCS, ILPCD could theoretically reduce stretching of the pudendal nerve.

The clinical anatomy of the posterior gastric artery revisited.

A consensus concerning the incidence, course and distribution of the posterior gastric artery (PGA) has yet to be reached. Recent literature has explored and subsequently demonstrated the importance of the identification of this vessel in surgical procedures such as subtotal gastrectomy, splenectomy and pancreatic transplantation. The gross anatomy of the PGA was examined in 120 adult human cadavers. The PGA was identified as that artery which provided the predominant arterial supply to the posterior wall of the superior portion of the gastric body near the cardiac region and fundus. A PGA was identified in 81.6% of specimens. The most common origin of the PGA was from the left gastric artery (type I), occurring in 41.8% of specimens. In decreasing order of prevalence, were origins from the splenic artery (Type II), occurring in 25.5%; from both the left gastric and splenic arteries as double PGAs (Type III) in 22.4%; and from the celiac trunk (Type IV) occurring in 10.2%. The importance of accurate delineation of the PGA is crucial for pancreatic transplantation and gastric tumor removal. In addition, knowledge of variations in this vessel's origin could prove useful in transcatheter arterial embolization for the treatment of chronic bleeding from gastric ulcers. Furthermore, ligation of this vessel during partial gastrectomy, pancreaticoduodenectomy, and parietal cell vagotomy may result in gastric wall necrosis and gastric stump leak.

Multiple variations of the hepatobiliary vasculature including double cystic arteries, accessory left hepatic artery and hepatosplenic trunk: a case report.

Anatomical variations in the origins and branching patterns of the hepatobiliary arterial system may be encountered during both conventional surgical and laparoscopic cholecystectomy. We report a rare case of double cystic arteries arising from both the right hepatic artery and the proximal part of the posterior superior pancreaticoduodenal artery. Additional variations consisting of an accessory left hepatic artery arising from a left gastric which in turn arose from the descending aorta superior to the origin of the celiac trunk and a small left hepatic artery arising from the hepatic proper artery were also noted. The celiac trunk bifurcated into the splenic artery and the common hepatic artery forming a hepatosplenic or lienohepatic trunk. The possible clinical implications are discussed.

Benign anatomical mistakes: "ampulla of Vater" and "papilla of Vater".

The anatomy of the ampullary termination of the bile and pancreatic ducts is complex; appropriate terminology for this area is confusing and inaccurate. We examine the terms "ampulla of Vater" and "papilla of Vater" for anatomical and historical correctness. The term "ampulla" refers to a dilated part of a duct or other channel. Thus, this word is topographically correct to describe the dilatation at the confluence of the bile and main pancreatic ducts; historically, however, there is considerable reason to believe that its first description was by Santorini rather than Vater. The eponymous term "papilla of Vater" is also incorrect historically. The use of eponyms is firmly entrenched in the medical literature, but some are so problematic that they should be discarded. The eponymous terms for both the ampulla and the papilla should be replaced with the terms "hepatopancreatic ampulla" (or "biliaropancreatic ampulla") and "major [or "greater"] duodenal papilla," respectively.

The history of anatomy and surgery of the preperitoneal space.

Preperitoneal (properitoneal) space is the space between the peritoneum and transversalis fascia. Bogros (1786-1825) described a triangular space in the iliac region between the iliac fascia, transversalis fascia, and parietal peritoneum. In the modern concept, this space lies between the peritoneum and posterior lamina of the transversalis fascia. In 1858, Retzius described the homonymous space, situated anterior and lateral to the urinary bladder (prevesical space). In 1975, Fowler reported that the preperitoneal fascia of the groin is distinct from the transversalis fascia. Preperitoneal herniorrhaphy may be subdivided into 2 approaches: transperitoneal and inguinal. We present herein the evolution of approaches to the preperitoneal space from use of the transperitoneal (or posterior) to use of the anterior preperitoneal and posterior preperitoneal approaches. As anatomic knowledge has increased, the evolution of laparoscopic surgery has paralleled that of open procedures.

Absence of the left inferior thyroid artery: clinical implications.

Dissection of an adult male cadaver revealed an absence of the left inferior thyroid artery; its usual area of distribution to the thyroid gland was supplied by the right inferior thyroid artery. Absence of the left inferior thyroid artery occurs in 1-6% of cases. The inferior thyroid artery arises commonly from the thyrocervical trunk, passes posterior to the carotid sheath and supplies the inferior pole of the corresponding lobe of the thyroid gland; its branches can course anterior or posterior to or between branches of the recurrent laryngeal nerve. During thyroid surgery it is imperative to identify the relationship of the inferior thyroid artery to the recurrent laryngeal nerve or to establish its absence because injury to the nerve can be a major complication; awareness of significant variations of the surgical anatomy of the thyroid gland is vital for preserving the integrity of important structures.