Thiel embalming in neonates: methodology and benefits in medical training.

Current teaching and training methods for surgical techniques in the pediatric population involve artificial models (manikins), animals or adult human cadavers embalmed using various techniques. We found no references in the literature concerning the use of the Thiel method in the pediatric population. The aim of this study, therefore, was to assess the viability of using pediatric human cadavers embalmed through Thiel's technique and to compare them with standard pediatric manikins. After donation of a 24-week stillborn, the Thiel technique was carried out for fixation following the usual protocol. A video recording with eye-tracking glasses was used to perform an examination, and techniques. The same procedures were conducted on a pediatric manikin. Medical students, medical residents and physicians were asked to respond to questions in an online survey after being shown the video. A total of 92 responses were obtained. The Thiel-embalmed stillborn was assessed as superior to the manikin in all items. Our study confirmed that this technique is feasible even with extremely small donors. The value of this form of preservation for medical training is not widely known though it is receiving increasing interest. Our results show that Thiel fixation in pediatrics is clearly more highly valued than a manikin and offers great potential. This innovative application of the Thiel method in the pediatric population is technically possible. It poses no additional difficulties and is very positively assessed for undergraduate and postgraduate teaching.

Phonosurgery Training in Human Larynx Preserved with Thiel's Embalming Method.

BACKGROUND: To describe the suitability of larynges preserved with Thiel's embalming method for phonosurgery training. METHODS: A training model for phonosurgery techniques simulating vocal pathology and glottal insufficiency is developed to compare and evaluate the perception of embalmed vocal cords through a voluntary and anonymous survey rated on a scale of 1-5. A total of 10 residents and young otolaryngologists participated in the surgical training in phonosurgery. RESULTS: Ten larynges preserved in formalin and 10 Thiel's embalmed larynges were used for the investigation. Phonosurgery procedures were performed following microflap and injection laryngoplasty techniques. The larynges preserved with Thiel's method demonstrated vocal cords that maintain their pliability and good tissue quality allowing a sensation of realism compared to the living body and providing suitable conditions for realistic laryngeal training. Participants held a positive experience, believed them to be useful and that these models of embalmed larynges were similar to the clinical setting and improved skills and confidence in performing phonosurgery. CONCLUSIONS: The human larynges embalmed with Thiel's method maintain the pliability of the vocal cords, thus representing a unique model to practice and reproduce training for endolaryngeal procedures without the risks of contamination, anatomical variation, or rigidity of other models.

Could Training in an Anatomical Model Be Useful to Teach Different Neovagina Surgical Techniques? A Descriptive Study about Knowledge and Experience of Techniques for Neovagina Surgery.

Neovagina surgery in patients with vaginal agenesis is rare. No consensus exists regarding the best surgical technique. The aims of the current study were to show a new Thiel-embalmed cadaveric model to teach the surgical steps for different techniques of neovagina surgery and to evaluate opinions of this surgical teaching procedure. Four techniques-modified McIndoe, Vecchietti, Davydov, and vulvoperineal pediculated flaps-were recorded using an external camera and/or laparoscopic vision during their execution in a dissection room on "feminized" male cadavers. To determine the opinion of this teaching model, we designed an anonymous online survey that was available to participants via a computer application. After watching the video, more than 92% of participants agreed that feminized male cadavers were an excellent procedure for teaching these surgical techniques. Before watching this video, the most employed techniques were the McIndoe and Vecchietti procedures. After watching the video, modified McIndoe and vulvoperineal flaps were preferred by participants because they were considered to be easier to perform. It was considered that this model was useful for training neovagina techniques and, moreover, it should be recommended before techniques were performed on a real patient. Further investigation is needed to validate this model.

Can the simultaneous laparoscopic approach improve the learning of vaginal surgery with meshes in the anatomical model?

AIMS: To evaluate the usefulness of simultaneous laparoscopic assistance to improve understanding of the nonvisible surgical steps in Thiel-embalmed cadaver models for training in vaginal surgery using vaginal mesh kits and to evaluate opinions of this surgical learning procedure in comparison with other learning models. METHODS: Recording of anterior compartment prolapse repair with vaginal mesh kits using an external camera simultaneously with laparoscopic vision during the execution of the procedure at the dissection room. To measure the usefulness of this procedure, we designed an anonymous online survey that was made available to program participants via a computer application (a link to video 1 and the survey is available at encuesta@um.es). RESULTS: After watching the video, 97.2% of participants agreed that laparoscopic vision combined with the vaginal approach was useful in learning this surgical technique, and 95.8% agreed they had learned details of the surgical anatomy of the pelvis. All participants agreed that it should be mandatory to train in these techniques with cadavers before practice with live patients. In addition, 84.7% responded that the cadaveric model was superior to animal and other types of models. CONCLUSION: Laparoscopic inspection of the procedure performed with the vaginal approach allowed a better understanding of the surgical technique by making "visible" the anatomical structures that were commonly only palpated. Use of the cadaverous model was considered most efficient for training in this surgical technique.

Homo sapiens, Chimpanzees and the Enigma of Language.

OBJECTIVES: The present study explores the hypothesis that the anatomical bone structures of the oral cavity have probably evolved under the influence of language function. The possible changes have been evaluated by comparing two close species essentially differentiated from each other by spoken language. MATERIALS AND METHODS: Twenty dry skulls and 20 mandibles of modern Caucasians were compared with 12 dry skulls and 12 mandibles of chimpanzees, with the analysis of 37 variables and the definition of new anatomical parameters. RESULTS: A number of highly significant differences were found between humans and chimpanzees. The human temporomandibular joint is comparatively less flat and has a more limited excursive movement range, with structural elements that seem to be lighter. A significant difference is noted in mandibular alveolar vergency and in the internal slope of the mandibular symphysis where the oral cavity's morphology is modified, thereby increasing the free space for tongue movements in humans. The chin, which is unique to the human species, is quantified through the external slope of the mandibular symphysis with a lesser angle in humans. DISCUSSION: It is obvious that there are differences between humans and chimpanzees in the bone morphology of the oral cavity structures. This has been confirmed with the analysis of new variables. Together with other factors (bipedalism, habits, and genetics) speech in humans must have played an important role in the aforementioned differences between humans and chimpanzees. The number of mandibular movements involved in speech is far greater than those used in chewing, which must have conditioned the evolution of the oral structures implicated in the development of language. On average, humans weigh 70 kg and chimpanzees 44 kg. However, the majority of the variables studied in skulls and mandibles are greater in chimpanzees, which suggests that the evolution of the oral zone in humans has suffered a reduction in size with changes in shape. The refinement of the supralaryngeal vocal tract in the human species must have co-evolved with speech fairly recently. The human skull has temporomandibular joints that are comparatively less flat with a more limited movement. There is a greater lingual space and there is also a chin that suggests a muscular stimulant. This leads to the conclusion that, at least in part, speech is behind all these changes, although it is difficult to establish a cause-effect relationship.

Variations in clinical presentation of unicornuate uterus with non-communicating rudimentary horn (class IIB of the American Fertility Society classification).

OBJECTIVE: The unicornuate uterus is a rare uterine malformation (2.4-13.7% of all uterine malformations (Engmann et al., 2004)) which usually features a rudimentary accessory horn in more than 75% of the cases. Pregnancy in the rudimentary horn is rare, but the complications attached to such pregnancies could be defined as the first clinical manifestation of rudimentary horn. CASE REPORTS: We hereby describe five cases of unicornuate uterus with rudimentary horn (UUWRH), each one with a different clinical presentation and without any correct preoperative diagnosis, and henceforth reflect on the practical aspects learnt about the differential diagnosis and management of this rare malformation. CONCLUSION: Our experience with UUWRH is that perhaps asymptomatic cases are not as rare as reported in medical literature. We highlight the need for a greater awareness of the differential diagnosis of genital malformations and accurate in the exact subtype and their correct treatment.

Use of Eye Tracking as an Innovative Instructional Method in Surgical Human Anatomy.

OBJECTIVE: Tobii glasses can record corneal infrared light reflection to track pupil position and to map gaze focusing in the video recording. Eye tracking has been proposed for use in training and coaching as a visually guided control interface. The aim of our study was to test the potential use of these glasses in various situations: explanations of anatomical structures on tablet-type electronic devices, explanations of anatomical models and dissected cadavers, and during the prosection thereof. An additional aim of the study was to test the use of the glasses during laparoscopies performed on Thiel-embalmed cadavers (that allows pneumoinsufflation and exact reproduction of the laparoscopic surgical technique). The device was also tried out in actual surgery (both laparoscopy and open surgery). DESIGN: We performed a pilot study using the Tobii glasses. SETTING: Dissection room at our School of Medicine and in the operating room at our Hospital. PARTICIPANTS: To evaluate usefulness, a survey was designed for use among students, instructors, and practicing physicians. RESULTS: The results were satisfactory, with the usefulness of this tool supported by more than 80% positive responses to most questions. There was no inconvenience for surgeons and that patient safety was ensured in the real laparoscopy. CONCLUSION: To our knowledge, this is the first publication to demonstrate the usefulness of eye tracking in practical instruction of human anatomy, as well as in teaching clinical anatomy and surgical techniques in the dissection and operating rooms.

Estudio básico e implicaciones clínicas del falso tendón del ventrículo izquierdo. ¿Está asociado al soplo inocente infantil o a enfermedad cardiaca? / Basic study and clinical implications of left ventricular false tendon. Is it associated with innocent murmur in children or heart disease?

Introducción y objetivos. El falso tendón del ventrículo izquierdo es una estructura descrita anatómicamente por Turner. Se desconoce su función dentro de la fisiología cardiaca. Se ha postulado, sin alcanzar consenso, su relación con diversas alteraciones eléctricas o funcionales. El objetivo es conocer cuándo aparece, su prevalencia, su composición histológica y su asociación con el soplo inocente infantil o con enfermedad cardiaca. Métodos. La investigación básica se realizó por la disección anatómica en cadáveres de corazones humanos adultos para describir el falso tendón y su histología. La investigación clínica se realizó en población pediátrica mediante ecocardiografía y se analizó su relación con cardiopatía, el soplo inocente infantil u otras alteraciones. Prenatalmente se realizaron ecocardiografías fetales a diferentes edades gestacionales. Resultados. La presencia del falso tendón es la norma en la disección cardiaca, y está constituido por fibras de tejido muscular y conectivo. En la población pediátrica, la presencia ecocardiográfica del falso tendón fue del 83%, y solo mostró relación estadísticamente significativa con el soplo inocente infantil y una menor aceleración de la aorta. Por ecocardiografía fetal, se objetivó su presencia desde al menos la semana 20 de gestación. Conclusiones. El falso tendón del ventrículo izquierdo es una normalidad clínica visible por ecocardiografia fetal ya desde la semana 20, con presencia hasta la edad adulta sin relación con enfermedad, únicamente con la presencia de soplo inocente en edad pediátrica; queda por determinar si es la causa del soplo y si es su ausencia o anomalías estructurales lo que se relaciona con enfermedad (AU)

Introduction and objectives. Left ventricular false tendon is a structure of unknown function in cardiac physiology that was first described anatomically by Turner. This condition may be related to various electrical or functional abnormalities, but no consensus has ever been reached. The purpose of this study was to determine the time of appearance, prevalence and histologic composition of false tendon, as well as its association with innocent murmur in children and with heart disease. Methods. The basic research was performed by anatomic dissection of hearts from adult human cadavers to describe false tendon and its histology. The clinical research consisted of echocardiographic study in a pediatric population to identify any relationship with heart disease, innocent murmur in children, or other abnormalities. Fetal echocardiography was performed prenatally at different gestational ages. Results. False tendon was a normal finding in cardiac dissection and was composed of muscle and connective tissue fibers. In the pediatric population, false tendon was present in 83% on echocardiography and showed a statistically significant association only with innocent murmur in children and slower aortic acceleration. The presence of false tendon was first observed on fetal echocardiography from week 20 of pregnancy. Conclusions. Left ventricular false tendon is a normal finding visualized by fetal echocardiography from week 20 and is present until adulthood with no pathologic effects except for innocent murmur during childhood. It remains to be determined if false tendon is the cause of the murmurs or if its absence or structural anomalies are related to disease (AU)

Basic Study and Clinical Implications of Left Ventricular False Tendon. Is it Associated With Innocent Murmur in Children or Heart Disease?

INTRODUCTION AND OBJECTIVES: Left ventricular false tendon is a structure of unknown function in cardiac physiology that was first described anatomically by Turner. This condition may be related to various electrical or functional abnormalities, but no consensus has ever been reached. The purpose of this study was to determine the time of appearance, prevalence and histologic composition of false tendon, as well as its association with innocent murmur in children and with heart disease. METHODS: The basic research was performed by anatomic dissection of hearts from adult human cadavers to describe false tendon and its histology. The clinical research consisted of echocardiographic study in a pediatric population to identify any relationship with heart disease, innocent murmur in children, or other abnormalities. Fetal echocardiography was performed prenatally at different gestational ages. RESULTS: False tendon was a normal finding in cardiac dissection and was composed of muscle and connective tissue fibers. In the pediatric population, false tendon was present in 83% on echocardiography and showed a statistically significant association only with innocent murmur in children and slower aortic acceleration. The presence of false tendon was first observed on fetal echocardiography from week 20 of pregnancy. CONCLUSIONS: Left ventricular false tendon is a normal finding visualized by fetal echocardiography from week 20 and is present until adulthood with no pathologic effects except for innocent murmur during childhood. It remains to be determined if false tendon is the cause of the murmurs or if its absence or structural anomalies are related to disease.

Colgajos pediculados procedentes de la arteria esfenopalatina: estudio anatómico y quirúrgico / Pedicle flaps based on the sphenopalatine artery: Anatomical and surgical study

Introducción: Los colgajos locales pediculados a la arteria esfenopalatina permiten reconstruir amplios defectos de la base del cráneo (BC). Material y métodos: De enero de 2008 a enero de 2013 se analizaron 64 lesiones con afectación de la BC intervenidos con un abordaje endonasal endoscópico que requirieron una reconstrucción con colgajos locales pediculados a la arteria esfenopalatina. Adicionalmente se estudiaron cuatro fosas nasales correspondientes a dos cabezas de cadáver donde se analizaron endoscópicamente las medidas y la flexibilidad de cada uno de los colgajos. Resultados: Grupo quirúrgico. Se emplearon 64 colgajos nasoseptales (CNS), en cuatro casos asociados a un colgajo cornete medio (CCM) y en un caso complementado con un colgajo del cornete inferior (CCI). Se evidenciaron 5 fístulas postquirúrgicas (8%). Un 7% de los pacientes con lesiones iniciales presentaron una anosmia definitiva. Disección anatómica. La longitud del CNS varió entre 5,2 cm y 7,7 cm oscilando la anchura entre 3 cm y 4,5 cm. El CCI presentó una distancia anteroposterior entre 4,2 cm y 5 cm y una anchura entre 1,2 cm y 2,8 cm. La longitud media del CCM varió entre 3,5 cm y 4,2 cm con una anchura entre 1,4 cm y 1,9 cm. Conclusión: El CNS es el colgajo local que presenta una mejor versatilidad en el sellado de los defectos craneales, siendo los colgajos pediculados a la arteria nasal posterolateral una excelente alternativa (AU)

Introduction: Local pedicle flaps based on the sphenopalatine artery make it possible to reconstruct large defects of the skull base (SB). Material and methods: From January 2008 to January 2013, 64 lesions with involvement of SB were analysed. These lesions were treated using endoscopic endonasal approach and required a pedicle flap based on the sphenopalatine artery. In addition, measurements and flexibility of the flaps were examined in 4 cadaveric nasal cavities. Results: Surgical group. Sixty-four nasoseptal flaps (NSF) were used, in 4 cases associated with a middle turbinate flap (MTF), and in 1 case supplemented with an inferior turbinate flap (ITF). Five cerebrospinal fluid fistulas (8%) were noted. Among patients with initial lesions, 7% presented an anosmia. Cadaveric group. The length of the NSF varied between 5.2 cm and 7.7 cm and the width ranged from 3 cm to 4.5 cm. The ITF provided an anterior-posterior distance between 4.2 cm and 5 cm, with a width between 1.2 cm and 2.8 cm. The mean length of MTFs varied between 3.5 cm and 4.2 cm, with a width between 1.4 cm and 1.9 cm. Conclusion: The most versatile local flap for the reconstruction of skull base defects is the NSF, and flaps pedicled to the posterolateral nasal artery offer an excellent alternative (AU)

[Pedicle flaps based on the sphenopalatine artery: anatomical and surgical study]. / Colgajos pediculados procedentes de la arteria esfenopalatina: estudio anatómico y quirúrgico.

INTRODUCTION: Local pedicle flaps based on the sphenopalatine artery make it possible to reconstruct large defects of the skull base (SB). MATERIAL AND METHODS: From January 2008 to January 2013, 64 lesions with involvement of SB were analysed. These lesions were treated using endoscopic endonasal approach and required a pedicle flap based on the sphenopalatine artery. In addition, measurements and flexibility of the flaps were examined in 4 cadaveric nasal cavities. RESULTS: Surgical group. Sixty-four nasoseptal flaps (NSF) were used, in 4 cases associated with a middle turbinate flap (MTF), and in 1 case supplemented with an inferior turbinate flap (ITF). Five cerebrospinal fluid fistulas (8%) were noted. Among patients with initial lesions, 7% presented an anosmia. Cadaveric group. The length of the NSF varied between 5.2 cm and 7.7 cm and the width ranged from 3 cm to 4.5 cm. The ITF provided an anterior-posterior distance between 4.2 cm and 5 cm, with a width between 1.2 cm and 2.8 cm. The mean length of MTFs varied between 3.5 cm and 4.2 cm, with a width between 1.4 cm and 1.9 cm. CONCLUSION: The most versatile local flap for the reconstruction of skull base defects is the NSF, and flaps pedicled to the posterolateral nasal artery offer an excellent alternative.

Anatomía radiológica de las arterias etmoidales: estudio por TC en cadáver / Radiological anatomy of the ethmoidal arteries: CT cadaver study

Introducción y objetivos: El objetivo del trabajo es realizar un estudio de la anatomía radiológica de las arterias etmoidales. Métodos: Se realizó un estudio descriptivo con imágenes de tomografía computarizada correspondientes a 20 cabezas de cadáver perfundidas con material radiopaco. Se analizaron diferentes parámetros anatómicos. Resultados: La arteria etmoidal anterior se localizó en el 95% (38/40) de los casos. En el 87,55% (35/40) de las fosas se originó de la arteria oftálmica, encontrando en seis casos variantes de la normalidad. La longitud media del canal etmoidal anterior fue de 8,43±0,74mm con un ángulo de entrada en la base de cráneo de 37,3±5,48º. En el 90% de los casos (36/40), se localizó entre la segunda y la tercera lamela. La arteria etmoidal posterior sólo pudo localizarse en (14/40) fosas nasales. El 28,5% (4/14) presentaron variantes en su origen. La longitud media del canal etmoidal posterior fue de 7,1±1,02mm realizando un ángulo anterior a su salida de la órbita de 7,11±4,07º La distancia desde la espina nasal hasta la arteria etmoidal anterior fue de 55,51±5,52mm. El ángulo realizado entre la espina nasal y el canal etmoidal anterior fue de 57,67±1,68º. La distancia entre el nasión y el canal etmoidal anterior fue de 29,31±2,53mm, de la arteria etmoidal anterior a la arteria etmoidal posterior fue de 11,24±2,14mm y de la arteria etmoidal posterior al nervio óptico de 7,26±1,33mm. Se apreciaron celdas supraorbitarias en el 15% (6/40) de las fosas. Conclusiones: La técnica utilizada permitió realizar un análisis vascular completo del trayecto de las arterias etmoidales (AU)

Introduction and objectives: Our aim was to study the radiological anatomy of the ethmoidalarteries. Methods: A descriptive study was performed including CT images of 20 cadaver heads. The specimens were perfused with a radiopaque material and various anatomical parameters were analysed. Results: The anterior ethmoidal artery was found in 95% (38/40) of cases. It originated from the ophthalmic artery in 87.5% (34/40) of nasal cavities. In six cases, normal variants were found. The mean length of the anterior ethmoidal canal was 8.43±0.74mm. The angle performed into the skull base was 37.3±5.48º. In 90% of cases (36/40), it was located between the second and third lamella. The posterior ethmoidal artery was localised only in 14/40 cases, with 28.5% (4/14) of them showing normal variants. The mean length of the posterior ethmoidal canal was 7.1±1.02mm. The angle performed into the skull base was 7.11±4.07º. The distance from sill to the anterior ethmoid artery was 55.51±5.52mm. The angle between the nasalspine and the anterior ethmoidal canal was 57.67±1.68º. The distance between the nasion and the anterior ethmoidal canal was 29.31±2.53mm, the distance was 11.24±2.14mm from the anterior ethmoid artery to the posterior ethmoid artery and from the posterior ethmoid artery to the optic nerve, 7.26±1.33mm. Supraorbital cells were observed in 15% (6/40) of the cases. Conclusions: A complete vascular study of the ethmoidal arteries was possible by using this technique (AU)

The female gubernaculum: role in the embryology and development of the genital tract and in the possible genesis of malformations.

The female gubernaculum is an embryonic structure that gives rise to the uterine round ligament and seems to be important in Müllerian development. In the absence of androgens and anti-Müllerian hormone, the paramesonephric or Müllerian ducts complete their invagination and development, interfering with the connection of the tissue column that begins at the inguinal cone (the gubernaculum) and targets the mesonephric duct and caudal ligament of the gonad. The gubernaculum then grows over the Müllerian ducts, incorporating its muscular fibres. Outside and above this point, the Müllerian ducts give rise to the Fallopian tubes, whereas medially to the point of insertion of the gubernaculum, the Müllerian ducts develop into the normal uterus, the adequate formation of which is also induced by the mesonephric ducts. Diverse human anatomical and physiological characteristics such as the simplex uterus, as well as pathological conditions and certain female genital malformations, could be related to gubernaculum dysfunction. The main conclusions in this article are: (1) The female gubernaculum is the origin of the uterine round ligament but probably not of the uteroovarian ligament. Gubernacula are composed of muscular fibres that probably derive from the abdominal wall and that, when fixed and fused with the Müllerian ducts, allow or induce, together with the mesonephric ducts, the adequate development and formation of the uterus. (2) The female gubernaculum seems to be responsible for many of the specific human characteristics of Müllerian development, including the uterus simplex, the anteflexion and low intra-abdominal position of the uterus, and the disposition of uterine muscular fibres. (3) The female gubernaculum seems to be related to pathologies arising from the round ligaments and inguinal hernia. Likewise, certain uterine malformations (e.g., didelphys uterus, Rokitansky syndrome) and accessory and cavitated uterine masses might be related to gubernaculum dysfunction.

[Radiological anatomy of the ethmoidal arteries: CT cadaver study]. / Anatomía radiológica de las arterias etmoidales: estudio por TC en cadáver.

INTRODUCTION AND OBJECTIVES: Our aim was to study the radiological anatomy of the ethmoidal arteries. METHODS: A descriptive study was performed including CT images of 20 cadaver heads. The specimens were perfused with a radiopaque material and various anatomical parameters were analysed. RESULTS: The anterior ethmoidal artery was found in 95% (38/40) of cases. It originated from the ophthalmic artery in 87.5% (34/40) of nasal cavities. In six cases, normal variants were found. The mean length of the anterior ethmoidal canal was 8.43 ± 0.74 mm. The angle performed into the skull base was 37.3 ± 5.48°. In 90% of cases (36/40), it was located between the second and third lamella. The posterior ethmoidal artery was localised only in 14/40 cases, with 28.5% (4/14) of them showing normal variants. The mean length of the posterior ethmoidal canal was 7.1 ± 1.02 mm. The angle performed into the skull base was 7.11 ± 4.07°. The distance from sill to the anterior ethmoid artery was 55.51 ± 5.52 mm. The angle between the nasal spine and the anterior ethmoidal canal was 57.67 ± 1.68°. The distance between the nasion and the anterior ethmoidal canal was 29.31 ± 2.53 mm, the distance was 11.24 ± 2.14 mm from the anterior ethmoid artery to the posterior ethmoid artery and from the posterior ethmoid artery to the optic nerve, 7.26 ± 1.33 mm. Supraorbital cells were observed in 15% (6/40) of the cases. CONCLUSIONS: A complete vascular study of the ethmoidal arteries was possible by using this technique.