Lower Four Cranial Nerves in the Management of Glomus Jugulare: Anatomical Study

Abstract Introduction The surgical management that achieves minimal morbidity and mortality for patients with glomus and non-glomus tumors involving the jugular foramen (JF) region requires a comprehensive understanding of the complex anatomy, anatomic variability, and pathological anatomy of this region. Objective The aim of this study is to propose a rational guideline to expose and preserve the lower cranial nerves (CNs) in the lateral approach of the JF. Methods The technique utilized is the gross and microdissection of 4 fixed cadaveric heads to revise the JF's surgical anatomy and high part of the carotid sheath compared with surgical cases to understand and preserve the integrity of lower CNs. The method involves radical mastoidectomy, microdissection of the JF, facial nerve, and high neck just below the carotid canal and the JF. The CNs IX, X, XI, and XII are microscopically dissected and kept in sight up to the JF. Results This study realized well the surgical and applied anatomy of the lower CNs with relation to the facial nerve and JF. Conclusions The JF anatomy is complicated, and the key to safely operate on it and preserving the lower CNs is to find the posterior belly of the digastric muscle, to skeletonize the facial nerve, to remove the mastoid tip preserving the stylomastoid foramen, to skeletonize the sigmoid sinus and posterior fossa dura not only anterior but also posteroinferior to reach and drill the jugular tubercle.

Extracranial landmarks for surgical skull base approaches / Puntos de referencia extracraneales para abordajes quirúrgicos de la base del cráneo

SUMMARY: Surgical operations regarding to skull base are challenging and reliable anatomical landmarks are required. There is a lack of knowledge on anatomical variations in this region. The aim of this study was to determine the safe extracranial landmarks for surgical approach to the skull base. In this study, 23 adult dry skulls were evaluated: the age and sex of the specimens were unknown. All measurements were taken from external surface of inferior aspect of the skull by using digital calipers accurate to 0.01 mm. In right and left sides; the distances between the external acoustic meatus (EAM) and the following anatomical landmarks were measured: articular tubercle (AT); anterior margin of squamous suture (ASS); superior margin of squamous suture (SSS); posterior margin of squamous suture (PSS); end point of styloid process (SP); midpoints of pterygomaxillary fissure (PMF); foramen ovale (FO); foramen spinosum (FS); and of carotid canal (CC).The distances of the external acoustic meatus to the anatomical structures on the right and left sides were: EAM-SP; 24.24±3.19 mm, 23.16±3.17 mm; EAM-PMF; 46.56±4.51mm, 46.25±3.96 mm; EAM-FO; 27.57±2.87 mm, 28.70±2.85 mm; EAM-FS; 22.53±3.19 mm, 22.72±3.47 mm; EAM-CC; 17.35±3.56 mm, 17.19±3.39 mm; EAM-AT; 19.31±3.79 mm, 18.95±3.42 mm; EAM-ASS; 43.14±4.80 mm, 46.82±4.61 mm; EAM-SSS; 49.17±4.74 mm, 48.83±3.34 mm and EAM-PSS; 36.15±4.24 mm, 35.39±4.25 mm, respectively. We think that the findings obtained from this study related to external acoustic meatus can be an important reference for surgical anatomy and surgical procedures in skull base.

RESUMEN: Las cirugías relacionadas con la base del cráneo son un desafío, las cuales requieren puntos de referencia anatómicos confiables. Existe una falta de conocimiento sobre las variaciones anatómicas en esta región. El objetivo de este estudio fue determinar los puntos de referencia extracraneales seguros para el abordaje quirúrgico de la base del cráneo. En este estudio se evaluaron 23 cráneos secos adultos: se desconocía la edad y el sexo de los ejemplares. Las medidas se tomaron de la superficie externa de la cara inferior del cráneo utilizando calibradores digitales con una precisión de 0,01 mm. En lados derecho e izquierdo se midieron las distancias entre el meato acústico externo (MAE) y los siguientes puntos de referencia anatómicos: tubérculo articular (TA); margen anterior de la sutura escamosa (MASE); margen superior de sutura escamosa (MSSE); margen posterior de sutura escamosa (MPSE); punto final del proceso estiloides (PFPE); puntos medios de la fisura pterigomaxilar (PMFP); foramen oval (FO); foramen espinoso (FE); y del canal carotídeo (CC). Las distancias del meato acústico externo a las estructuras anatómicas de los lados derecho e izquierdo fue- ron: MAE-PFPE; 24,24 ± 3,19 mm, 23,16 ± 3,17 mm; MAE-PMFP; 46,56 ± 4,51 mm, 46,25 ± 3,96 mm; MAE-FO; 27,57 ± 2,87 mm, 28,70 ± 2,85 mm; MAE-FE; 22,53 ± 3,19 mm, 22,72 ± 3,47 mm; MAE-CC; 17,35 ± 3,56 mm, 17,19 ± 3,39 mm; MAE-TA; 19,31 ± 3,79 mm, 18,95 ± 3,42 mm; MAE-MASE; 43,14 ± 4,80 mm, 46,82 ± 4,61 mm; MAE-MSSE; 49,17 ± 4,74 mm, 48,83 ± 3,34 mm y MAE-MPSE; 36,15 ± 4,24 mm, 35,39 ± 4,25 mm, respectivamente. Creemos que los hallazgos obtenidos de este estudio relacionados con el meato acústico externo pueden ser una referencia importante para la anatomía quirúrgica y los procedimientos quirúrgicos en la base del cráneo.

Anatomic landmarks for a safe arthroscopic approach to the deep gluteal space: a cadaveric study / Hitos anatómicos para un abordaje artroscópico seguro del espacio glúteo profundo: un estudio cadavérico

SUMMARY: To determine the morphometric landmarks and anatomical variants relevant to the arthroscopic approach to the deep gluteal space. Twenty deep gluteal spaces from cadaveric specimens were dissected. The anatomical variants of the sciatic nerve (SN) were determined according to the Beaton and Anson classification. A morphometric study of the distances in the subgluteal space was carried out to define the anatomical references to achieve a safe arthroscopic approach for piriformis syndrome [GT-SN=Distance from greater trochanter (GT) to SN emergence; GT-IT=Distance from GT to ischial tuberosity (IT); GT-IGA=distance from GT to inferior gluteal artery (IGA) emergence; IT-SN=distance from IT to SN emergence; IT-IGA=distance from IT to IGA]. The SN showed the most frequent anatomical pattern with an undivided nerve coming out of the pelvis below the piriformis muscle (Beaton type A) in 16 specimens (80 %). The common peroneal nerve emergence in the subgluteal space through the piriformis muscle (PM) with the tibial nerve being located at the lower margin of the piriformis muscle (Beaton type B) was observed in 4 specimens (20 %). The morphometric measurements of the surgical area of study were: GT-SN=7.23 cm (±8.3); GT-IT=8.56 cm (±0.1); GT-IGA=8.46 cm (±0.97); IT-SN=5.28 cm (±0.73), IT- IGA=5.47 cm (±0.74). When planning surgery for the deep gluteal syndrome in adult patients, the fact that the emergence of the SN in the subgluteal space is approximately 7 cm from the greater trochanter and 5 cm from the ischial tuberosity must be considered.

RESUMEN: El objetivo del estudio fue determinar referentes morfométricos y variantes anatómicas relevantes en el abordaje artroscópico del espació subglúteo. Se disecaron veinte regiones glúteas procedentes de cadáver. Las variaciones anatómicas del nervio ciático (SN) se determinaron de acuerdo con la clasificación de Beaton y Anson. Se llevó a cabo un estudio morfométrico de distancias en el espacio subglúteo, con objeto de determinar referencias que permitan un abordaje artroscópico seguro del sindrome piriforme [GT-SN= distancia trocánter mayor (GT) a la emergencia del nervio ciático (SN); GT-IT= distancia GT a la tuberosidad isquiática (IT); GT-IGA= distancia GT a la emergen- cia de la arteria glútea inferior (IGA); IT-SN= distancia IT a la emergencia del SN; IT-IGA= distancia IT a la IGA]. El patrón más frecuente del SN fue su emergencia no dividida por el margen inferior del músculo piriforme (tipo A Beaton) en 16 especímenes (80 %). La salida del nervio fibular común a través del músculo piriforme (PM) con el nervio tibial localizado en el margen inferior del PM (tipo B Beaton) se observó en 4 especímenes (20 %). Las medidas en el área quirúrgica de estudio fueron: GT-SN= 7,23 cm ± 8,3; GT-IT= 8,56 cm ± 0,1; GT-IGA= 8,46 cm ± 0,97; IT-SN= 5,28 cm ± 0,73 IT-IGA= 5,47 cm ± 0,74. En la cirugía del síndrome glúteo profundo en adultos, debe considerarse que la sa- lida del SN hacia el espacio subglúteo tiene lugar aproximadamente a 7 cm del GT y a 5 cm de la IT.

Computed Tomography Arteriography for Detecting the Origin of the Inferior Pyloric Artery in Patients with Gastric Cancer

OBJECTIVE: To analyze the detection rate of the inferior pyloric artery (IPA) in patients with gastric cancer by computed tomography arteriography (CTA). MATERIALS AND METHODS: Fifty-four patients (48 males and 6 females; mean age, 59.0 ± 1.5 years) who had undergone radical gastrectomy for gastric cancer from September 2016 to July 2017 at our institution were recruited prospectively. Patients underwent abdominal contrast-enhanced CT scans and CTA imaging reconstruction before the operation. The origin of the IPA in all cases was determined by a radiologist based on CTA images and verified by the surgeon. The accuracy of CTA in diagnosing the origin of the IPA was calculated. Dominant vessels of the origin were analyzed. RESULTS: IPAs were detected by CTA in 51 patients (94.4%). Among these, IPAs originated from the right gastroepiploic artery (RGEA) (24 cases), the gastroduodenal artery (GDA) (4 cases), and the anterior superior pancreaticoduodenal artery (ASPDA) (20 cases). In the remaining 3 cases, the IPAs contained two branches originating from the RGEA and ASPDA, respectively. During surgery, in 2 (3.7%) of the 54 cases of gastric cancer, IPAs could not be detected; the IPAs originated from the RGEA (22 cases), GDA (5 cases), and ASPDA (24 cases). One case had an IPA originating from both the RGEA and the GDA. Finally, the accuracy of CTA in diagnosing the origin artery of the IPA was 85.2% (46/54). CONCLUSION: CTA can detect the origin of the IPA accurately, which can aid surgeons while performing pylorus-preserving operations.

Morphological Analysis on the Occipital Condyles and Review of the Literature / Análisis Morfológico de los Cóndilos Occipitales y Revisión de la Literatura

Most anatomical and biomechanical studies on the craniovertebral junction have involved morphological or morphometric analysis on the occipital condyles. Some of these studies have provided important findings based on different surgical procedures. The shape, size and angle of the occipital condyles and the locations of the intracranial and extracranial orifices of the hypoglossal canal are highly important because they may affect the lateral approaches to the craniovertebral junction. To determine the frequency of occurrence of different morphological types of occipital condyle. 214 occipital condyles in 107 dry human skulls were analyzed and the classification of their morphological types was determined through assessing digitized photographic images. Among the 107 skulls analyzed, 59.8 % were male and 40.2 % were female. Their ages ranged from 11 to 91 years, with a mean of 57.56 years. Of the total of 10 morphological types of occipital condyle that were found, more than 50 % were of the "8", "S" and ring types. Condyles of "8" and "S" shape were the main types found in male skulls: the "8" shape prevailed on the left side and the "S" shape on the right side. However, in female skulls, these two types had equal bilateral distribution.

La mayor parte de los estudios anatómicos y biomecánicos de la unión cráneo-vertebral han sido realizados sobre el análisis morfológico o de la morfometría de los cóndilos occipitales. Algunos de estos trabajos tienen previsto importantes hallazgos basados en diferentes procedimientos quirúrgicos. De tal forma, el tamaño y ángulo del cóndilo occipital bien como su localización de los orificios intracraneales y extracraneales del canal hipogloso son de gran importancia, ya que pueden afectar a los enfoques laterales de la unión cráneo-vertebral. El objetivo del estudio fue determinar la prevalencia de los tipos morfológicos de cóndilos occipitales. Fueron analizados 214 cóndilos de 107 cráneos secos de humanos y la clasificación de los tipos morfológicos fue determinada a partir de los análisis de estudio de imágenes fotográficas digitalizadas. De los 107 cráneos que fueron analizados, 59,8 % eran de sexo masculino y 40,2 % de sexo femenino, cuyas edades comprendidas entre 11 y 91 años con una media de 57.56 años. De un total de 10 tipos morfológicos de los cóndilos occipitales encontrados, más del 50 % eran de tipo ocho, S y anillo. Los cóndilos en forma de "8" y "S" fueron los principales tipos encontrados, en el sexo masculino, la forma en "8" prevaleció en el lado izquierdo, y el tipo morfológico en "S", en el lado derecho del cráneo. Mientras que en el sexo femenino esos dos tipos tuvieron una equitativa distribución bilateral.

Morphometric evaluation of the uncinate process and its importance in surgical approaches to the cervical spine: a cadaveric study

<p><b>INTRODUCTION</b>The uncinate process (UP) has an important role because of its relationship with the vertebral artery and spinal roots. Degenerative diseases cause osteophyte formation on the UP, leading to radiculopathy, myelopathy and vertebral vascular insufficiency, which may require surgical management. This study aimed to evaluate the morphometry of this region to shed light on the anatomy of the UP.</p><p><b>METHODS</b>Morphometric data was obtained from 13 male formaldehyde-fixed cadavers. Direct measurements were obtained using a metal caliper. Computed tomography (CT) morphometry was performed with the cadavers in the supine position.</p><p><b>RESULTS</b>Direct cadaveric measurements showed that the height of the UP increased from C3 (5.8 ± 1.0 mm) to C7 (6.6 ± 0.5 mm). On CT, the corresponding measurements were 5.9 ± 1.2 mm at C3 and 6.9 ± 0.6 mm at C7. The distance between the left and right apex of the UP from C3 to C7 also increased on both direct cadaveric and CT measurements (C3: 20.8 ± 1.0 mm and C7: 28.1 ± 2.4 mm vs. C3: 23.7 ± 3.4 mm and C7: 29.0 ± 3.0 mm, respectively). On CT, the distance between the UP and superior articular process at the C3 to C7 levels were 9.8 ± 1.7 mm, 7.9 ± 1.8 mm, 7.9 ± 1.6 mm, 7.8 ± 1.3 mm and 8.2 ± 1.7 mm, respectively.</p><p><b>CONCLUSION</b>Direct cadaveric and CT measurements of the UP are useful for preoperative evaluation of the cervical spine and may lead to better surgical outcomes.</p>

Re-orientation of gynaecology residents on pelvic surgical anatomy using human cadaver.

Background and Objectives: The residents of gynaecology should have sound knowledge on pelvic anatomy and have to be adequately trained on common surgical procedures. The training programme was conducted in the dissection hall of Anatomy department of Rural Medical college Loni .During residency, they may not receive adequate training on common surgical procedures for various reasons like shortage of cases, infrequent performance of certain procedures, inability of the faculty to give time ,attention for training in OT and fear of possible complications and medico legal litigations. Material and methods: Twelve residents in Gynaecology and two senior faculty members each from the department of Gynaecology and Anatomy participated in training programme. Five training sessions of dissection of a single human female cadaver ,each lasting for two and half hour duration, were conducted. Pretest and post test were performed with prevalidated and pre tested questionnaire and results compared to assess the impact of training. Level of satisfaction of residents about this innovative method of teaching and training was assessed through 7 point Likert scale. Results: Training programme resulted in significant improvement in the residents knowledge on pelvic surgical anatomy and common surgical gynaecological Procedures. Faculty members identified new insights into the interdisciplinary process of teaching . Conclusion: Surgical training using human cadaver was effective and feasible .It made the teaching process interactive and interesting. Residents expressed happiness about the innovative method of teaching.

Free Hand Pedicle Screw Placement in the Thoracic Spine without Any Radiographic Guidance : Technical Note, a Cadaveric Study

Thoracic pedicle screw fixation techniques are still controversial for thoracic deformities because of possible complications including neurologic deficit. Methods to aid the surgeon in appropriate screw placement have included the use of intraoperative fluoroscopy and/or radiography as well as image-guided techniques. We describe our technique for free hand pedicle screw placement in the thoracic spine without any radiographic guidance and present the results of pedicle screw placement analyzed by computed tomographic scan in two human cadavers. This free hand technique of thoracic pedicle screw placement performed in a step-wise, consistent, and compulsive manner is an accurate, reliable, and safe method of insertion to treat a variety of spinal disorders, including spinal deformity.

Cirurgia da base do crânio: uma desafiadora especialidade da medicina moderna / Skull base surgery: a challenging speciality of modern medicine

A cirurgia da base do crânio emerge como uma especialidade da medicina moderna. Seu principal objetivo é tratar lesões, principalmente tumores, situados em complexa topografia anatômica e que, há duas décadas, eram considerados inoperáveis. O objetivo desta revisão é fornecer ao médicos generalistas uma visão dos aspectos conceituais, históricos, patológicos, epidemiológicos, clínicos e terapêuticos em cirurgia da base do crânio.

Skull base surgery has emerged as a specialty in modern medicine. Its main objective is to treat injuries, especially tumors located in anatomically complex sites that two decades ago were considered inoperable. The aim of this review is to provide general practitioners with a view of conceptual, historical, pathological, epidemiological, clinical and therapeutic aspects of skull base surgery.

Tetralogía de Fallot con atresia pulmonar: Morfopatología y anatomía quirúrgica / Tetralogy of Fallot with pulmonary atresia: Morphopathology and surgical anatomy

Se detalla la morfopatología de la tetralogía de Fallot con atresia pulmonar como un espectro de variaciones que sirve de fundamento para destacar la anatomía quirúrgica de esta cardiopatía y se muestra la base embriológica que determina su estructura. Se estudiaron 35 corazones con el sistema secuencial segmentario. Se determinó: situs atrial, conexiones entre los segmentos cardíacos y entre el ventrículo derecho y la vasculatura arterial pulmonar. El situs atrial fue solitus, predominó la conexión atrioventricular concordante (33), las conexiones ventriculoarteriales fueron concordantes (17), doble salida de ventrículo derecho (9) y única vía de salida (9). Todos presentaron atresia valvular pulmonar; el tronco pulmonar fue hipoplásico (20), atrésico proximal (6) y ausente (9), ramas pulmonares confluentes e hipoplásicas (25), ausencia de confluencia (5), ausencia total de ramas y de conductos arteriosos (5) y colaterales aortopulmonares (10). Los corazones mostraron un espectro morfopatológico de severidad que expresa la tendencia a la desaparición de la conexión entre el ventrículo derecho y la circulación arterial intrapulmonar. Se resaltan las formas de la irrigación arterial pulmonar como fundamento para unifocalizar el flujo hacia los pulmones y se hace hincapié en la utilidad de la clasificación anatomoquirúrgica de Barbero Marcial. El conocimiento embriológico es útil para entender las conexiones vasculares del ventrículo derecho con los derivados de los sextos arcos aórticos, los vasos arteriales intrapulmonares y las colaterales aortopulmonares.

The morphopathology of tetralogy of Fallot with pulmonary atresia is detailed as a spectrum of variations which is the foundation to highlight the surgical anatomy of this cardiopathy and it is shown the embryological basis which determines its structure. Thirty five hearts were studied with the methodology of the segmental sequential system. The atrial situs, the connections between the cardiac chambers and between the right ventricle and the arterial pulmonary vasculature were determined. The atrial situs was solitus, the concordant atrioventricular connection was the most frequent (33), the ventriculoarterial connections were concordant (17), double outlet right ventricle (9) and single outlet (9). All hearts had atresia of the pulmonary valve; the pulmonary trunk was hypoplastic (20), atretic proximally (6) and completely absent (9), confluent and hypoplastic pulmonary branches (25), absence of confluence (5), complete absence of pulmonary branches and arterial ducts (5) and presence of aortopulmonary collaterals (10). The hearts show a morphopathologic spectrum of severity which documents the tendency in disappearing the connection between the right ventricle and the intrapulmonary arterial circulation. The determination of the arterial supply to the lungs is highlighted to unifocalize the blood flow toward the lungs. The usefulness of Barbero Marcial's surgical classification is emphasized. The embryologic knowledge is basic in understanding the vascular connections between right ventricle and the derivatives of embryonic sixths aortic arches, the intrapulmonary arterial vessels and the aortopulmonary collaterals.

Surgical anatomical measurements of patellar ligaments for blind method of medial patellar desmotomy of cattle during upward patellar fixation in Bangladesh / Mediciones anatómicas quirúrgicas del ligamento patelar por técnica ciega en la desmotomía medial patelar de ganado durante la fijación superior de la patela en Bangladesh

The study was aimed to determine the accurate location of giving incision and the width of the incision required to correct the problem of upward patellar fixation during blind method of medial patellar desmotomy. We took measurements of patellar ligaments in stifle joint of 50 indigenous and 50 crossbred slaughtered cattle without any apparent musculo-skeletal disorders were analysed. The average length and width of lateral, middle, and medial patellar ligaments for indigenous cattle were 9.360 +/- 0.339 and 3.056 +/- 0.226; 10.230 +/- 0.382 and 2.019 +/-0.258; 10.519 +/- 0.429 and 2.430 +/-0.232; for crossbred cattle 10.636 +/- 0.601 and 3.608 +/- 0.368; 11.580 +/- 0.724 and 2.330 +/- 0.205; 12.366 +/- 0.710 and 2.890 +/- 0.234 cm respectively. The average groove width for indigenous cattle and crossbred cattle between middle and medial ligament were 1.356 +/- 0.160 and 1.828 +/-0.186 cm and the highest width of groove between middle and medial patellar ligaments from the level of most cranial bulging of the cranial tibial tuberosity in the upward direction were 4.234 +/- 0.269 and 5.645 +/-0.358 cm respectively. Parameters measured were significantly different (p0.05) between indigenous and crossbred cattle. This study was suggested that incision should be made 4.234 +/- 0.269 and 5.645+/-0.398 cm proximally from the level of the most cranial bulging of cranial tibial tuberosity at the groove between middle and medial patellar ligaments, 2.430 +/-0.232 and 2.890+/-0.186 cm the mean width of the medial ligament to be cut during blind method of medial patellar desmotomy in indigenous and crossbred cattle respectively during surgical correction of upward patellar fixation.

El estudio fue dirigido a determinar la ubicación exacta de la incisión y el ancho necesario de la incisión para corregir el problema de la fijación superior patelar durante la técnica ciega de la desmotomia medial patelar. Se tomaron y analizaron medidas del ligamento patelar en la rodilla de 50 bovinos indígenas y 50 bovinos mestizos de criadero, sacrificados sin aparentes trastornos músculo-esqueléticos. El promedio de longitud y ancho lateral, central y medial del ligamento patelar para el ganado indígena fueron 9,360 +/- 0,339 y 3,056 +/- 0,226; 10,230 +/- 0,382 y 2,019 +/- 0,258; 10,519 +/- 0,429 y 2,430 +/- 0,232, y para el ganado mestizo 10,636 +/- 0,601 y 3,608 +/- 0,368; 11,580 +/- 0,724 y 2,330 +/- 0,205; 12,366 +/- 0,710 y 2,890 +/- 0,234 cm, respectivamente. El promedio del ancho del surco para el ganado bovino indígena y el mestizo entre el ligamento medio y ligamento medial fue 1,356 +/- 0,160 y 1,828 +/- 0,186 cm, y el máximo ancho del surco entre el ligamento medio y ligamento medial patelar desde el nivel más craneal del abultamiento de la tuberosidad tibial craneal en dirección hacia superior fueron 4,234 +/- 0,269 y 5,645 +/- 0,358 cm, respectivamente. Los parámetros medidos fueron significativamente diferentes (p 0,05) entre el ganado indígena y el ganado mestizo. Este estudio puede sugerir que la incisión puede ser hecha 4,234 +/- 0,269 y 5,645 +/- 0,398 cm proximalmente desde el nivel más craneal del abultamiento de la tuberosidad tibial craneal hasta el surco entre el ligamento patelar medio y medial. 2,430 +/- 0,232 y 2,890 +/- 0,186 cm fue la media del ancho del ligamento medio a ser cortada durante la técnica ciega de la desmotomía medial patelar del ganado indígena y mestizo respectivamente, durante la corrección quirúrgica de fijación superior patelar.

Anatomy of the facial nerve and its implication in the surgical procedures / Anatomía del nervio facial y sus implicancias en los procedimientos quirúrgicos

Facial palsy, parotid diseases and others are a relatively common clinical condition with a variety of causes. Irrespective of its etiology, facial palsy always represents a very serious problem for the patient. Parotid gland diseases also are very common occurrence. In this particular case, the knowledge of surgical anatomy of the facial nerve and its correlations with the parotid gland is very important for an adequate preservation in the cases of surgery of benign and malignant diseases of the parotid gland. Although the surgical anatomy of the facial nerve has been well documented, the concept of surgical treatment for parotid tumors, facial palsy (neurorraphy techniques) and submandibular surgical approach are rarely challenged now.

La parálisis facial, enfermedades de la parótida y otras patologías son una condición clínica relativamente común con una variedad de causas. Independientemente de su etiología, la parálisis facial siempre representa un problema muy serio para el paciente. Las enfermedades de la glándula parótida son también de una ocurrencia común. En este caso particular, el conocimiento de la anatomía quirúrgica del nervio facial y su correlación con la glándula parótida es de mucha importancia para una adecuada preservación de la misma, en casos de cirugía como tratamiento de enfermedades benignas o malignas. Aunque la anatomía quirúrgica del nervio facial es bien documentada, el concepto de tratamiento quirúrgico para los tumores parotídeos, parálisis facial (técnicas de neurorrafia) y acercamiento quirúrgico submandibular son raramente impugnados hoy en día.

Histomorphometric Characteristics of the Facial Nerve / 체질인류학회지

With the development of microsurgery, autogenous nerve grafting is being used widely in the treatment of the injured facial nerve. To use a donor graft for repair of the facial nerve, fascicular area and fascicular number should be considered in the selection of the donor site. This study demonstrated a detailed morphologic description of the facial nerve, including a microscopic assessment of nerve size and shape, and fascicular number and diameters. 40 embalmed hemi-sectioned head specimens from Korean adult cadavers were dissected to identify the facial nerve branches and nerve samples for histologic examination were cut from the anterior margin of the parotid gland.At the border of the parotid gland, the facial nerve specimens were found to have an average of 11 branches (ranging from 8 to 16). The branches were distributed among the five distinct branches, the buccal branch had the greatest number of branches (3.47), and the zygomatic branch had the largest diameters (0.93 mm). The number of fascicles varied from one to 9 over the course of the nerve, the trunk had the greatest number of fascicles (4.36), and averages indicated a tendency for fascicular numbers to decrease distally, from trunk (4.36) to upper division (3.72) to lower division (3.60) to marginal mandibular branch (2.37). The total fascicular area was averaging 2.72 mm2, 1.88 mm2, and 1.04 mm2 at trunk, upper division, and lower division, respectively. However no significant differences of the fascicular diameter could be shown between five branches. This results of detailed facial nerve microanatomy should help in the treatment of the injured facial nerve.

Anatomia microcirúrgica do hipocampo na Amígdalo-hipocampectomia seletiva sob a perspectiva da técnica de Niemeyer e método pré-operatório para maximizar a corticotomia / Hippocampal microsurgical anatomy regarding the selective amygdalohippocampectomy in the Niemeyer’s technique perspective and preoperative method to maximize the corticotomy

O conhecimento da anatomia microcirúrgica do hipocampo tem importância fundamental na cirurgia da epilepsia do lobo temporal. Uma das técnicas mais utilizadas na cirurgia da epilepsia é a técnica de Niemeyer. OBJETIVO: Descrever em detalhes a anatomia do hipocampo e mostrar uma técnica na qual pontos de referências anatômicos pré-operatórios visualizados na RNM são usados para guiar a corticotomia. MÉTODO: Foram utilizados 20 hemisférios cerebrais e 8 cadáveres para dissecções anatômicas microcirúrgicas do lobo temporal e hipocampo para identificação e descrição das principais estruturas do hipocampo. Foram estudados prospectivamente 32 pacientes com epilepsia do lobo temporal refratários ao tratamento clínico submetidos a amígdalo-hipocampectomia seletiva pela técnica de Niemeyer três parâmetros anatômicos foram mensurados na RNM pré operatória e transferidos para o ato cirúrgico. RESULTADOS: O hipocampo foi dividido em cabeça, corpo e cauda e sua anatomia microcirúrgica descrita em detalhes. As medidas adquiridas são apresentadas e discutidas. CONCLUSÃO: A complexa anatomia do hipocampo pode ser entendida de uma forma tridimensional durante dissecções microcirúrgicas. As medidas pré-operatórias mostraram-se guias anatômicos úteis para corticotomia na técnica de Niemeyer.

The deep knowledge of hippocampal microsurgical anatomy is paramount in epilepsy surgery. One of the most used techniques is those proposed by Niemeyer. PURPOSE: To describe the hippocampal anatomy in details and to present a technique which preoperative anatomical points in MRI are identified to guide the corticotomy. METHOD: Microsurgical dissections were performed in twenty brain hemispheres and eight cadaveric heads to identify temporal lobe and hippocampus structures. Thirty two patients with drug-resistent temporal lobe epilepsy underwent a selective amygdalohippocampectomy with Niemeyer’s technique being measured three preoperative MRI preoperative distances to guide the corticotomy. RESULTS: The hippocampus was divided in head, body and tail and its microsurgical anatomy described in details. The MRI measurements are presented and discussed. CONCLUSION: The knowledge of the complex anatomy of the hippocampus can be achieved in a three-dimensional way during microsurgical dissections not. The preoperative MRI measurement is a reasonable guide to perform temporal corticotomy in Niemeyer’s techinique.

Retropharyngeal Lymph Node Dissection / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Little information about the surgical anatomy and technique for retropharyngeal node dissection has been published. The purpose of this study was to review our surgical technique and results of retropharyngeal lymph node dissection. MATERIALS AND METHODS: Eleven advanced oropharyngeal and hypopharyngeal squamous cell carcinoma patients who had been treated with resection of primary tumor and standard neck dissection including retropharyngeal lymph node dissection from 1994 to 1999 were evaluated retrospectively. RESULTS: One of 11 patients had positive retropharyngeal lymph node. The surgical technique used for retropharyngeal lymph node dissection were total laryngopharyngectomy, mandibular splitting or mandibulectomy approach. There was no specific complication of retropharyngeal lymph node dissection except one case of Horner's syndrome. CONCLUSION: Retropharyngeal lymph node dissection was a safe procedure, bet it required total laryngopharyngectomy, madibular splitting or mandibulectomy approach. It was possible to remove retropharyngeal lymph made en-bloc with primary tumor in most cases.

Microsurgical Anatomy of the Supraclinoid Internal Carotid Artery / 대한뇌혈관학회지

As the internal carotid artery(ICA) spans the cavernous sinus and supraclinoid segments, it assumes an S-shaped configuration on lateral view that is referred as the carotid siphon. The supraclinoid carotid artery begins where the artery emerges through the dural ring from the clinoidal segment, thereby forming the distal half of the siphon. The artery enters the subarachnoid space medial to the anterior clinoid process, just inferior to the optic nerve, and then pass posteriorly, and laterally to the side of the optic chiasm. The vessel then angles forward as it nears the anterior perforated substance at the medial end of Sylvian fissure, where it bifurcates into the anterior and middle cerebral arteries. The supraclinoid portion of the ICA can be divided into three segments: ophthalmic, communicating, and choroidal, based on the site of origin of the ophthalmic, posterior communicating, and anterior choroidal arteries, respectively.

Microsurgical Anatomy of the Supraclinoid Internal Carotid Artery / 대한뇌혈관학회지

As the internal carotid artery(ICA) spans the cavernous sinus and supraclinoid segments, it assumes an S-shaped configuration on lateral view that is referred as the carotid siphon. The supraclinoid carotid artery begins where the artery emerges through the dural ring from the clinoidal segment, thereby forming the distal half of the siphon. The artery enters the subarachnoid space medial to the anterior clinoid process, just inferior to the optic nerve, and then pass posteriorly, and laterally to the side of the optic chiasm. The vessel then angles forward as it nears the anterior perforated substance at the medial end of Sylvian fissure, where it bifurcates into the anterior and middle cerebral arteries. The supraclinoid portion of the ICA can be divided into three segments: ophthalmic, communicating, and choroidal, based on the site of origin of the ophthalmic, posterior communicating, and anterior choroidal arteries, respectively.

A Case of Recurred Squamous Cell Carcinoma on Scalp Using a Extended Posterolateral Neck Dissection / 대한이비인후과학회지

The metastasis of nodal pattern of malignant scalp tumors of the posterior half of the scalp including the occipital area and the nape of the neck takes place primarily in the retro-auricular and suboccipital area, and secondarily in the posterior triangle of the neck. The regional node dissection that includes the removal of the retro-auricular and suboccipital nodes in continuity with the posterior triangle and jugular chain of lymph nodes is called the posterolateral neck dissection. Recently, we experienced a case of an extended posterolateral neck dissection for recurred squamous cell carcinoma on scalp. We hereby present this case with the operative technique and surgical anatomy.

Surgical Anatomy around the Maxillary Sinus Ostium in Cadavers

OBJECTIVES: The goal of this study is to observe the anatomy around the maxillary sinus ostium and gain an understanding that will help prevent serious complications during middle meatal antrostomies. MATERIALS AND METHODS: Dissection of the maxillary sinuses was carried out in 64 embalmed frozen cadavers, 105 maxillary sinuses. Using a digital ruler, forceps and a malleable probe, we measured the important anatomical relationships around the maxillary sinus ostium and uncinate process, the accessory ostium, and the nasolacrimal duct. RESULTS: 1) The mean width of the uncinate process was 4.9 mm in the mid portion ; 2) A natural ostium of the canal type was observed in 76% of cases ; 3) An accessory ostium was found in 18% of cases and the mean size was 3.17x2.41 mm ; and 4) The mean shortest distance between the nasolacrimal duct and the natural ostium was 4.8 mm. CONCLUSION: Surgeons must keep surgical anatomy in mind to prevent complications when performing endoscopic sinus surgery.

Surgical Management of Middle Cerebral Artery Aneurysm

Although the surgical technique of the management of an middle cerebral artery(MCA) aneurysm is not more difficult than that of an aneurysm in any other location, the surgical management outcome of this aneurysm is not better than that of other location aneurysms. This is probably due to occurrence of an intracerebral hemorrhage more frequently in an MCA aneurysm than other location aneurysms. This is required the proper surgical management of this aneurysm to be reviewed. The key points of surgery for MCA aneurysm can be summarized as follows: gently wide dissection and splitting of the sylvian fissure without injury of main sylvian veins; early adequate exposure of the M1 sites for temporary clips applications; avoid injuries of small branches of the MCA in sylvian fissure by using a low pressure suction during removing the intrasylvian hematoma; avoid injury of lenticulostriate arteries and narrowing of the parent arteries during clipping of aneurysms; and successful aneurysm obliteration with minimal brain retraction. Preoperative imagination of the configulation of aneurysm and the relationship between the aneurysm and surrounding vessels, such as M1, M2 and lenticulostriate arteries, from angiographic informations will decrease the incidence of premature aneurysmal ruptureduring surgery and improve the surgical management outcome of patients with MCA aneurysm. From September 1982 to December 1998, the authors has surgically treated 1025 patients of the cerebral aneurysms. Among these patients, 274 patients(26.7%) had the MCA anurysms. The surgical outcomes of these MCA aneurysm patients were good in 222 patients(81.0%) and death in 22 patients(8.0%). The authors discusses surgical anatomy and techniques for the management of MCA aneurysms on the basis of the author's experiences and a review of the literatures in order to improve the surgical management outcomes of patients with MCA aneurysm in the future.