Angiographic and electron-beam computed tomography studies of retrograde cardioplegia via the coronary sinus.

Retroperfusion of the coronary sinus does not provide homogeneous distribution of cardioplegic solution. The goal of this study was to analyze the distribution of flow during retrograde cardioplegic infusion in cadaveric human hearts with two different techniques of coronary sinus cannulation: (1) internal occlusion of the coronary sinus by balloon inflation and (2) external occlusion by tightening the orifice of the coronary sinus around a simple catheter. To evaluate differences between the two techniques, angiographic and electron-beam computed tomographic studies were performed. Computed digital angiography was performed on 14 hearts. Angiographic patterns varied according to type of coronary sinus cannulation. With the balloon inflation technique, the marginal vein and the anterior descending vein were perfused first; the posterior descending vein was not perfused. This vein was opacified secondarily through a venovenous anastomosis located at the apex of the heart. Backward flow into the right atrium (steal phenomenon) was demonstrated. At completion of retroperfusion, the inferior part of the septum remained poorly opacified. Conversely, angiographic findings after external occlusion of the coronary sinus revealed simultaneous injection of all venous channels. The entire septum was well opacified at completion of retroperfusion. Electron-beam computed tomographic study was performed on eight hearts with the external occlusion technique and nine with the internal occlusion technique. The computed tomographic findings confirmed the results of digital angiography. The peak myocardial enhancement and the peak rising rate of myocardial enhancement within the interventricular septum were significantly more important (p < 0.0001) when the external coronary sinus occlusion mode was used than when the internal coronary sinus occlusion mode was used. In all hearts except one, the right ventricular wall was not opacified, regardless of the type of cannulation and the type of radiologic analysis. This study demonstrates the importance of coronary sinus cannulation technique in optimizing the protection of the interventricular septum with retrograde cardioplegic infusion.

Endoscopic technique for suturing posterior chamber intraocular lenses.

A challenge of the sutured posterior chamber intraocular lens (IOL) technique is to perform blind actions behind the iris. To avoid imprecise transscleral sutures and complications, we use an endoscopic procedure with 2 goals: to control the entry site of the needle penetration and of the haptic location. The endoscopic technique allows retroiris control during transscleral suturing and iridociliary IOL implantation. It is a safe, precise method that avoids the risks of blind procedures behind the iris.

Morphologic classification of the mitral papillary muscles.

BACKGROUND AND AIMS OF THE STUDY: Mitral homograft replacement requires a good knowledge of the anatomy of the papillary muscles. Clinical experience with mitral homografts has revealed an as yet unexplored aspect of the morphology of the mitral subvalvular apparatus, that is correspondence between papillary muscle sub-divisions and chordal attachment to the leaflets. METHODS: To further our understanding we subjected 65 normal hearts to close scrutiny which confirmed our perioperative observations. RESULTS: We could establish a classification based on the ways that the papillary muscles relate to the leaflets via the chordae. Four types are described. In type I the papillary muscle is single. In type II the papillary muscle has two heads, one of which sends chordae exclusively to the posterior leaflet. In type III the papillary muscle is also divided, one head supporting the commissural area exclusively. Type IV PM resembles type III but is distinguished from it in the way that the head supporting the commissure is very short. In this type the different heads also originate at different levels on the ventricular wall from the apex to the base.

Autologous pericardial patch harvesting site for cardiac valve repair: anatomic and morphometric considerations.

BACKGROUND AND AIMS OF THE STUDY: Short-term glutaraldehyde-fixed autologous pericardium is widely used in cardiac valve repair or in autologous pericardial bioprosthesis construction. The thinner the tissue, the better the fixation. The aim of this study was to determine thickness and useful surface area of pericardium in relation to harvesting site using a digital thickness counter (0.01 mm precision). METHODS: Parietal pericardium fragments were obtained from the pericardial sac of six fresh cadavers (group I). In the other groups, pericardial strips (80 x 30 mm) were obtained from patients undergoing surgery: group II patients (n = 5 females) and group III (n = 10 males) were non-cardiomegalic (cardiothoracic ratio (CTR)<0.5), while group IV patients (n = 5) were all cardiomegalic (CTR >0.5). RESULTS: Results were reported on a coloric scale according to measurement position. In group I, mean surface area was 93+/-18 cm2, and thickness gradually increased from 0.1 to 0.6 mm, maximally on the diaphragm, along the left heart side. In other groups, a gradual increase in thickness was identified towards the diaphragmatic zone. Significant differences in tissue thickness appear as a result of cardiomegaly, but are not related to the sex of the patients. CONCLUSIONS: Pericardium taken from the right anterior aspect of the pericardial sac in patients without cardiomegaly is the most appropriate tissue for valve reconstructive surgery, due to its thin nature and hence better fixation properties.

[Damage to the inguino-femoral nerves in the treatment of hernias. An anatomical hazard of traditional and laparoscopic techniques]. / La blessure des nerfs inguino-fémoraux dans les cures de hernie. Un danger anatomique des techniques traditionnelles et laparoscopiques.

Laparoscopic techniques currently constitute an alternative proposed for the repair of hernias of the inguinofemoral region. Nerve injuries have led some teams to recommend technical principles based on the anatomical relations of these nerves with the subperitoneal fascia transversalis and inguinal fossae. An anatomical study consisting of dissection of nonembalmed cadavres, allowed, after evisceration, dissection of the lumbar plexus and its terminal branches, particularly those supplying the inguinofemoral region: iliohypogastric and ilio-inguinal nerves, the genitofemoral nerve, the femoral nerve and the lateral cutaneous nerve of the thigh. Via transperitoneal laparoscopy, the posterior surface of the anterior abdominal wall is centered on the deep inguinal ring, containing testicular vessels and the vas deferens. This deep inguinal ring receives the genitofemoral nerve. Medially, the anterior parietal peritoneum describes three folds formed by the outline of the epigastric artery, umbilical artery and urachus on the midline. The outline of Hesselbach's ligament separates the deep inguinal ring from Hesselbach's triangle, the zone of weakness of direct inguinal hernia. The iliac psoas muscle pass laterally underneath the inguinal ligament, while the external iliac vessels, subsequently becoming the femoral vessels, are located medially. Pectineal ligament lies on the posterior surface of the femoral ring between the umbilical artery and the epigastric artery. Installation of an abdominal wall prosthesis, either transperitoneally or retroperitoneally, must be centered on the deep inguinal ring, and its solid sutures are located medially to the pectineal ligament and anterior abdominal wall. On the other hand, the nerves at risk of being damaged are situated laterally: the ilio-inguinal and ilio-hypogastric nerves in the plane between external oblique and internal oblique above the anterior superior iliac spine, lateral cutaneous nerve of the thigh under the inguinal ligament close to the anterior superior iliac spine, genitofemoral nerve with the spermatic cord in the deep inguinal ring and femoral nerve underneath the inguinal ligament with the psoas muscle lateral to the external iliac artery. No stapling must be performed under the plane of the inguinal ligament to avoid damage to the femoral vessels and lateral to the deep inguinal ring to avoid nerve damage.

[The anatomy collections of the Paris V University: their role in medical teaching for two centuries]. / Les collections d'anatomie de l'université Paris V: leur rôle dans l'enseignement de la médecine depuis deux siècles.

The Museum of anatomy of the University Paris V exhibits a collection of ancient and high quality dissections and waxworks, very well preserved, which were used for teaching anatomy and have been classified historic monument since 1992.

[Radio-anatomical guides for the dorsal puncture-biopsy]. / Repères radio-anatomiques pour la ponction-biopsie dorsale.

This paper describes a specific prone oblique view very helpful to thoracic vertebral bone biopsy under fluoroscopic control. In this position the costal head and neck axis gives the direction of the procedure. A puncture between two ribs following this direction easily avoids both the pleura and spinal canal. This thoracic biopsy of the vertebral body and disc under fluroscopic control becomes a reliable diagnostic tool.

[Micro-endoscopy of the lacrimal apparatus combined with Erbium YAG laser: an anatomical study. New methods of imaging]. / Micro-endoscopie des voies lacrymales combinée au laser YAG Erbium: étude anatomique. Nouvelles méthodes d'imagerie.

PURPOSE: To study the anatomic structure and the endoscopic aspect of the lacrimal drainage system and to evaluate the efficacy of the Erbium laser with microendoscope in lacrimal obstruction. METHODS: Twenty lacrimal ducts from ten fresh cadaver heads were used to lead a special rigid probe of 1.1. mm diameter (Endognost Schwind). This probe combined a flexible endoscopic probe of 500 mu, an Erbium laser fiber of 375 mu and an irrigation. The probe was introduced through the inferior canaliculus. Progressing in the lacrimal system, all the images were analysed. Then, we used the laser fiber to open the lacrimal sac mucosa and the lacrimal bone. RESULTS: The anatomo-endoscopic analysis was performed using endoscopic data. We appreciated essentially the walls of valves and sinuses that appeared only functional when increasing the irrigation flow. The laser could easily open the mucosa and the lacrimal bone but not the maxilla. DISCUSSION: The small size of the cannula allows to use the system for the diagnosis of lacrimal obstructions. The combined laser allows to treat at same time canalicular obstructions and lower obstructions. CONCLUSION: The endocanalicular study of the lacrimal drainage system can diagnose the type of obstruction and can treat it. A clinical study is requested to confirm these results.

[Quantitative 3D anatomy of the lumbar spine]. / Anatomie quantitative tridimensionnelle du rachis lombaire.

PURPOSE OF THE STUDY: There are many anatomic descriptions of the spine, but most concentrate on qualitative information. Quantitative data is however important to achieve a better clinical approach, to adapt implant size and to construct geometric models of spine mechanics. MATERIAL AND METHODS: We examined 32 dry spines (160 lumbar vertebrae) obtained from the Orfila Museum anatomy laboratory at the Saints-Pères School of Medicine in Paris. We drew 178 landmarks on the surface of each vertebra and recorded the 3D spatial coordinates of each point using a Fastrack electromagnetic system operating with +/- 0.2 mm precision. The coordinates of the digitalized points were expressed in a local x-y-z axis field (x=posteroanterior axis, y=right-left axis, z=caudocranial axis). The origin O was half way between the "centers" of the vertebral plates. After calculating 112 linear, angular and surface parameters, results were analyzed with the Statview statistics system. RESULTS: All parameters exhibited gaussian distribution. The transpedicular vertebral depth, corresponding to the maximal penetration of a pedicular screw before touching the anterior wall, was nearly constant: 48 mm (mean). The mean height of the pedicle was approximately 16 mm for L1 to L4 and 21 mm for L5. Pedicle width was 7 mm for L1 and L2 then rapidly widened to reach 10 mm for L5. It was noteworthy that the narrowest pedicle (4 mm) was found in 10% of the L1 vertebrae. There was an exponential rise in the sagittal tilt of the pedicles from L1 to L5, measuring approximately 8 degrees for L1 and rising to 24 degrees for L5. DISCUSSION: Our sample of human spines with unknown clinical characteristics (age, sex) is representative of anatomy laboratory populations, generally composed of subjects over 40 years of age, and is thus adapted for studies of the degenerative spine. Our findings are generally in agreement with data reported in the literature and also provided complementary quantitative data concerning the transpedicular vertebral depth that was found to be a rather constant feature of the lumbar spine. It measured between 40 and 56 mm for 95% of the study population. The dimensions of the pedicle is particularly important: the width must be known to determine the size of pedicle screws; it measured between 7 and 12 mm in 95% of the population. The largest mean cross section of the pedicle was found for L5 (82mm(2)), but measured less than 60 mm(2) in 10% of the vertebrae, suggesting predisposition to spondylolysis.

[The canons of morphotypes in adults. Anatomic atlas and database]. / Les canons des morphotypes chez l'adulte. Atlas anatomique et datalise.

Orthopedic surgery for subjects of small stature, (between 130 cm and 160 cm), after the end of the normal growth cycle, requires a definition of the individual's morphotype, according to the standard canons. There exists a "classic canon", from Mediterranean culture, which divides the human body, from the waist, into two unequal parts (in the longitudinal dimension), which can vary from excessive shortness to excessive height. These proportions are strongly hereditary. In the transversal sense, there exists also measurements which can widely vary. These, are also strongly hereditary. Thus, defining five measurements: Stature. Height from the waist to the ground. Height from the waist to the top-head. Width of the shoulders. Width of the pelvis. From these five measurements, in the longitudinal and transversal dimensions, we obtain the well defined outlines of the subject's morphotype as well as, all other variations of this morphotype. Because there are separate variations of the transversal and longitudinal canons. A canon is specific to a group or a population. There are an infinite number of canons on this earth. Before starting limb lengthening surgery, it's necessary to define the morphotype (canon) of the subject. The harmony or dysharmony of his body proportions. As well as determine, at which point of lengthening, will the patient realise a true benefit for this difficult surgery.

[Partial arthrodeses of the wrist: experimental studies]. / Arthrodèses partielles du poignet: études expérimentales.

The partial arthrodeses of the wrist joint are well known as a method of treatment of several articular pathologies. Although there exists controversies about the final range of motions. In the goal to compare the state of the ligaments to the final range of motions we realised some of the most popular intracarpal arthrodeses in an anatomical laboratory. For our study we used 10 fresh cadaver specimens with the mean age of 88 years (84-95). The arthrodeses were realised with Kirschner wires. Biggest range of motion (more than 70%) was obtained after scapho-lunatum, scapho-capitatum and luno-triquetrum arthrodeses, while after luno-capitatum, scapho-luno-capitatum and triquetro-hamato-luno-caitatum it was the poorest--less than 50% of the initial state. We found a correlation between the state of the ligaments and the final results--in specimens with tears of the ligaments the results were closer to the perfect-ones from the clinical series. In our opinion the measurement of radial and ulnar deviation in clinical practice is not exact and should not be considered in the elaboration of scientific databases.

[The fibrous frame of the rotator cuff. Contributions of an in vivo three dimensional study of the tendons of the rotator cuff]. / Le squelette fibreux de la coiffe des rotateurs. Apports de l'étude tridimensionnelle in vivo des tendons de la coiffe des rotateurs.

The presence of a fibrous frame within the rotator cuff has been recently emphasized. This frame may be of interest in understanding of shoulder physiology and in attempts to improve shoulders disorders treatments. We report an original method to study the fibrous frame. MRI were done in healthy volunteers. 3D reconstruction were obtained and provided a 3D image of the fibrous frame. This technic should allow to calculate, for instance, the angles between the cuff muscles and the upper end of the humerus.

[Innervation of Denonvilliers' recto-vesical septum. Anatomic study]. / Innervation du septum recto-vésical de Denonvilliers. Etude anatomique.

OBJECTIVE: The retro vesical septum (DENONVILLIERS) can be dissected and separated of the prostate and the bladder. The neurovascular bundles bound laterally this septum and it must be removed during radial prostatectomy. The aim of this study was to know if this septum is crossed by nerves. MATERIAL AND METHODS: Dissection of cadaver--histological study of recto-vesical fascia. RESULTS: Nerves are present coming from the neurovascular bundle to the septum and end in the prostate. CONCLUSION: These anatomical observations conduct to recommend to remove systematically the recto-vesical septum during radical prostatectomy for cancer.

[The pericardium: a heterogeneous tissue. Anatomic and morphometric considerations]. / Le péricarde: un tissu hétérogène. Considérations anatomiques et morphométriques.

BACKGROUND AND AIMS OF THE STUDY: Short-term glutaraldehyde fixed autologous pericardium is widely used in cardiac valve repair or in autologous pericardial bioprosthesis construction. The thinner the tissue, the better the fixation. The aim of this study was to determine thickness and useful surface area of pericardium in relation to harvesting site using a digital thickness counter (0.01 mm precision). Parietal pericardium fragments were obtained from the pericardial sac of six fresh cadavers (group I). In the other groups, pericardial strips (80 x 30 mm) were obtained from patients undergoing surgery: group II patients (n = 5 females) and group III (n = 10 males) were non-cardiomegalic (cardiothoracic ratio (CTR) < 0.5)), while group IV patients (n = 5) were all cardiomegalic (CTR > 0.5). Results were reported on a coloric scale according to measurement position. In group I, mean surface area was 93 +/- 18 cm2, and thickness gradually increased from 0.1 to 0.6 mm, maximally on the diaphragm, along the left heart side. In other groups, a gradual increase in thickness was identified towards the diaphragmatic zone. Significant differences in tissue thickness appear as a result of cardiomegaly, but are not related to the sex of the patients. Pericardium taken from the right anterior aspect of the pericardial sac in patients without cardiomegaly is the most appropriate tissue for valve reconstructive surgery, due to its thin nature and hence better fixation properties.

[Anatomic study of the pubic-urethral ligaments in women: role of urethral suspension]. / Etude anatomique des ligaments pubo-uréthraux chez la femme: rôle dans la suspension de l'urèthre.

OBJECTIVE: In 1963, the studies by Zacharin emphasized the importance of the suspensory apparatus of the female urethra, consisting of two non-extensible fibrous bands composed of 3 distinct ligaments. The objectives of this study were to evaluate the role of these ligaments in support of the urethra and to define the value of their preservation in cystectomy with bladder replacement in women. MATERIAL AND METHODS: Five fresh female cadavres with a mean age 78 years (range: 75-82) were used for dissection of the suspensory apparatus of the urethra via a suprapubic then sagittal approach by section of the pelvis 2 cm from the midline. Histological studies of the urethra were then performed. RESULTS: The suspensory apparatus of the urethra was found to be a paired, symmetrical system composed of 2 paired and symmetrical fibrous bands. Dissection of these bands revealed three anterior, intermediate and posterior pubourethral ligaments. The posterior pubourethral ligament was inserted on the anterior and lateral surfaces of the urethra and vagina (underneath the bladder neck) on anatomical studies, but also on histological sections. Section of the posterior pubourethral ligament allowed great mobility of half of the urethra. Section of these ligaments totally released the urethra from the pubis. CONCLUSION: Our study confirmed the importance of this ligamentous system in suspension of the urethra and demonstrated the value of preservation of these structures in cystectomy with bladder replacement in women.

[Can a precise vesiculectomy be performed during radical prostatectomy?]. / Peut-on faire une vésiculectomie réglée au cours de la prostatectomie radicale?

OBJECTIVE: To define the anatomical landmarks allowing precise vesiculectomy to be performed during radical prostatectomy for cancer. MATERIAL AND METHODS: 12 non-formalin-preserved anatomical subjects were dissected as during retropubic and perineal prostatectomy, with and without coloured latex vascular injection. RESULTS: Three anatomical landmarks were defined: 1) Denonvilliers' fascia; 2) vas deferens; 3) arteries supplying the seminal vesicles. CONCLUSIONS: These three anatomical landmarks ensure: complete resection, preservation of adjacent anatomical structures and elective haemostasis.