Lateral Lymph Node Dissection for Locally Advanced Rectal Carcinoma: A Step-by-Step Description of Surgical Anatomical Planes During Cadaveric Dissection and Minimally Invasive Surgery.

PURPOSE: Total mesorectal excision (TME) is accepted as gold standard method in rectal cancer globally. But there is no standard for lateral lymph nodes. Combination of neoadjuvant treatment plus lateral lymph node dissection (LLND) in select patients might be a promising method. Our purpose is to describe the anatomic landmarks of LLND on cadavers and minimally invasive surgery. MATERIALS AND METHODS: Local advanced rectal cancer and lateral lymph node (LLN) metastasis are accepted as an indication of neoadjuvant treatment. LLND was performed according to preoperative imaging after radiochemotherapy. RESULTS: Twenty-eight (10.5%) of 267 patients with rectal cancer who had suspected lateral lymph node metastasis (LLNM) with magnetic resonance imaging (MRI) underwent LLND in addition to TME after neoadjuvant chemoradiotherapy. Eight of them had LLNM. Three patients had bilateral LLND and only 1 had LLNM. The median number of harvested lymph nodes was 6. The rates of LLNM increased with the presence of poor prognosis markers. One regional and 1 distant recurrence were detected in patients who had no LLN metastasis compared with2 regional and 4 distant recurrences in the LLN-positive group. CONCLUSIONS: Local advanced rectal cancer cases may benefit from LLND, but it does not appear to have an effect on overall survival. There is no consensus whether size and/or morphologic criteria in MRI are the ideal guide for LLND.

Combined Autologous Adductor Magnus and Partial Quadriceps Tendon Technique for Medial Patellofemoral Ligament Reconstruction and Cellularized Scaffold Implantation of the Patella.

There are many studies in the literature on the use of adductor magnus and quadriceps tendons in primary or revision surgery of patellofemoral instability in skeletally immature patients. In this Technical Note, the combination of both tendons is presented with cellularized scaffold implantation cartilage surgery in the patella.

The adductor magnus tendon is a viable option for medial patellofemoral ligament reconstruction, but with a busy surrounding neurovascular topography.

PURPOSE: To describe the proximity of the neurovascular structures surrounding the adductor magnus (ADM), to delineate a safe boundary focusing on the techniques used during graft harvest and to evaluate whether the length of the ADM tendon is sufficient for safe medial patellofemoral ligament (MPFL) reconstruction. METHODS: Sixteen formalin-fixed cadavers were dissected. The area surrounding the ADM, the adductor tubercle (AT) and the adductor hiatus was exposed. The following measurements were performed: the (1) total length of MPFL, (2) distance between the AT and the saphenous nerve, (3) the point where the saphenous nerve pierces the vasto-adductor membrane, (4) the point where the saphenous nerve crosses the ADM tendon, (5) the musculotendinous junction of the ADM tendon, and (6) the point where the vascular structures exit the adductor hiatus. Additionally, (7) the distance between the ADM musculotendinous junction and the nearest vessel (popliteal artery), (8) the distance between the ADM (at the level where the saphenous nerve crosses) and the nearest vessel, (9) the length between the AT and the superior medial genicular artery, and finally (10) the depth between the AT and the superior medial genicular artery were analyzed. RESULTS: The in situ length of the native MPFL was 47.6 ± 42.2 mm. The saphenous nerve pierces the vasto-adductor membrane at a mean distance of 100 mm, although it crosses the ADM itself at an average of 67.6 mm. The vascular structures, on the other hand, become vulnerable at a distance of 89.1 ± 114.0 mm from the AT. After harvesting the ADM tendon, the mean length was found to be 46.9 mm, which was insufficient for fixation. Partial release from the AT resulted in a more adequate length for fixation (65.4 ± 88.7 mm). CONCLUSION: The adductor magnus tendon is a viable option for the dynamic reconstruction of the MPFL. Knowledge of the surrounding busy neurovascular topography is paramount for a procedure typically performed in a minimally invasive way. The study results are clinically relevant, as they suggest that tendons should be shorter than the minimum distance from the nerve. If in some cases the length of the MPFL is longer than the distance of the ADM from the nerve, the results suggest that a partial dissection of the anatomical structures might be needed. Direct visualization of the harvesting region might be considered in such cases.

A new modified pararectus approach and visualization: an anatomical study.

INTRODUCTION: The aim of our study was to visualize all the windows used in the pararectus approach with detailed cadaver images to facilitate better understanding of orthopedic surgeons and, in addition, was to modify the incision used in the pararectus approach to a more cosmetic bikini incision. MATERIALS AND METHODS: In total, 20 cadavers fixed in 10% formalin were used in this study. Of these cadavers, 14 were male and six were female, with a mean age at death of 57 (42-82 years). The four windows were defined as follows in all the cadavers: pubic, quadrilateral, sacroiliac, and iliac windows. RESULTS: The most important structure at risk in the pubic window was the corona mortis, as it was observed in 12 (60%) cadavers. In men, the spermatic cord was an important structure at risk in the pubic window. The obturator vessels and nerves were the structures at most risk in the quadrilateral window due to their close location with the quadrilateral surface. The obturator nerve on the medial side and at the entrance of the pelvis through the linea terminalis and lumbosacral truncus were the structures at most risk close to the sacroiliac joint in the sacroiliac window. CONCLUSION: This anatomical study includes highly instructive visual shapes and cadaver images for the acetabulum and pelvis, whose anatomical structures are quite complex. We have found that this modified pararectus approach provides excellent access to the internal pelvic rim. CLINICAL RELEVANCE: The anatomical data regarding the modified pararectus approach in this study will assist orthopedic surgeons in the surgical management of acetabular and pelvic fractures.

Protection of the innervation of the tensor fasciae latae in hip direct anterior and anterolateral approaches: a cadaver study.

PURPOSE: This study aims to reveal the exact course of the superior gluteal nerve (SGN) branch innervating the tensor fascia lata (TFL) and show how it can be protected in the direct anterior approach (DAA) and anterolateral approach (ALA). METHODS: The anterolateral regions of 22 thighs from formalin-fixed cadavers were dissected. 3 anatomical points were determined. Point A, B, C indicates where the SGN enters the gluteus minimus (GMin) fibres, the SGN leaves the gluteal muscles, the SGN enters the TFL, respectively. Measurements were made on 3 separate lines. RESULTS: On the anterior superior iliac spine (ASIS) and the head of the fibula line (Line 1), the horizontal-vertical distances from point B and C to the ASIS were 7.99 ± 3.65 mm-40.40 ± 11.50 mm and 11.74 ± 6.61 mm-70.35 ± 14.11 mm respectively. The horizontal-vertical distances from point A, B, C to the greater trochanter (GT) were 32.41 ± 9.97 mm-55.28 ± 12.25 mm; 67.70 ± 8.54 mm-17.76 ± 13.57 mm; 63.92 ± 9.96 mm-13.00 ± 7.92 mm on the GT and the head of the fibula line (Line 2), respectively. The horizontal-vertical distances from point A, B, C to the GT were 24.58 ± 9.83 mm-42.54 ± 12.86 mm; 9.45 ± 7.92 mm-36.25 ± 9.06 mm; 26.18 ± 11.12 mm-64.05 ± 11.67 mm on the ASIS and the GT line (Line 3). CONCLUSIONS: In the DAA, the increased risk of damaging the branch of the SGN that innervates the TFL must be kept in mind. The protection of this branch can be ensured with easy and applicable rules.

Posteromedial Compartment Arthroscopy of the Knee and Resection of Osteophytes: An Anatomic Perspective on Posteromedial Knee Impingement.

Posteromedial knee pain is a common clinical problem. It is often accompanied by degenerative changes or tears in the posterior horn of the medial meniscus and/or pain during deep flexion of the knee. In more advanced cases, it is accompanied by the osteophytic formation of a cam lesion that develops gradually in the posterior of the medial condyle of the femur and, with it (or less frequently without it), an osteophytic lesion at the posterior of the tibia (i.e. pincer lesion) occurs. It is believed that resection of the cam lesion may delay the progression of knee osteoarthritis, similarly to repairing the posterior horn of the medial meniscus. In this technical note, we describe a 2-portal technique for resection of cam lesions by posteromedial knee arthroscopy using anatomic landmarks. Using both portals provides better visualization and a better approach.

Comparison of textbook versus three-dimensional animation versus cadaveric training videos in teaching laparoscopic rectal surgery: a prospective randomized trial.

AIM: The aim of this prospective randomized study was to compare the effectiveness of various educational tools in laparoscopic rectal surgery, including surgical textbooks, animation and cadaveric videos. METHOD: Initially, an electronic assessment test assessing knowledge of laparoscopic rectal surgery was created and validated. The test was sent to graduates completing a general surgery residency programme in Turkey, who were then randomized into four groups based on the type of study material. After a 4 week study period, the volunteers were asked to answer the same electronic assessment test imported into an edited live laparoscopic rectal surgery video. Pre- and posteducation assessment tests among the groups were compared. RESULTS: A total of 168 volunteers completed the pre-education assessment test and were randomized into four groups. Pre-education assessment test scores were similar among the groups (p > 0.05). Of 168 volunteers, 130 (77.3%) completed the posteducation assessment test. Posteducation assessment test scores were significantly higher in the three-dimensional (3D) animation + cadaveric video group (p < 0.01), the 3D animation group (p < 0.01) and the cadaveric group (p < 0.01) compared with the textbook group. Moreover, posteducation assessment test scores were significantly higher in the 3D animation + cadaveric video group than the 3D animation group (p < 0.01). Each group's posteducation assessment test scores were significantly higher than the pre-education assessment test scores, with the exception of the textbook group. CONCLUSION: Our study demonstrates that 3D animation + cadaveric videos, 3D animation alone and cadaveric videos are all superior to a surgical textbook when teaching laparoscopic rectal cancer surgery. Finally, our results show that 3D animation and cadaveric videos are also superior to textbooks in enabling an understanding of rectal surgery.

Radiological Evaluation of Femoral Intercondylar Notch and Tibial Intercondylar Eminence Morphometries in Anterior Cruciate Ligament Pathologies Using Magnetic Resonance Imaging.

PURPOSE: To determine the relationship between femoral-tibial morphometries and anterior cruciate ligament (ACL) pathologies using magnetic resonance imaging (MRI). METHODS: We retrospectively evaluated 455 patients (211 females and 244 males) who underwent knee MRI with suspected ACL pathology. Imaging findings were classified as normal ACL (n = 119), degeneration of the ACL (n = 116), partial ACL tear (n = 103), and complete ACL tear (n = 117). In all groups, the femoral intercondylar notch width (INW), intercondylar distance (CD), notch width index (NWI), and intercondylar notch angle (INA), the angles between the tibial plateau and tibial spines (MPA and LPA), intercondylar eminence peak angle (IEA), and tibial slope angles (MSA and LSA) were measured. RESULTS: Femoral INW and NWI were significantly lower in patients with ACL pathology (p < 0.05). They were also lower in patients with tear compared to degeneration. The INA was significantly smaller in patients with ACL pathology (p < 0.001) and the significance continued in both genders. The LSA was only increased in patients with complete tear (p < 0.01) and the difference seems existing in both genders. It was also found that the LPA and IEA demonstrated significant increases in patients with ACL pathology (p < 0.01 and < 0.05, respectively) and the significance in LPA continued in both genders. Significant differences between males and females were found for the INW and CD in all 4 groups (p < 0.001). In addition, the INA, LPA and LSA were independent predictors in determining the risk of ACL pathology. CONCLUSION: The ACL pathologies are associated with femoral-tibial morphometries and these associations exist in both genders. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00490-7.

Computer-based multimodal training module facilitates standardization of complete mesocolic excision technique for right-sided colon cancer: Long-term oncological outcomes.

AIM: The aim of this study is to demonstrate our video training tool developed to teach and standardize complete mesocolic excision (CME) for right-sided colon cancer and also to present our long-term oncological outcomes. METHOD: Educational narrative videos were produced to demonstrate the technical steps of CME. First, a three-dimensional animation video was prepared. Then cadaveric dissections were recorded in a step-by-step fashion, following the sequences of open and minimally invasive surgery. These were followed by videos of real-life demonstrations of surgical procedures, enhanced by superimposed animations of key anatomical structures. In order to demonstrate the impact of this training module on outcomes of patients undergoing CME, we retrospectively queried data from before (2005-2010) and after (2011-2019) implementation of standardized CME in our practice. RESULTS: A total of 180 consecutive patients underwent right hemicolectomy between 2005 and 2019. Fifty-four patients underwent surgery before and 126 patients after CME principles were elaborated and standardized. Of those patients who had surgery after the training module, 58 (46%) underwent open surgery and 68 (54%) underwent laparoscopic colectomy. Demographics, perioperative parameters and morbidity were comparable between the groups. The 5-year overall and disease-free survival rates were significantly improved after implementation of CME training (p = 0.059 and p = 0.041, respectively). Also, 5-year overall and disease-free survival rates for all patients were considerably better than our reported national outcomes. CONCLUSION: Our comprehensive step-by-step training video module for the CME technique demonstrates surgical anatomical planes and important vascular structures and variations. The video also helps standardization of the CME technique and should contribute to improved histopathological and oncological outcomes.

Measurement of interscalene space volume in diagnosis of thoracic outlet syndrome: a cadaver study

Background/aim: The aim of this study was to measure the volume of interscalene space in thoracic outlet region on cadavers and radiological images and to analyze the potential value of these measurements in diagnosis and treatment of thoracic outlet syndrome (TOS). Materials and methods: The dimensions of the anterior interscalene space in 8 formalin-fixed human cadavers were studied by direct measurement and additionally evaluation of the volume of this space were done by using mold and volume calculation formula of square pyramid, due to resembling a pyramid. In the second phase of this study, interscalene space volume was calculated by formula and compared to calculations from computed tomography (CT) sections in 18 TOS and 16 control patients. Results: There was a strong correlation between the volume calculated by formula (4.79 ± 2.18 cm3) and by mold (4.84 ± 1.58 cm3), (R = 0.934, p = 0.001) in cadavers. The average volume measured in TOS patients (2.05 ± 0.32 cm3) was significantly smaller than control patients (4.30 ± 1.85 cm3, p < 0.0001). There were excellent or good results in 14 patients whereas in 4 patients who had neurogenic TOS achieved fair results after surgery. In these 4 patients the average volumes of abnormal sides were close to the healthy sides. Conclusion: In our study, volume of interscalene space in TOS patients was statistically smaller than control group. Also, the volume was even smaller in patients with excellent or good results after surgery. In this respect, volumetric measurements from CT sections could be used in diagnosis and treatment selection in TOS patients.

Development and Implementation of a Novel Computer-Based Training Module for the Standardization of Splenic Flexure Mobilization.

BACKGROUND: Computer-based training modules use various multimedia components such as text, graphics, animation, and videos that can theoretically facilitate the learning process. Splenic flexure mobilization (SFM) is a crucial step for tension-free colorectal/anal anastomosis that can be a technically demanding step. This study is designed to demonstrate our novel training module for SFM with high-vessel ligation during surgery and present the anatomical landmarks and embryological plans for SFM. MATERIALS AND METHODS: A step-by-step educational video was prepared to standardize and teach the technical steps of the SFM. 3D animation was prepared and cadaveric dissection was performed in a step-by-step manner similar to minimally invasive surgery. This is followed by the laparoscopic technique. Since we have started this modular training program in our department, a consecutive of 100 patients underwent laparoscopic low anterior resection and coloanal anastomosis with covering stoma. Demographics, characteristics, and postoperative outcomes were evaluated. RESULTS: Surgical anatomical planes and important vascular structures/variations are both shown by 3D animation, cadaveric dissection, and laparoscopic surgery. Out of 100 consecutive cases, there were no mortality, 5 anastomotic leakages 1 of which necessitates reoperation, and 2 splenic injuries which were managed conservatively. CONCLUSION: This unique educational video module for SFM demonstrates surgical anatomical planes and important vascular structures/variations. The employment and implementation of time-independent multimedia components lead to effective training and can theoretically facilitate the learning process.

Redefining the collateral system between the superior mesenteric artery and inferior mesenteric artery: a novel classification.

AIM: The aim of this study was to evaluate the arterial collateral vasculature between the superior mesenteric artery and the inferior mesenteric artery (IMA) from a surgical perspective. METHOD: A total of 107 fresh adult cadavers (94 male) were studied with emphasis on the vascular anatomy of the left colon. Dissections were carried out mimicking the anterior resection technique. The vasculature of the left mesocolon and the collaterals between the superior mesenteric artery and the IMA with respect to their relationship to the inferior mesenteric vein (IMV) were assessed and classified. Collaterals were classified into three different groups: marginal anastomoses (via the marginal = pericolic artery), intermediate mesocolic anastomoses (parallel to the marginal artery but neither adjacent to the IMV nor close to the duodenum) and central mesocolic anastomoses (next to the IMV at the level of the duodenojejunal junction and the lower border of the pancreas). RESULTS: All patients had a marginal anastomosis. However, the marginal anastomosis, as the only anastomosis between the superior and inferior mesenteric arteries at the splenic flexure, was observed in 41 cases (38%). In addition to the marginal artery, intermediate mesocolic anastomoses were found in 49 (46%) and a central mesocolic anastomosis was observed in 17 (16%) of the 107 cases in the splenic flexure mesocolon. It is in this latter variant that collateral vessels can be compromised during ligation/transection of the IMV. CONCLUSION: This new classification can contribute to a precise mesocolic dissection technique and splenic flexure mobilization and help prevent ischaemic damage to the descending colon.

Abdominal palpation and percussion maneuvers do not affect bowel sounds.

OBJECTIVES: Medical textbooks suggest that the frequency of bowel sounds may be altered by performing auscultation after palpation or percussion. We hypothesize that the frequency of bowel sounds is not affected by the order of abdominal examination. MATERIAL AND METHODS: Both healthy volunteers (n= 80) and patients (n= 100) were enrolled in this crossover randomized study. Two different examination orders, one as inspection, palpation, percussion, auscultation (IPPA) and the other order as inspection, auscultation, palpation, percussion (IAPP) were used by two observers, one of which was blinded to the order of the physical examination and only performed auscultation. Bowel motilities of 40 participants were analyzed with duplex Doppler USG by a radiologist. The effects of changing the order of abdominal examination and palpation-percussion maneuvers on the frequency of bowel sounds were evaluated. RESULTS: Gender distribution was similar between the healthy patients and controls, and mean age of the entire study population was 47 (18-60) years. Differences between the mean bowel sound frequencies for abdominal examinations in order IPPA-IAPP versus IAPP-IPPA were evaluated for both healthy subjects and the patients. There were no differences between the first and second listening, nor were there differences between examinations performed in either order. Duplex Doppler Ultrasonographic (USG) assessments were performed on 20 healthy subjects and 20 patients before and after palpation and percussion; there were no statistically significant differences between the two listenings (p= 0.694). CONCLUSION: According to both abdominal examinations and Doppler USG, the order of auscultation, whether performed before or after palpation or percussion, did not change the frequency of bowel sounds in this subject population.

Comparison of Mesenteric Lengthening Techniques in IPAA: An Anatomic and Angiographic Study on Fresh Cadavers.

BACKGROUND: The IPAA technique restores anal functionality in patients who have had the large intestine and rectum removed; however, 1 of the most important reasons for pouch failure is tension on the anastomosis. OBJECTIVE: The aim of this study was to compare technical procedures for mesenteric lengthening used for IPAA to reduce this tension. DESIGN: After randomization, 4 different techniques for mesenteric lengthening were performed and compared on fresh cadavers. SETTING: This was a cross-sectional cadaveric study. MAIN OUTCOME MEASURES: In the first group (n = 5), stepladder incisions were made on the visceral peritoneum of the mesentery of the small intestine. In the second and third groups, the superior mesenteric pedicle was divided, whereas the ileocolic pedicle (n = 7) or marginal vessels (n = 6) were preserved during proctocolectomy. In the fourth group (n = 7), the superior mesenteric pedicle was cut without preserving any colic vessels. Mesenteric lengthening was analyzed. Angiography was performed to visualize the blood supply of the terminal ileum and pouch after mesenteric lengthening. RESULTS: Average mesenteric lengthening was 5.72 cm (± 1.68 cm) in group 1, 3.63 cm (± 1.75 cm) in group 2, 7.03 cm (± 3.47 cm) in group 3, and 7.29 cm (± 1.73 cm) in group 4 (p = 0.011 for group 2 when compared with the others). LIMITATIONS: The study was limited by nature of being a cadaver study. CONCLUSIONS: Stepladder incisions through superior mesenteric pedicle trace are usually sufficient for mesenteric lengthening. In addition, division of the superior mesenteric pedicle with either a preserving marginal artery or without preserving ileocolic and marginal arteries leads to additional mesenteric lengthening.

The importance of costoclavicular space on possible compression of the subclavian artery in the thoracic outlet region: a radio-anatomical study.

OBJECTIVES: The purposes of this study were to identify possible compression points along the transit route of the subclavian artery and to provide a detailed anatomical analysis of areas that are involved in the surgical management of the thoracic outlet syndrome (TOS). The results of the current study are based on measurements from cadavers, computed tomography (CT) scans and dry adult first ribs. METHODS: The width and length of the interscalene space and the width of the costoclavicular passage were measured on 18 cervical dissections in 9 cadavers, on 50 dry first ribs and on CT angiography sections from 15 patients whose conditions were not related to TOS. RESULTS: The average width and length of the interscalene space in cadavers were 15.28 ± 1.94 mm and 15.98 ± 2.13 mm, respectively. The widths of the costoclavicular passage (12.42 ± 1.43 mm) were significantly narrower than the widths and lengths of the interscalene space in cadavers (P < 0.05). The average width and length of the interscalene space (groove for the subclavian artery) in 50 dry ribs were 15.53 ± 2.12 mm and 16.12 ± 1.95 mm, respectively. In CT images, the widths of the costoclavicular passage were also significantly narrower than those of the interscalene space (P < 0.05). The measurements from cadavers, dry first ribs and CT images were not significantly different (P > 0.05). CONCLUSIONS: Our results showed that the costoclavicular width was the narrowest space along the passage route of the subclavian artery. When considering the surgical decompression of the subclavian artery for TOS, this narrowest area should always be kept in mind. Since measurements from CT images and cadavers were significantly similar, CT measurements may be used to evaluate the thoracic outlet region in patients with TOS.

Applied anatomy for tibial intraosseous access in adults: A Radioanatomical Study.

Intraosseous access is a method for providing vascular access in resuscitation of critically ill and injured patients when traditional intravenous access is difficult or impossible. There is a lack of detailed description for the landmark for the insertion point in the literature. The aim of this study was to determine the exact location for intraosseous access. Radiographic computed tomography (CT) images of a total of 50 dry tibia bones were obtained. With 5-mm intervals, for all transverse images and by selecting transverse section, measurements were taken from the thickness of the cortex at anterior margin and mid-line medial surface, distance from anterior margin, and mid-line medial surface of the tibia to the posterior wall of medullar cavity, distance from anterior margin and mid-line medial surface of the tibia to the posterior surface of the tibia. The thinner part of the cortex of the tibia and the larger width of the medullar cavity is at 0.5 cm below the tibial tuberosity in the midline of the medial surface. The application region for proximal tibia access and landmark and most suitable insertion point for intraosseous infusion should be at level 0.5 cm below the tibial tuberosity in the midline of the medial surface. It was recommended that standard length for intraosseous canule should be 17 mm except for the thickness of skin. In conclusion, presented study provides certain localization for intraosseous access and standard length for intraosseous canule and this will be more effective in using this technique. Clin. Anat. 31:593-597, 2018. © 2017 Wiley Periodicals, Inc.

The Cervical Arteries: An Anatomical Study with Application to Avoid the Nerve Root and Spinal Cord Blood Supply.

AIM: Injury to the vascular supply to the cervical spinal cord can lead to the anterior spinal artery syndrome, which is often associated with transforaminal corticosteroid injections to the cervical foramina. The purpose of this cadaveric study was to examine the morphology of the cervical arteries and to emphasize their clinical importance. MATERIAL AND METHODS: Five formalin-fixed human cadavers were used to determine the morphology of the radicular arteries from the vertebral, ascending and deep cervical arteries in the cervical foraminal region. RESULTS: The mean diameter of the vertebral arteries was 5.50 mm. The radicular arteries arose from the vertebral artery originating from its posterior aspect at each level and the C6 radicular artery was larger in diameter than others. Their diameters ranged from 0.75 mm to 1.02 mm. The mean diameter of the ascending cervical artery was 1.5 mm (range 1.21 to 1.80 mm). Its arising spinal branches were located at the C3-4 or C4-5 levels. The diameters of radicular branches arising from the ascending cervical artery ranged from 0.80 mm to 1.40 mm. The mean diameter of the deep cervical artery was 1.71 mm (range 1.3 to 2.1 mm) and was usually slightly larger than the ascending cervical arteries. These deep cervical radicular arteries always entered the C5-6, C6-7 and C7-T1 foramens and those of the radicular branches arising from the deep cervical artery ranged from 0.43 mm to 1.49 mm (mean, 1.08 mm). CONCLUSION: Understanding the vascular supply to the cervical spinal cord is important for preventing serious complications such as spinal cord ischemia.

Cervical extraforaminal ligaments: an anatomical study.

PURPOSE: The purpose of this study was to elucidate the anatomy and clinical importance of extraforaminal ligaments in the cervical region. METHODS: This study was performed on eight embalmed cadavers. The existence and types of extraforaminal ligaments were identified. The morphology, quantity, origin, insertion, and orientation of the extraforaminal ligaments in the cervical region were observed. RESULTS: Extraforaminal ligaments could be divided into two types: transforaminal ligaments and radiating ligaments. It was observed that during their course, transforaminal ligaments cross the intervertebral foramen ventrally. They usually originate from the anteroinferior margin of the anterior tubercle of the cranial transverse process and insert into the superior margin of the anterior tubercle of the caudal transverse process. The dorsal aspect of the transforaminal ligaments adhere loosely to the spinal nerve sheath. The length, width and thickness of these ligaments increased from the cranial to the caudal direction. A single intervertebral foramen contained at least one transforaminal ligament. A total of 98 ligaments in 96 intervertebral foramina were found. The spinal nerves were extraforaminally attached to neighboring anterior and posterior tubercle of the cervical transverse process by the radiating ligaments. The radiating ligaments consisted of the ventral superior, ventral, ventral inferior, dorsal superior and dorsal inferior radiating ligaments. Radiating ligaments originated from the adjacent transverse processes and inserted into the nerve root sheath. The spinal nerve was held like the hub of a wheel by a series of radiating ligaments. The dorsal ligaments were the thickest. From C2-3 to C6-7 at the cervical spine, radiating ligaments were observed. They developed particularly at the level of the C5-C6 intervertebral foramen. CONCLUSIONS: This anatomic study may provide a better understanding of the relationship of the extraforaminal ligaments to the cervical nerve root.

Variations in the Vascular Anatomy of the Right Colon and Implications for Right-Sided Colon Surgery.

BACKGROUND: Knowledge of the normal pattern and variations of the blood supply of the right colon is crucial for better outcomes after colon surgery. OBJECTIVE: The purpose of this study was to describe the precise vascular anatomy of the right colon according to surgical perspective. DESIGN: Adult fresh cadavers were dissected between January 2013 and October 2015, focusing on the venous and arterial anatomy of the right side of the colon. SETTINGS: Macroscopic anatomical dissections were performed on 111 adult fresh cadavers with emphasis on the vascular anatomy of the right colon. The colic tributaries of the superior mesenteric artery and vein were documented in writing. Furthermore, the dissections were recorded with a video camera. RESULTS: The incidence of colic arteries arising from the superior mesenteric artery included ileocolic artery, 100%; right colic artery, 33.3%; middle colic artery, 100%; and accessory middle colic artery, 11,7%. All 111 cadavers had a single ileocolic vein, which drained into the superior mesenteric vein in 103 cases (92.8%), into the gastro-pancreatico-colic trunk in 7 cases (6.3%), and into the jejunal trunk in 1 case (0.9%). The drainage site of the ileocolic vein to the superior mesenteric vein varied, and in 9% of cases the ileocolic vein did not accompany the ileocolic artery. The gastro-pancreatico-colic trunk was detected in 87 cases (78.4%); with several forms of the origin of the respective branches, the gastropancreatic trunk was detected in 24 cases (21.6), and the classic gastrocolic trunk of Henle was not detected. Variations were found in the formation and drainage routes of other venous colic tributaries of the superior mesenteric vein. LIMITATIONS: This study is limited by its use of cadavers in that it is impossible to trace each vessel to its origin in live surgery. CONCLUSIONS: Surgeons must watch, observe, and bear in mind that vascular variations can occur. Awareness of these complex variations may improve the quality of surgery and may prevent devastating complications during right-sided colon resections.

Location of Needle Tips on Plexus Brachialis in Different Supraclavicular Block Techniques: A Cadaver Study.

OBJECTIVE: The present study was performed on cadavers to evaluate the efficacy of the different supraclavicular block techniques (Vongvises, Dalens, plumb-bob and inter-SCM) by investigating the location of the needle tip on the brachial plexus and to determine the most suitable block techniques according to the site of the surgery. METHODS: The study was performed on one embalmed and nine fresh cadavers. After the dissection, the skin of the cadavers was restored in its original position. Then, they are positioned, and the needle was inserted according to the technique described by the authors in the original articles. The distances between the needle tip and the three trunks were measured, and the location of the needle tip on the brachial plexus was determined. RESULTS: A significant difference in the proximity of the needle tip to the middle of the middle truncus was noted only in the inter-SCM technique compared with the Dalens technique at both sides (p<0.05). CONCLUSION: In our study, the distance between the needle tip and truncus medius was the shortest in the plumb-bob technique at both sides. Both in the plumb-bob and inter-SCM techniques, the distribution of the needle tip over the trunci of the plexus brachialis was homogenous. In Dalens technique, the needle tip reached the truncus superior or between the truncus superior and n. suprascapularis in 95% of the cases. Further, we concluded that moving the insertion point approximately 1 cm caudal and maintaining the anteroposterior needle direction in the Vongvises technique would result in a successful brachial plexus block.