The anatomy of the lateral circumflex femoral artery in anterolateral thigh flap.

OBJECTIVE: To determine systematically the pattern of the cutaneous perforator of the lateral circumflex femoral artery (LCFA) in anterolateral thigh perforator (ALT) flap. MATERIAL AND METHOD: Sixty dissections of the LCFA were carried out in 30 preserved cadavers. The number; type, origin, and location of the cutaneous perforators of the LCFA were studied and measured. RESULTS: There were 169 perforators. In 79.3%, the perforators originated from the descending branch, 18.3% from the transverse branch. The perforator of the medial descending and the ascending branch were found in 1.8% and 0.6%, respectively. The most cutaneous perforators were concentrated in the middle third (14 to 28 cm from the ASIS) of the anterolateral thigh region. CONCLUSION: The perforator of the descending branch, which was located ranging from 21 to 35 cm, was appropriate for flap designing to avoid the perforator of the transverse branch, which was difficult to harvest.

Anatomical study of the superior gluteal artery perforator (S-GAP) for free flap harvesting.

OBJECTIVE: To present the appropriate superior gluteal branch for free flap harvesting. MATERIAL AND METHOD: The characteristic and external diameter of the pedicles and the main perforators, and length of the pedicles were studied in both sides of 30 formalin-preserved cadavers. RESULTS: The patterns of the pedicle could be classified into four types, the vertical, the horizontal, the descending, and the penetrating main branches. The descending branch was the longest (7.33 +/- 1.3 cm). While the pedicle and perforator of the horizontal branches was the largest (2.7 +/- 0.6 mm and 1.2 +/- 0.2 mm, respectively). However, it was difficult to dissect the vertical and the horizontal branches because the vessel courses did not run in the direction of the muscle fiber. Whereas the penetrating main branches were observed in the intermuscular septum so, it was easy to approach the pedicle. The length (5.3 +/- 1.3 cm) and external diameter (2.17 +/- 0.5 mm) of the pedicle were adequate for free flap harvesting. CONCLUSION: In the anatomical study the penetrating pedicle was recommended to use for the S-GAP flap.

The anatomy of the thoracodorsal artery in perforator flap for resurfacing shallow defect.

OBJECTIVE: To systematically determine the location and number of cutaneous perforators greater than 0. 5 mm in diameter of the lateral branch of the thoracodorsal artery perforator flap for resurfacing shallow defect. MATERIAL AND METHOD: Sixty dissections of the thoracodorsal arterial system were carried out in 30 preserved cadavers. The location and number of cutaneous perforators greater than 0.5 mm in diameter of the lateral branch of the thoracodorsal artery perforator flap were studied and measured. RESULTS: Seventy-six perforators were found in 60 flaps (1.3 perforators per flap). The first perforator was exited in all dissections. It emerged from the latissimus dorsi muscle 9.8 cm below the dome of the axilla. In 21.67% of the cases, the second perforator of the thoracodorsal artery arose 3.4 cm distal to the origin of the first perforator The third perforator was found in 5% of dissections, and originated 3.0 cm away from the origin of the second perforator In addition, most perforators penetrated the muscle within 7.0-14. 0 cm below the dome of the axilla. CONCLUSION: The center of the flap designed should be placed between 7 to 14 cm from the dome of the axilla.

Neurovascular anatomy of the penis and pelvis in Thai males: applications to male-to-female and pelvic surgeries.

OBJECTIVE: To determine the neurovascular profiles in the pelvis and penis for applying to sex reassignment surgery. MATERIAL AND METHOD: Dissection of the pelvis and penile shaft was performed in 12 soft-preserved and 32 fresh adult male cadavers respectively. The neurovascular structures were located and documented, and the distances between anatomical landmarks were measured. Thirty-two specimens from the glans penis were obtained for immunohistochemical analysis to analyze its innervation and blood supply. RESULTS: Several anatomical variations of penile arterial supply were found. They are the presence of the accessory pudendal artery, multiple cavernous and bulbourethral arteries. The unilateral dorsal artery was observed in 10 of 32 cadavers, predominantly on the left. From the root to the neck of the penis, the dorsal nerves were divided into two groups. The first group of fibers innervating the glans coursed along the dorsolateral surface of the shaft and pierced the entire area of the corona. The other group diverged to distribute throughout the lateral surface to innervate the lateral and ventral portions. The mean distance between the left and right medial main branches that terminated in the glans was 1.18 cm. Immunohistochemical analysis revealed that the main nerves, after entering the glans, divided into terminal branches that concentrated around urethra. A mean distance from the main nerves to the epithelium was 0.71 cm. CONCLUSION: This detailed anatomy in the pelvis and along the penis should provide a valuable guide for sex reassignment surgery and intrapelvic operations.

Neurovascular anatomy of the deep inferior epigastric perforator flap for breast reconstruction.

OBJECTIVE: To find out the most suitable perforator and cutaneous nerve for strategic design of the deep inferior epigastric perforator (DIEP) flap. MATERIAL AND METHOD: The characteristics of the pedicles, perforators, intercostal nerves and the relationship between nerves and vessels in DIEP flaps were studied in 31 formalin-preserved cadavers. RESULTS: Four hundred and five perforator vessels were divided into three vertical rows. These perforators were mostly contained in the medial row (45.4%), the average size of the perforators in the lateral row was the largest (1.0+/- 0.3 mm). The largest perforators (1.4+/- 0.3 mm) were mostly located within 1 cm horizontally from the umbilicus. Lateral row perforators, usually rectilinear course (82.7%), traveled with nerves from the beginning. Whereas, the perforators in the medial row usually coursed obliquely (86.4%) and were not related to nerves initially, they joined before piercing the rectus sheath. CONCLUSION: The present findings indicate that it would be more beneficial to use the lateral row perforators.

Comparison of economic bipolar vessel sealer and biclamp for the hemostasis of large-sized cadaver arteries.

OBJECTIVE: The purpose of the present study was to compare the bursting pressure of large arteries sealed with hand made bipolar vessel sealer (BVS) using flexible electrosurgical system (HemoSaccab) and the BiClamp. MATERIAL AND METHOD: Sixteen common carotid arteries from a fresh cadaver were sealed using BVS and BiClamp 4 times sequentially for burst testing. A catheter was placed into the open end of the specimen and secured with a purse-string suture. The catheter was connected to a pressure monitor and saline was infused until there was leakage from the sealed end defining the bursting pressure in mmHg. Both devices were used to seal an additional 2 vessels in each group, which were sent for histologic examination. Student's t-test was performed. RESULTS: The BVS's mean burst pressure was statistically higher than that of the BiClamp (573 vs 442 mmHg) (p < 0.001). CONCLUSION: The flexible system of BVS is superior to the BiClamp device for sealing the common carotid artery because the BiClamp automatically finished the sealing process before the sealing area was completely dessicated.

A randomized, prospective study comparing the use of the missile trocar and the pyramidal trocar for laparoscopy access.

BACKGROUND: The missile trocar was developed for smooth abdominal penetration of the primary port. It contains a longitudinal tunnel connecting the abdominal cavity with the outside. OBJECTIVE: To evaluate the efficacy of the missile trocar compared with the traditional method using the Veress needle. MATERIAL AND METHOD: The times required to enter the abdominal cavity and the difficulty of the procedure were compared with the traditional Veress needle. A blind technique was used on 100 consecutive patients in a randomized fashion. RESULTS: The missile trocar technique took 2.7 +/- 1.6 minutes to perform compared with 3.9 +/- 1.3 min in the Veress needle group (p = 0.001), and the difficulty of the procedure was 2.1 +/- 1.9 cm (p = 0.433) rated from 10-cm scale. No carbon dioxide leakage or serious complications occurred in any patient. CONCLUSION: The results of the present study indicate that a long-tip missile trocar technique may be used safely when the technique is fully understood. This procedure is a relatively quick alternative approach for laparoscopy.

Minimally invasive surgery training in soft cadaver (MIST-SC).

OBJECTIVES: The purpose of this study was to evaluate the surgical anatomy, tissue plane, organ consistency of soft cadaver and the possibility of minimally invasive surgery training in soft cadaver. SETTING: Surgical Training Center. Department of Anatomy and Department of Surgery Faculty of Medicine, Chulalongkorn University. DESIGN: Prospective descriptive study. MATERIAL AND METHOD: 2 soft cadavers were scheduled for fully laparoscopic surgery in upper gastrointestinal, colorectal, hepatopancreatobiliary and solid organs surgery. All the procedures were performed by the experienced surgical staffs and assisted by surgical staffs and/or surgical residents. The surgical anatomy, tissue plane, organ consistency and the satisfactory in performing the procedures were recorded for evaluation. RESULTS: The surgical anatomy, the tissue consistency the anatomical plane were very well preserved with mean score of 4.72 +/- 0.45. All the surgeons were satisfied with the findings, the mean score was 4.97 +/- 0.18. All the plan procedures were completely performed with great satisfactory results. CONCLUSION: The Minimally Invasive Surgery Training in Soft Cadaver (MIST-SC) was feasible with great satisfactory. This successful integration of basic and advanced laparoscopic procedures into the soft cadaver setting would be the next step in evolution of MIS training.

The new laparoscopic proctocolectomy training (in soft cadaver).

OBJECTIVES: The purpose of the present study was to evaluate the quality of preservation (tissue plane, named vessels identification, consistency of colon and rectum), quality of performing procedures, difficulties and problems and finally the satisfaction of surgeons in laparoscopic proctocolectomy in soft cadaver. SETTING: Colorectal Division, Department of Surgery and Surgical Training Center Department of Anatomy, Faculty of Medicine, Chulalongkorn University. DESIGN: Prospective descriptive study MATERIAL AND METHOD: 10 soft cadavers were scheduled for laparoscopic proctocolectomy. The procedures (colon-rectum mobilization and named vessels identification) were performed by 14 experienced surgeons (8 colorectal surgeons) and assisted by surgical residents. The quality of preservation, successfulness and the satisfaction in performing the procedures were recorded using questionnaires for evaluation. RESULTS: The preservation was very good in every aspect especially tissue plane between colon, mesocolon and retroperitoneum which was clearly dissected, same asfasciapropria of rectum. The named vessels and the tissue consistency were very well preserved and tolerated to laparoscopic equipment handling. The surgeons were satisfied with the tissue handling and dissections. There were two difficulties, the first was air leakage but simply corrected with purse string suture and the second was unflavored smell which was not concerned. Laparoscopic proctocolectomy could be completely performed in soft cadaver. CONCLUSION: Laparoscopic proctocolectomy could be performed in soft cadavers with great satisfaction. Repeated practice is possible, so the surgeons can gain their experiences outside the operating theatre. This success may shorten the learning curve and may be the new era in cadaver-based training.

Pattern of angular change of the anterior cruciate ligament across the range of knee flexion and the related anatomical dimensions.

Improper femoral and/or tibial tunnel placements are major causes of failure in anterior cruciate ligament (ACL) reconstruction. The 52 embalmed cadaveric knees were measured the dimensions of the surgical related structures using vernier caliper and goniometer. The intercondylar notch width was 17.4 +/- 2.3 mm and slope of the roof was 31.3 +/- 3.4 degrees. The average length of ACL was 21.6 +/- 2.5 mm. The relation of tibial attachment was 47.98% of the width of the lateral tibial plateau and 49.8% anteriorly, when it was measured through ACL attachment. Angle of ACL in sagittal plane was decreased during knee flexion. On the contrary, angle of ACL in coronal plane was increased during knee flexion. According to this study), The expected femoral tunnel at 10.00 am to 10.30 am could be performed by arthroscopic transtibial technique using the 48% of tibial width anteriorly for intraartricular tibial-tunnel drill-guide placement and aiming for sagittal and coronal plane of 52.0+/-4.6 / 20.9+/-3.9, 46.2+/-5.1 / 26.8+/-4.6 degrees, and 41.6+/-5.1 / 32.0+/-4.3 degrees while knee flexion degree were as 60, 90, and 120 degrees, respectively.

Dilating missile trocar for primary port establishment: a cadaver study.

The missile trocar was developed for controllable entry force, smaller fascial defects and post-operative pain improvement. The trocar was composed of a fascial-dilating long-conical head and a handle. Accompanied with this trocar, the authors designed a rectus sheath-hooking instrument to promote negative intra-abdominal pressure during the trocar puncture. The hooking procedure allowed room air to pass through the central canal of the trocar and fill the space between the intestinal loops and the trocar tip. The abdominal access procedure succeeded in forty-five attempts in fresh cadavers. No second attempt was done. The trocar accessed into the peritoneal cavity at every attempt without intestinal penetration. The missile trocar may be an alternative device for establishment of the primary port. Its efficacy and safety still has to be proved.

Rectus sheath hooking: alternative method of abdominal wall lifting and fixing for laparoscopy: a pilot cadaver bio-mechanical study.

Four bio-mechanical tests were used to study properties of the rectus sheath for laparoscopic abdominal access procedure and to provide surgical exposure by the ChulaLift gasless retractor. The profile of forces and displacement showed how some patients were good candidates for the gasless operation. The lifting weight should not excess 10 kg for minimal harm and optimal exposure. The rectus hooking could be an alternative choice for abdominal wall fixing during the first trocar entry. One-cm width hooking, the rectus sheath could withstand 18-20 kg lifting force. The exposure provided by the gasless technique was narrow between the lateral ports compared to the conventional technique. The rectus sheath could be hooked to provide effective fixing of the area to be penetrated by the first trocar, and this fascial layer could be lifted to produce exposure in the gasless technique.