Bloqueos Nerviosos. Bases Anatómicas del Dolor Somático Abdomino-Pélvico / Nerve Blocks. Anatomy of the Somatic Innervation of the Abdomino-Pelvic Cavity

El dolor abdominal es una de las sintomatologías que afectan con frecuencia la cavidad abdomino-pélvica. Dicha cavidad posee una inervación somática en la que intervienen del séptimo a doceavo nervios intercostales, ramos colaterales y terminales del plexo lumbar y el nervio pudendo; siendo objetivo de este trabajo la descripción anatómica del dolor abdominopélvico a través del plexo lumbar, nervios intercostales y nervio pudendo, sus diferentes patrones y variaciones de conformación, y las implicancias de éstas últimas en las distintas maniobras clínico-quirúrgicas. Se realizó un estudio descriptivo, observacional y morfométrico de la inervación somática de la cavidad abdomino-pélvica, en 50 preparaciones cadavéricas, fijadas en solución de formaldehído, de la Tercera Cátedra de Anatomía, Facultad de Medicina, Universidad de Buenos Aires, entre Agosto/2017-Diciembre/2019. La descripción clásica del plexo lumbar se encontró en 35 casos; la presencia del nervio femoral accesorio en ningún caso; así como también la ausencia del nervio iliohipogástrico en ningún caso; el nervio obturador accesorio se halló en 2 casos; el nervio genitofemoral dividiéndose dentro de la masa muscular del psoas mayor en 6 casos; el nervio cutáneo femoral lateral emergiendo únicamente de la segunda raíz lumbar en 6 casos y por último se encontró la presencia de un ramo del nervio obturador uniéndose al tronco lumbosacro en un caso. Los nervios intercostales y el nervio pudendo presentaron una disposición clásica en todos los casos analizados. Es esencial un adecuado conocimiento y descripción del plexo lumbar, nervios intercostales y nervio pudendo para un adecuado abordaje de la cavidad abdomino-pélvica en los bloqueos nerviosos.

SUMMARY: Abdominal pain is one of the symptoms that affect the abdominal-pelvic cavity. The abdominal-pelvic cavity has a somatic innervation involving the seventh to twelfth intercostal nerves, collateral and terminal branches of the lumbar plexus and the pudendal nerve. The objective of this work is the description of the lumbar plexus, intercostal nerves and pudendal nerve, its different patterns and structure variations, as well as its implications during pain management in patients. A descriptive, observational, and morphometric study of patterns and structure variations of the lumbar plexus, intercostal nerves and pudendal nerve was conducted in 50 formalin-fixed cadaveric dissections of the Third Chair of Anatomy at the School of Medicine in the Universidad de Buenos Aires from August 2017 to December/2019. The standard description of the lumbar plexus was found in 35 cases; accessory femoral nerve was not present in any of the cases; absence of the iliohipogastric nerve was also not found in any case, while the accessory obturating nerve was found in 2 cases; genitofemoral nerve dividing within the muscle mass of psoas in 6 cases; lateral femoral cutaneous nerve emerging only from the second lumbar root in 6 cases and finally, presence of a branch of the obturating nerve was found joining the lumbosacral trunk in one case. The pudendal and intercostal nerve patterns presented a typical pathway in all cases. Adequate knowledge and description of the lumbar plexus, intercostal nerves and pudendal nerve is essential for an adequate approach of the abdominal-pelvic cavity in nerve blocks.

Função sexual pós-histerectomia: quais os impactos e aspectos técnicos envolvidos? / Sexual function after hysterectomy: what are the impacts and technical aspects involved?

Objetivo: Identificar o impacto da histerectomia para patologias benignas sobre a sexualidade feminina. Métodos: Revisão de literatura com busca na plataforma PubMed, sendo selecionados 23 artigos em português e inglês publicados entre 2016 e 2021. Resultados: Foi descrita, majoritariamente, melhora na função sexual após histerectomia, semelhante às abordagens totais ou supracervicais e independentemente da via de acesso cirúrgico, apesar de impacto ligeiramente menor com a via laparoscópica. Na laparoscopia, houve melhor desfecho sexual no fechamento da cúpula vaginal, quando comparado ao fechamento via vaginal. Ademais, a ooforectomia concomitante apresentou resultados conflitantes e inconclusivos. Conclusão: A histerectomia afeta positivamente a saúde sexual feminina e aspectos técnicos podem interferir na função sexual, porém os dados são limitados. Devido à importância do tema, necessitam-se de mais estudos com metodologias padronizadas para possibilitar análises mais detalhadas.

Objective: To identify the impact of hysterectomy for benign pathologies on female sexuality. Methods: Literature review with search on PubMed platform, being selected 23 articles in Portuguese and English published between 2016 and 2021. Results: Improvement in sexual function after hysterectomy was mostly described, being similar in total or supracervical approaches and independent of the surgical access route, although it had slightly lower impact when laparoscopic. In the laparoscopic approach, there was better sexual outcome in the vaginal dome closure when compared to vaginal closure. In addition, concomitant oophorectomy showed conflicting and inconclusive results. Conclusion: Hysterectomy positively affects female sexual health and technical aspects may interfere with sexual function, but data are limited. Due to the importance of the theme, more studies with standardized methodologies are needed to enable more detailed analyses.

Pelvic autonomic nerve preservation in rectal cancer: anatomical concept and clinical significance / 中华胃肠外科杂志

Colorectal cancer is one of the most common cancers in the world, and surgery is the mainstage treatment. Urogenital and sexual dysfunction after radical resection of rectal cancer has become an important problem for patients, which seriously affects the quality of life. Some patients give up radical surgery for rectal cancer because of the concerns about sexual and urinary dysfunction. The cause of this problem is intraoperative of injury pelvic autonomic nerve. The preservation of the hypogastric nerve during the surgery is important for the male ejaculation. Pelvic splanchnic nerves are mainly responsible for the male erection. The anatomical origin, distribution, and urogenital function of these two nerves are detailed described in this article. At the same time, this article introduces the classification, key points of the operation and the evaluation of autonomic nerve preservation surgery. With the rapid development of minimally invasive surgery, performing radical surgery for rectal cancer is important, we also need to fully understand the anatomical concept of pelvic autonomic nerves, and apply modern minimally invasive surgical techniques to preserve the patient's pelvic autonomic nerves as well. It is an compulsory course and an important manifestation for the standardization of rectal cancer surgery.

Classification system of radical surgery for rectal cancer based on membrane anatomy / 中华胃肠外科杂志

Because the classification system of radical surgery for rectal cancer has not been established, it is impossible to select the appropriate surgical method according to the clinical stage of the tumor. In this paper, we explained the theory of " four fasciae and three spaces " of pelvic membrane anatomy and then combined this theory with the membrane anatomical basis of Querleu-Morrow classification for radical cervical cancer resection. Based on this theory and the membrane anatomy of Querleu-Morrow classification of radical cervical cancer resection, we proposed a new classification system of radical rectal cancer surgery based on membrane anatomy according to the lateral lymph node dissection range of the rectum. This system classifies the surgery into four types (ABCD) and defines corresponding subtypes based on whether the autonomic nerve was preserved. Among them, type A surgery is total mesorectal excision (TME) with urogenital fascia preservation, type B surgery is classical TME, type C surgery is extended TME, and type D surgery is lateral extended resection. This classification system unifies the anatomical terminology of the pelvic membrane, validates the feasibility of using the " four fasciae and three fascial spaces " theory to classify rectal cancer surgery, and lays the theoretical foundation for the future development of a unified and standardized classification of radical pelvic tumor surgery.

Descripción anatómica de la miología del miembro pélvico y su relación topográfica con el sistema vascular y nervioso en un ejemplar de pudú ( Pudu puda ) / Anatomical description of pelvic limb myology and its topographic relationship with vascular and nervous systems in pudú ( Pudu puda )

RESUMEN: El pudú (Pudu puda) pertenece a la familia Cervidae y se estima que su población actual total es menor a 10.000 ejemplares, razón por la cual se encuentra en la categoría de "Casi Amenazado" y dentro de la lista roja de la Unión Internacional para la Conservación de la Naturaleza (IUCN). La causa de la reducción de su población, es la pérdida y la fragmentación de los bosques del sur de Chile, caza, depredación, atropellos, entre otros. En las últimas situaciones mencionadas, es frecuente observar lesiones en la zona corporal caudal y miembros pélvicos del animal. Debido a lo anterior, se considera importante generar estudios morfológicos en el pudú que puedan ser un aporte en el conocimiento de ésta especie en particular. El presente trabajo corresponde a un estudio descriptivo anatómico del miembro pélvico de un ejemplar de pudú hembra. Se describió la musculatura y sus principales relaciones con vasos sanguíneos y nervios desde proximal hacia distal, dividiendo al miembro pélvico en cuatro regiones topográficas: cintura pélvica, femoral, crural y del pie. Además, se realizó de forma complementaria un estudio morfométrico de cada región topográfica y cada músculo que la compone. Los resultados fueron comparados con rumiantes domésticos, en relación a lo descrito en la bibliografía anatómica clásica, observando que el ejemplar analizado posee características anatómicas similares a lo descrito para pequeños rumiantes, sin embargo, existen diferencias importantes de tomar en consideración, tales como: el m. de la fascia lata presenta dos porciones sobrepuestas; el m. sóleo presenta un mayor desarrollo; el paquete vasculo nervioso femoral se observa atravesando la porción craneal del m. sartorio y el m. gracilis forma parte del tendón calcáneo común. La información entregada en este estudio corresponde a un aporte anatómico que permite ampliar el conocimiento científico de ésta especie poco estudiada, protegida y vulnerable.

SUMMARY: The Pudu (Pudu puda) belongs to the family Cervidae and it is estimated that its total current population is less than 10,000 specimen, which is why it is part of the "Near Threatened" category and on the red list of the International Union for Conservation of Nature (IUCN). The cause of the reduction of its population is the loss and the fragmentation of the forests of the south of Chile, hunting, predation, crashes, among others. In the latter situations, it is common to observe injuries in the caudal area and pelvic limbs of the animal. Due to the above, it is considered important to generate morphological studies in the Pudú that can be a contribution in the knowledge of this particular species. The present study corresponds to an anatomical descriptive study of the pelvic limb of a female Pudú. Musculature and its main relationships with blood vessels and nerves were described from proximal to distal, dividing the pelvic limb into four topographic regions: pelvic waist, femoral, crural and foot. In addition, a morphometric study of each topographic region and each muscle was performed as complementary analysis. The results were compared to domestic ruminants, in relation to those described in the classic anatomical bibliography, observing that the analyzed specimen has anatomical characteristics similar to that described for small ruminants, however, several important differences were observed and should be taken into consideration: the M. tensor fascia latae presents two overlapping portions; the M. soleus is more developed; the vasculature of the femoral nerve is observed through the cranial portion of the M. sartorius and M. gracilis is part of the common calcaneus tendon. The information provided in this study corresponds to an anatomical contribution that allows furthering scientific knowledge of this protected and vulnerable species.

Comparative anatomy of the pelvic nerves in bearded capuchins (Sapajus sp) / Anatomia comparativa dos nervos da pelve de macacos-prego (Sapajus sp)

Bearded capuchins (Sapajus sp), unexpectedly, share with chimpanzees behavioral features such as high cognitive ability, good memory, tool use with intermittent bipedalism, and social tolerance; although its anatomy is still little studied. To test the hypothesis that bearded capuchins might share similar anatomical features with chimpanzees, we investigated the pelvic nerves of the bearded capuchin and compared them with the data in the previous literature for modern humans, chimpanzee, and baboons in terms of origin, trajectory and innervated structures, when the data are available. Variation is very common in the primates because of, inter alia, 1) the problem of the anatomical position, i.e., some primatologists used the human anatomical position to describe those in non-human primates, while others used the non-human anatomical position, and the definition of anatomical position (human or non-human position) is not clear; 2) the lateralized and semi-bend pelvis limbs in non-humans primates compared with modern humans; 3) the absence of the some muscles (e.g., scansorius and ilioschiofemoralis) in modern humans in the thigh; and 4) the difference in the numbers of vertebrae among the authors, even in the same species, such as chimpanzees and bearded capuchins.(AU)

Macacos-prego (Sapajus sp), inesperadamente, compartilham com chimpanzés comportamentos como alta cognição e memória, uso de ferramentas com o bipedalismo intermitente, tolerância social. No entanto, sua anatomia ainda é pouco estudada. Para verificar a hipótese com qual espécie e/ou grupo de primatas os macacos-prego compartilham mais características, o objetivo deste trabalho foi estudar os nervos pélvicos do Sapajus e compará-los com dados da literatura anatômica sobre os seres humanos, chimpanzés e babuínos, considerando aspectos como origem, trajetória e estruturas inervadas. Foi observado que existem grandes variações nos nervos pélvicos entre os primatas estudados aqui, quais sejam, 1) o problema da posição anatômica, i.e., alguns primatologistas consideram a posição anatômica humana para os primatas, outros consideram a posição anatômica animal, e a opção por um ou outro não é clara nos textos; 2) o problema dos membros pélvicos em primatas não humanos serem lateralizados e semi-fletidos em relação aos seres humanos modernos; 3) o problema da ausência, nos seres humanos modernos, de alguns músculos da coxa em relação aos outros primatas como o escansório e o iliosquiofemoral; e 4) o problema da diferença do número de vértebras nos primatas estudados aqui, inclusive com diferenças para a mesma espécie citadas por diferentes autores tanto para chimpanzés como para macacos-prego.(AU)

Nerve-sparing radical hysterectomy: time for a new standard of care for cervical cancer? / 부인종양

No abstract available.

Efficacy and oncologic safety of nerve-sparing radical hysterectomy for cervical cancer: a randomized controlled trial / 부인종양

OBJECTIVE: A prospective, randomized controlled trial was conducted to evaluate the efficacy of nerve-sparing radical hysterectomy (NSRH) in preserving bladder function and its oncologic safety in the treatment of cervical cancer. METHODS: From March 2003 to November 2005, 92 patients with cervical cancer stage IA2 to IIA were randomly assigned for surgical treatment with conventional radical hysterectomy (CRH) or NSRH, and 86 patients finally included in the analysis. Adequacy of nerve sparing, radicality, bladder function, and oncologic safety were assessed by quantifying the nerve fibers in the paracervix, measuring the extent of paracervix and harvested lymph nodes (LNs), urodynamic study (UDS) with International Prostate Symptom Score (IPSS), and 10-year disease-free survival (DFS), respectively. RESULTS: There were no differences in clinicopathologic characteristics between two groups. The median number of nerve fiber was 12 (range, 6 to 21) and 30 (range, 17 to 45) in the NSRH and CRH, respectively (p<0.001). The extent of resected paracervix and number of LNs were not different between the two groups. Volume of residual urine and bladder compliance were significantly deteriorated at 12 months after CRH. On the contrary, all parameters of UDS were recovered no later than 3 months after NSRH. Evaluation of the IPSS showed that the frequency of long-term urinary symptom was higher in CRH than in the NSRH group. The median duration before the postvoid residual urine volume became less than 50 mL was 11 days (range, 7 to 26 days) in NSRH group and was 18 days (range, 10 to 85 days) in CRH group (p<0.001). No significant difference was observed in the 10-year DFS between two groups. CONCLUSION: NSRH appears to be effective in preserving bladder function without sacrificing oncologic safety.

Conventional versus nerve-sparing radical surgery for cervical cancer: a meta-analysis / 부인종양

OBJECTIVE: Although nerve-sparing radical surgery (NSRS) is an emerging technique for reducing surgery-related dysfunctions, its efficacy is controversial in patients with cervical cancer. Thus, we performed a meta-analysis to compare clinical outcomes, and urinary, anorectal, and sexual dysfunctions between conventional radical surgery (CRS) and NSRS. METHODS: After searching PubMed, Embase, and the Cochrane Library, two randomized controlled trials, seven prospective and eleven retrospective cohort studies were included with 2,253 patients from January 2000 to February 2014. We performed crude analyses and then conducted subgroup analyses according to study design, quality of study, surgical approach, radicality, and adjustment for potential confounding factors. RESULTS: Crude analyses showed decreases in blood loss, hospital stay, frequency of intraoperative complications, length of the resected vagina, duration of postoperative catheterization (DPC), urinary frequency, and abnormal sensation in NSRS, whereas there were no significant differences in other clinical parameters and dysfunctions between CRS and NSRS. In subgroup analyses, operative time was longer (standardized difference in means, 0.948; 95% confidence interval [CI], 0.642 to 1.253), while intraoperative complications were less common (odds ratio, 0.147; 95% CI, 0.035 to 0.621) in NSRS. Furthermore, subgroup analyses showed that DPC was shorter, urinary incontinence or frequency, and constipation were less frequent in NSRS without adverse effects on survival and sexual functions. CONCLUSION: NSRS may not affect prognosis and sexual dysfunctions in patients with cervical cancer, whereas it may decrease intraoperative complications, and urinary and anorectal dysfunctions despite long operative time and short length of the resected vagina when compared with CRS.

Descripción anatómica de la inervación del miembro pélvico de león africano (Panthera leo) / Anatomical description of pelvic limb innervation of African lion (Panthera leo)

El león africano (Panthera leo) pertenece a la familia felidae del orden carnívora, corresponde a un depredador de gran tamaño, en Chile se encuentra únicamente en estado de cautiverio, sin embargo está presente en numerosos zoológicos. La preocupación e interés por el bienestar de estos animales ha aumentado, por lo cual, cada vez se realizan procedimientos médicos de mayor complejidad. Lo expuesto anteriormente genera la necesidad de profundizar los conocimientos anatómicos que existen de esta especie. Por lo anterior, el objetivo de este trabajo fue realizar un estudio anatómico detallado de la inervación del miembro pélvico del león y describir sus relaciones topográficas con el sistema músculo esquelético y vascular. Se disecó un cadáver de león hembra, adulta, presentando la descripción según las regiones topográficas: región del cíngulo miembro pélvico, región femoral, región crural y región del pie. Se realizó un registro fotográfico de las disecciones, el cual fue complementada con ilustraciones anatómicas representativas de cada región. Acorde a lo observado, podemos indicar que existe una gran similitud con lo descrito en el gato, destacando el gran desarrollo de los nervios y ramos musculares del león. La presente descripción, permite, ampliar el conocimiento de la anatomía del miembro pélvico del león africano, específicamente su inervación y relaciones musculares y vasculares.

The African Lion (Panthera leo) belongs to the felidae family of the order carnivore, corresponding to large predators. In Chile it is found only in a state of captivity and is present in many zoos. As the concern and interest in these animals has increased, more complex procedures are performed each day. This generates the need for anatomical knowledge of this specie. This anatomical study was performed in order to describe the innervation of the pelvic limb of an African lion and topographical relationship with skeletal muscles and vascular structures. A corpse of an adult female lion, 130 kg, was dissected and described by topographical regions. Proximal to distal: cingulum pelvic limb region, femoral region, crural region and foot region. Descriptions of each region were complemented by photographs and drawings. According to the descriptive study of the innervation of the pelvic limb, it was observed that there is a great similarity with that described in the domestic cat, excepting the great development of their nerves and muscular branches. This study provides information about the innervation of the pelvic limb of the African lion, showing the relation with muscular and vascular structures. The anatomical information provided in this study can be useful for medical procedures in this species and other big cats.

Various types of total laparoscopic nerve-sparing radical hysterectomies and their effects on bladder function / 부인종양

OBJECTIVE: This study was conducted to ascertain the correlation between preserved pelvic nerve networks and bladder function after laparoscopic nerve-sparing radical hysterectomy. METHODS: Between 2009 and 2011, 53 patients underwent total laparoscopic radical hysterectomies. They were categorized into groups A, B, and C based on the status of preserved pelvic nerve networks: complete preservation of the pelvic nerve plexus (group A, 27 cases); partial preservation (group B, 13 cases); and complete sacrifice (group C, 13 cases). To evaluate bladder function, urodynamic studies were conducted preoperatively and postoperatively at 1, 3, 6, and 12 months after surgery. RESULTS: No significant difference in sensory function was found between groups A and B. However, the sensory function of group C was significantly lower than that of the other groups. Group A had significantly better motor function than groups B and C. No significant difference in motor function was found between groups B and C. Results showed that the sensory nerve is distributed predominantly at the dorsal half of the pelvic nerve networks, but the motor nerve is predominantly distributed at the ventral half. CONCLUSION: Various types of total laparoscopic nerve-sparing radical hysterectomies can be tailored to patients with cervical carcinomas.

Estudo anatômico da porção intrapélvica do nervo isquiático em fetos de bovinos azebuados / Anatomical study of the intrapelvic portion of ischiatic nerve in fetuses in crossbred zebu cattle

O nervo isquiático é o maior de todos os nervos do organismo. Ele emerge da cavidade pélvica pelo foram e isquiático maior como um cordão amplo, plano e acinzentado. Dirige-se caudal e ventralmente sobre a parte distal e lateral do ligamento largo da pelve. Há muitas evidências clínicas e experimentais de que a maior parte das injúrias que acometem o nervo isquiático, em bovinos, envolve a contribuição do 6º nervo lombar para o referido nervo. Neste estudo foram analisados por meio de dissecção, a origem e sintopia do nervo isquiático, em 33 fetos de bovinos azebuados. O nervo isquiático mostra sua origem a partir dos ramos ventrais do 5º e 6º nervos lombares e do 1º, 2º e 3° nervos sacrais. A origem mais freqüente parao nervo isquiático é representada pelo ramo ventral do 6º nervo lombar e 1º e 2º nervos sacrais (100%). Em 39,4% desses casos, o nervo recebe contribuição do 5º nervo lombar e, em 12,1% dos casos, também do 3º nervo sacral. A participação mais conspícua na formação do nervo isquiático é a do 6º nervo lombar e 1º nervo sacral (39,4%), seguida somente do 1º nervo sacral em 33,33% e da associação do 1º e 2º nervos sacrais em 18,18%. O nervo isquiático revela íntima aposição na face ventral do sacro e em relação às raízes ventrais do 5º e 6º nervos lombares. De modo geral, os resultados obtidos em relação à origem do nervo e sua sintopia, não mostram discordância com os correspondentes dados obtidos na literatura referente a bovinos de origem européia.

The sciatic nerve is the largest of all nerves of the body. It emerges from the pelvic cavity through the major sciatic for a men as a wide, flat and brownish cord. It extends caudally and ventrally over the distaland lateral part of the pelvic broad ligament. There are several experimental and clinical evidences supporting that the majority of injuries affecting the sciatic nerve in bovines are associated with its 6th lumbar nerve. This study analyzed the sciatic nerve origin and topography by means of dissection in 33 crossbred zebu fetuses. The sciatic nerve originates from the ventral branches of the 5th and 6th lumbar nerves and 1st, 2nd and 3rd sacral nerves. The most frequent origin of the sciatic nerve is represented by the ventral branch of the 6th lumbar nerve and 1st and 2nd sacral nerves (100%). The most conspicuous participation in the sciatic nerve formation is from the 6th lumbar nerve and 1st sacral nerve (39.4%), followed only by the 1st sacral nerve in 33% and from the association of the 1st and 2nd sacral nerves in 18.18%. The sciatic nerve shows close apposition in the sacral ventral face and as to the 5th and 6th lumbar nerve ventral roots. In general, the obtained results concerning the nerve origin and its topography do not demonstrate any discrepancy when compared todata from the literature regarding European cattle.

Peripheral nerve injury and male sexual dysfunction / 法医学杂志

The genital organ is innervated by autonomic and somatic nerve. The former is both sympathetic and parasympathetic nerve and the later is comprised by sensory and motor fibers. The symptoms of male sexual dysfunction are sexopathy, erectile dysfunction, disorder of ejaculation and orgasm, and pianism. Not only different symptom but the same symptom can be induced by different injured nerve. The relationship between peripheral nerve injury and male sexual dysfunction should be understood correctly.

Criterios de homologación entre las cinturas escapular y pélvica y sus estructuras asociadas / Homologation criterion between the scapular and pelvic waists and their associated structures

Habitualmente las cinturas se estudian en forma separada junto al miembro correspondiente. Los músculos asociados a ellas se reunen en base a un criterio exclusivamente topográfico, resultando los siguientes grupos; músculos del dorso, del cuello, del tórax y del miembro pelviano. Para el miembro torácico se los trata como músculos comunes del miembro, sin tener en cuenta su inserción ni su intervación. En este trabajo se establecen los criterios de homotipia entre ambas cinturas y se proponen pautas para homologar los músculos que unen los miembros torácicos y pelvianos con el esqueleto axial. Para ello, se recurre a su clasificación en extrínsecos e intrínsecos, en base a su origen embriológico, inserción e inervación