Sacrococcygeal chordoma: Report of a case and review of the literature.

A review of 222 patients with sacrococcygeal chordoma from the English language literature since the first American case in 1913 reveals that men are affected twice as frequently as are women after age 40, but not before. A history of prior trauma can be found in about 20 percent of patients, but no clear etiologic relation can be proved. The evidence for a congenital origin from displaced notochordal tissue is equally inconclusive. Metastasis occurs in only about 10 percent of patients, but recurrence of the primary lesion is almost universal. Of 67 patients followed, 11 survived 10 years or longer after diagnosis of chordoma. Resection of the tumor rarely is complete. Preservation of sacral stability and of sacral nerve pathways to the rectum and the bladder limit the extent of permissable surgery. Repeated local excision of the tumor recurring after initial excision and irradiation remains the treatment of choice.

Vascular compression of the duodenum: Presentation of ten cases and review of the literature.

Ten cases of vascular compression of the duodenum are presented, and 125 cases in the literature since 1962 are reviewed. More common in women than in men, the lesion may result from supine immobilization, wearing body cast, or a rapid weight loss. In about one third of the patients, no predisposing factor can be found. Diagnosis is best made by cinefluoroscopy. Although conservative measures will provide relief in a few patients, most will require surgery. Section of the suspensory muscle and relocation of the duodenojejunal junction will relieve the symptoms in many patients. Duodenojejunostomy will be required in some others. Complete relief can be expected in all but a very few patients. Those who have developed neurotic eating habits from years of discomfort may not show immediate improvement. Untreated vascular compression of the duodenum may be chronic or may become acute with fatal results.

Cancer of bile duct with situs inversus.

We present a case of adenocarcinoma of the distal common bile duct in a 68-year-old woman with total situs inversus. Endoscopic retrograde cholangiopancreatography prior to surgery demonstrated segmental obstruction of the distal common bile duct. Obstructive jaundice was observed and the results of liver function studies were abnormal. All biopsy specimens obtained in the operating room were negative. The case met all the criteria of Child and Frey, but at the end of the procedure the tumor was found to involve the superior mesenteric vein, a factor not appreciated during the operative evaluation of the patient. The situs inversus did not produce any technical problems. The patient did not have any surgical complications, but she died 18 months later of the cancer.

Embryologic and anatomic basis of esophageal surgery.

The embryogenesis, congenital anomalies, and surgical anatomy and applications of the esophagus for benign and malignant processes are detailed in this article. Emphasis is placed on the role of embryology and the anatomy involved in surgical decisions.

Surgical embryology and anatomy of the breast and its related anatomic structures.

This article describes the embryology of the breast, its histologic appearances during the various phases of life, the gross anatomy of the breast, and its associated anatomic entities. The anatomy of the male breast also is reviewed. The surgical significance of each of these aspects is considered.

The vagus nerve and its vagaries.

Without any further comments we advise the surgeon performing open or laparoscopic vagotomy to know the anatomy and the vagaries of the vagus nerve. In view of the demonstration that the nerves of the greater curvature, identified as a concern in achieving a "complete" PGV, are projected from up to 20% of the nerve cell bodies of the dorsal motor nucleus of the vagus nerve in the brain stem, we believe it is appropriate to adopt the technique of EHSV as a means of avoiding the high recurrence rates reported with conventional highly selective vagotomy or proximal gastric vagotomy. When pyloric stenosis or outlet obstruction is present, anterior hemipylorectomy provides a solution. If surgeons adopt a laparoscopic approach to EHSV, they must be cognizant of all sites of preganglionic innervation, and (ideally) attempt to verify the "completeness" of vagotomy by Congo red testing. We look forward, also, to the work of Andrus and Schneider, who are evaluating alternative methods of achieving complete vagotomy.

Obturator hernia. Embryology, anatomy, and surgical applications.

Obturator hernia is a rare clinical entity. In most cases, it produces small bowel obstruction with high morbidity and mortality. The embryology, anatomy, clinical picture, diagnosis, and surgery are presented in detail.

Surgical embryology and anatomy of the pancreas.

Knowledge of the surgical embryology and surgical anatomy of the pancreas is vital to the general surgeon. This article discusses the entities related to pancreatic surgery. It also highlights some common embryologic anomalies of the pancreas.

Embryologic and anatomic basis of inguinal herniorrhaphy.

The embryology and surgical anatomy of the inguinal area is presented with emphasis on embryologic and anatomic entities related to surgery. We have presented the factors, such as patent processus vaginalis and defective posterior wall of the inguinal canal, that may be responsible for the genesis of congenital inguinofemoral herniation. These, together with impaired collagen synthesis and trauma, are responsible for the formation of the acquired inguinofemoral hernia. Still, we do not have all the answers for an ideal repair. Despite the latest successes in repair, we, to paraphrase Ritsos, are awaiting the triumphant return of Theseus.

Embryologic and anatomic basis of duodenal surgery.

The following points should be remembered by surgeons (Table 1). In writing about the head of the pancreas, the common bile duct, and the duodenum in 1979, the authors stated that Embryologically, anatomically and surgically these three entities form an inseparable unit. Their relations and blood supply make it impossible for the surgeon to remove completely the head of the pancreas without removing the duodenum and the distal part of the common bile duct. Here embryology and anatomy conspire to produce some of the most difficult surgery of the abdominal cavity. The only alternative procedure, the so-called 95% pancreatectomy, leaves a rim of pancreas along the medial border of the duodenum to preserve the duodenal blood supply. The authors had several conversations with Child, one of the pioneers of this procedure, whose constant message was to always be careful with the blood supply of the duodenum (personal communication, 1970). Beger et al popularized duodenum-preserving resection of the pancreatic head, emphasizing preservation of endocrine pancreatic function. They reported that ampullectomy (removal of the papilla and ampulla of Vater) carries a mortality rate of less than 0.4% and a morbidity rate of less than 10.0%. Surgeons should not ligate the superior and inferior pancreaticoduodenal arteries because such ligation may cause necrosis of the head of the pancreas and of much of the duodenum. The accessory pancreatic duct of Santorini passes under the gastrointestinal artery. For safety, surgeons should ligate the artery away from the anterior medial duodenal wall, where the papilla is located, thereby avoiding injury to or ligation of the duct. "Water under the bridge" applies not only to the relationship of the uterine artery and ureter but also to the gastroduodenal artery and the accessory pancreatic duct. In 10% of cases, the duct of Santorini is the only duct draining the pancreas, so ligation of the gastroduodenal artery with accidental inclusion of the duct is catastrophic. With the Kocher maneuver, surgeons reconstruct the primitive mesoduodenum and achieve mobilization of the duodenum, which is useful for some surgical procedures. Surgeons should not skeletonize more than 2 cm of the first part of the duodenum. If more than 2 cm of skeletonization is done, a duodenostomy using a Foley catheter may be necessary to avoid blow-up of the stump secondary to poor blood supply. Proximal duodenojejunostomy is advised for the safe management of patients with difficult duodenal stumps. Roux-en-Y choledochojejunostomy and duodenojejunostomy divert bile and food in the treatment of the complicated duodenal diverticulum. The suspensory ligament may be transected with impunity. It should be ligated before being sectioned so that bleeding from small vessels contained within can be avoided. Failure to sever the suspensory muscle completely, which is possible if the insertion is multiple, fails to relieve the symptoms of vascular compression of the duodenum (Fig. 18). Mobilization, resection, and end-to-end anastomosis of the duodenal flexure have been performed as a uniform surgical procedure, avoiding the conventional gastrojejunostomy. With a large, penetrating posterior duodenal or pyloric ulcer, surgeons should remember that The proximal duodenum shortens because of the inflammatory process (duodenal shortening) The anatomic topography of the distal common bile duct and the opening of the duct of Santorini and the ampulla of Vater is distorted Leaving the ulcer in situ is wise Careful palpation for or visualization of the location of the ampulla of Vater or common bile duct exploration with a catheter insertion into the common bile duct and the duodenum are useful procedures In most cases, the common bile duct is located to the right of the gastroduodenal artery at the posterior wall of the first part of the duodenum. (ABSTRACT TRUNCATED)

The surgical anatomy of the spleen.

The surgical embryology and anatomy of the spleen are reported with emphasis given to ligaments, blood supply, and segmentation. The anatomic entities involved with splenic surgery are presented. Surgical applications are emphasized. Knowledge of splenic anatomy and technique, with efforts to save the organ if possible, is paramount for good results.

Embryology, anatomy, and surgical applications of the preperitoneal space.

The preperitoneal space is presented from an embryologic, anatomic, and surgical standpoint in detail. Because this space is one of the most used areas for the repair of groin hernias, knowledge of its embryology and anatomy is essential.

Benign anatomical mistakes: right and left coronary ligaments.

Peritoneal attachments of the liver to the diaphragm include the falciform ligament, the left triangular ligament, and the coronary ligament with the right triangular ligament. It is often surgically convenient when the gastroesophageal junction is explored to refer to a "right" and a "left" coronary ligament, but this is anatomically unjustified. To reassess the issue there are no "right" and "left" coronary ligaments; there are only the left triangular ligament and the complex of coronary and right triangular ligament. The latter is the lateral unification of the layers of the coronary ligament. The liver is posteriorly connected to the diaphragm, and therefore the coronary ligament has superior and inferior layers rather than anterior and posterior layers. Embryologically these ligaments reflect the remnants of the developmental pathways of the liver in the septum transversum, and in the mature organism they are peritoneal connections. Besides the liver is suspended in the bare area mostly by fibrous attachments and by the hepatic veins. Consequently the term "ligament" for these structures has to be revised. Therefore we suggest the terms "left triangular peritoneal attachment" of the liver and "coronary peritoneal attachment" instead of "left triangular ligament" and "coronary ligament."

Benign anatomical mistakes: incidentaloma.

The concept of the "incidentaloma," a totally asymptomatic nonfunctional tumor that is clinically and biochemically silent and discovered "incidentally" in a totally asymptomatic patient, is a by-product of the evolving diagnostic techniques of the last three decades. Various authors have used the concept for "incidental" findings during diagnostic workup for symptoms unrelated to adrenal disease, or for "incidental" adrenal tumors unrelated to symptoms that could potentially be of adrenal origin. "Incidentaloma" has been used to encompass a wide and heterogeneous spectrum of pathologic entities including adrenocortical and medullary tumors, benign or malignant lesions, hormonally active or inactive lesions, metastases, infections, granulomas, infiltrations, cysts and pseudocysts, hemorrhages, and pseudoadrenal masses. The term "incidentaloma" does not indicate whether the mass is functional, or malignant, or adrenocortical in origin. "Incidentaloma" has also appeared in the literature in reference to other endocrine organs such as pituitary, thyroid, and parathyroids, as well as the liver or kidney. We question the scientific justification for this neologism and suggest that it should be abolished. Questionable lesions should be clearly and simply described as "incidentally found."

Benign anatomical mistakes: inferior pulmonary ligament.

The term inferior pulmonary ligament needs to be revised. There is no superior component to oppose the inferior. By all means the pulmonary ligament is not a ligament, and the term ligament should be reserved for regularly oriented thick connective tissue bundles between bones. The term triangular ligament describes its shape but not its topography. For most surgeons the broad ligament refers, rather, to the ligament of the uterus. Embryologically pulmonary ligament is a "meson" i.e., a remnant of the developmental pathway--the pleural fold in this case--and taking this into consideration the most convenient term seems to be mesopneumonium. Its upper part is related to the hilar area, and its lower free border is what we call pulmonary ligament. We suggest the term mesopneumonium to describe the whole "meson" from the mediastinum to the hilum, which corresponds better to topography, embryology, and function.

Surgical anatomy of the submandibular triangle.

The topographic anatomy of the submandibular triangle and its contents are described in terms of four surgical planes, with considerations of the anatomic complications during surgery. Attention is called to the importance of identifying and sparing five nerves in this triangle--the mandibular and cervical branches of the facial nerve, the hypoglossal nerve, the lingual nerve, and the chorda tympani.

Testicular atrophy and neuropathy in herniorrhaphy.

This study is based upon our collective experience with more than 3000 open herniorrhaphies, dissection of 99 cadavers from the external approach, and 39 cadavers from open dissections, including 14 laparoscopic dissections. These observations may be of use in avoiding pitfalls in hernioplasty, either from the classic external surgical approaches or those from within, whether transperitoneal or preperitoneal.

Embryological considerations of thyroid surgery: developmental anatomy of the thyroid, parathyroids and the recurrent laryngeal nerve.

The surgeon planning a thyroidectomy must be prepared to find variations in three important structures in the neck. He must be prepared to find ectopic thyroid nodules above, below or lateral to the normally located thyroid gland. Any unattached nodule should be considered malignant until proved otherwise. He must identify and preserve parathyroid glands that may not lie in the typical location. He must be prepared to encounter recurrent laryngeal nerves that do not recur. The surgeon who remembers the embryology of the structures in the neck may occasionally be astonished, but never surprised.

The surgical anatomy of the deep femoral artery.

Lower extremity ischemia is a common disorder that in the majority of cases is associated with occlusion of the superficial femoral artery. The deep femoral artery is recognized as an important collateral pathway to the genicular arterial system, thus accounting for the appearance of symptoms only after its involvement in the disease process. Surgical exposure of the deep femoral artery is often necessary in vascular reconstructive procedures. Furthermore, because it supplies the bulk of the thigh musculature, plastic surgeons have shown great interest in the muscular branches of the deep femoral artery when designing procedures that incorporate myocutaneous flaps. This article gives a detailed account of the embryology, anatomical relations, important variations, and branches of the deep femoral artery. Recommendations for the surgical exposure of this artery at different levels are also presented.

The surgical anatomy of the popliteal artery.

The popliteal artery is a common recipient site for above or below knee bypass grafts. It is also frequently affected by penetrating and blunt trauma involving the lower extremity. Exposure of this artery is, therefore, often required in both emergent and elective vascular procedures. In close proximity to the artery, within the confines of the popliteal fossa, are the tibial nerve, common peroneal nerve, and the popliteal vein. An understanding of the normal anatomy and the important variations in the popliteal bifurcation patterns is essential. In this report, we have combined data from new cadaver dissections with prior anatomical data to describe the anatomy of the popliteal fossa and important vascular anomalies.