Pancreatic heterotopia in mesentery.

INTRODUCTION: The pancreatic heterotopia of fortuitous operational discovery remains rare because of the medical imagery progress. We report a mesenteric localisation of aberrant pancreas identified during the assumption of responsibility of an abdominal emergency. OBSERVATION: A 26-year-old man was allowed with the urgencies for an acute obstruction of the small bowel. Surgical exploration revealed a distal support an ileo-parietal adherence near to an inflammatory hearth of appendicular origin. We noted, in addition to the mesentery of the first jejunal loop, a bilobate mass of glandular-like tissue with a pancreatic aspect. The adjacent jejunal handles were macroscopically healthy. The Pathological examination of the mass confirmed the existence of a mixed glandular exocrine and endocrine origin of pancreatic tissue, type I of the Heinrich's classification. CONCLUSION: This rare topographic entity of fortuitous discovery underlines the need for a meticulous surgical exploration of the abdominal cavity particularly in urgency when a summarized radiological assessment does not permit a complete morphological study.

An anatomical study of the intersigmoid fossa and applications for internal hernia surgery.

PURPOSE: To improve the knowledge of the morphometry and the surrounding anatomical structures of the intersigmoid fossa and to determine possible surgical applications. METHOD: Forty eight adult cadavers (29 female and 19 male; mean age 83 years) underwent dissection in the Laboratoire d'Anatomie des Alpes Francaises. Two injections in the right carotid resulted in a total body concentration of formalin of 1.3 %. The study parameters were the dimensions of the intersigmoid fossa orifice and the fossa's relationship to surrounding structures. Data were recorded and analyzed using Microsoft Office Excel (MS Cerp). A Pearson coefficient r was used to examine the correlation between the length of colon and the ISF volume. RESULTS: The intersigmoid fossa was present in 75 % of cases (n = 36). The average dimensions for the transverse diameter, longitudinal diameter, and the depth were, respectively, 20.5 ± 0.2, 20.3 ± 0.13, and 26.8 ± 0.2 mm. The primary and secondary roots bordering this fossa measured on average 59.1 ± 0.1 and 48.3 ± 0.13 mm. In 13.9 % of cases (n = 5), the maximum depth was >40 mm and in 16.7 % of cases (n = 6), one of the diameters of the orifice entry of the fossa was >40 mm. The ureter and external iliac artery were the most frequently encountered structures during the dissection of the fundus of the intersigmoid fossa. CONCLUSION: The intersigmoid fossa remains present in most of the reported dissections of cadavers. It constitutes an essential landmark in the surgery of the sigmoid colon due to its deep structural relationship with the left ureter and external iliac artery.

[Vascular relationships of the right great splanchnic nerve in the thorax]. / Rapports vasculaires thoraciques du nerf grand splanchnique droit.

AIM: The surgical assumption of responsibility of the pancreatic pain requires either a truncular coelioscopic or radicular neurectomy of greater splanchnic nerves (gsn). The goal of our work is to describe the way and relations of the right gsn which are variable and rarely described. This constitutes an undeniable peroperational hemorrhagic risk during splanchnicectomy. MATERIAL AND METHODS: After a double side thoracotomy and a bilateral sterno-clavicular desarticulation on 15 adult cadaveric subjects preserved by method of Winckler we removed the sterno-costal drill plate as well as the ventral rib arch and proceeded to a mediastinal evisceration of the thorax. Then we respected only the thoracic aorta and the oesophagus, the azygos venous system, the thoracic duct and the thoracic sympathetic chain. In some of the subjects, the azygos vein was injected (after catheterization of its stick) using gelatine coloured with blue paint. We studied the way and vascular relations of the right gsn. We measured the transverse distances between the origin of the gsn on one hand and the longitudinal axes of the azygos vein and the thoracic duct on the other hand. RESULTS: The relations of the right gsn trunk during its way related to the azygos vein in particular its constitutive origin and its affluents: ascending lumbar vein and twelfth intercostal vein. Sometimes the thoracic duct even a lymphatic node was near the gsn in the posterior infra-mediastinal space. A classification of the way and vascular relations of the right gsn in the thorax identified 3 anatomical types. The average distances separating the right gsn on one hand from the azygos vein and the thoracic duct on the other hand were respectively 5.7 mm and 11.2 mm. CONCLUSION: The vascular relations of the right gsn are very variable from one subject to another but primarily venous, sometimes lymphatic. They concerned the great thoracic vessels whose respect is essential in particular at the time of mini-invasive access procedure for a cœlioscopic splanchnicectomy.

[Anatomical radiology of the descending colon in the left pararenal space: about 1084 cases]. / Radio-anatomie du côlon descendant dans l'espace pararénal gauche : à propos de 1084 sujets.

AIMS: Due to the severity of colonic injuries and their frequency on the left side, we study relationships between the left kidney and the descending colon to identify subjects at risk of colonic perforation during percutaneous surgery of the left kidney. MATERIAL AND METHODS: Over a period of 3 years we exploited abdominal CT scans for 1084 patients in both sexes without any visceral or parietal lesions. We studied the situation and relationships of the lumbar part of the descending colon in the left pararenal space using a conventional grid technique. RESULTS: The preferential site of the colon in both sexes was laterorenal in 55.8% of cases. We also found the descending colon in a posterolateral situation in 21.1% of cases, and in an anterolateral situation in 14.8% of cases. In women, the posterolateral situation was twice more common than in men, but we did not observe any post-renal situation. Laterorenal and posterolateral situations were the most frequent in patients less than 50 years; while beyond this age 70.1% of subjects had a laterorenal type. CONCLUSION: Sex and age affect topographic variations of the lumbar part of the descending colon in the left pararenal space. Although they are rare or aberrant, some locations exist and should not be ignored by the operator. These locations are risk factors of colonic lesion during percutaneous approach of the left kidney.

Emergence and distribution of the ilioinguinal nerve in the inguinal region: applications to the ilioinguinal anaesthetic block (about 100 dissections).

The variations in the emergence and distribution of the ilioinguinal nerve are the cause of the failures of the ilioinguinal block and the difficulties at interpreting the ilioinguinal nerve syndrome. In order to identify its variations and set reliable anatomical landmarks for performing the ilioinguinal block, we dissected 100 inguinal regions of 51 adult corpses. The nerve was absent in seven cases and double in one case. The ilioinguinal nerve emerged from the internal oblique muscle, passing at 1 +/- 0.8 cm of the inguinal ligament and 3.33 +/- 2 cm of the ventral cranial iliac spine. It appeared behind the inguinal ligament and/or the ventral cranial iliac spine in 19 cases and presented a common trunk with the iliohypogastric nerve in 13 cases. In 47 cases, the nerve appeared in the form of a single trunk. Sixteen modes of division and eight types of predominantly anterior scrotal topographic distribution could be noted. These results show the high variability of the emergence and the sensory distribution of the ilioinguinal nerve. They enable us to propose techniques for ilioinguinal block performance using more accurate anatomical landmarks formed by the inguinal ligament and the ventral cranial iliac spine and a better diagnostic approach of ilioinguinal neuropathies.

[Management of exocrin pancreatic tumor. About 129 cases]. / Prise en charge des tumeurs du pancreas exocrine. A propos de 129 cas.

Management of exocrine pancreatic tumors is very difficult: Their impact is in upsurge and their diagnosis is very often made to an advanced stage that only allows the therapeutic palliative. To value the management of these tumors to the surgical clinic of Aristide Le Dantec hospital, authors achieved a retrospective survey on 8years (October 1994 to October 2002). Hundred twenty nine (129) cases of exocrine pancreatic tumors had been counted. It was about 71 men and 58 women of middle age of 56, 96 years. The length of middle evolution of the illness was of 8 months. The most frequent sign was jaundice, recovered at 80.9% of patients. Followed the thinning (79%), the pain (69%), the digestive stenosis (35%). Ultrasonography, scanner and x-ray of lungs permitted to make the diagnosis and the balance of extension. A laparoscopy had been made at 13 patients. A clinic and radiological classification had been used to distribute the tumors in 3 stages. At 46 patients in III stage, a therapeutic abstention had been decided. Patients to the II stage (n=77) had benefitted a palliative surgical treatment. It was about 74 biliary and digestive shunt and 3 alcoholic splanchnicectomy. The 6 patient to the I stage had benefitted a surgical resection. The middle hospitalization length was of 10.75 days. The rate of morbidity was 45.78%. Mortality was 29%. The median survival was of 3.6 months. The palliative surgical treatment had again indications facing these obstructive and locally advanced tumors. But the salute will come from the precocious diagnosis of these tumors to hope for a curative gesture.

Lumbar hernia: anatomical basis and clinical aspects.

INTRODUCTION: The purpose of this study was to describe the anatomy of the two orifices of the abdominal posterior wall where lumbar hernias could appear. They may protrude through the superficial lumbar triangle (JL Petit) or the deepest superior orifice (Grynfeltt). METHODS: The exact limits were precised by dissections in cadavers to explain the main differences of these two locations. We report two cases of spontaneous lumbar hernias discovered in outpatient clinic. RESULTS: Clinical diagnosis was difficult and both the patients were sent for lumbar lipoma but a meticulous examination gave us a clue. MRI was useful to confirm the defect in the posterior abdominal wall under the 12th rib. Only one patient was operated by a direct approach with a reinforcement of an unabsorbable mesh. No recurrence appeared during follow-up. CONCLUSION: Thanks to clinical and anatomical knowledge, these rare superior lumbar hernias were diagnosed and a correct surgical treatment permitted a quick recovery.

[The common celiacomesenteric trunk: about one case]. / Observation d'un tronc artériel coeliomésentérique commun.

The discovery of a coeliacomesenteric trunk is often fortuitous in a context of morphological or vascular exploration. About one case of this rare arterial remind us of its characteristic and different type. We emphasize the interest of not being unaware of this variation in radiological practice and vascular pathology. In our observation, the coeliacomesenteric trunk's ostium is oval with a tall axis of 14 mm; its route of 8mm is median and its arterial ending divide into hepatosplenogastric trunk and superior mesenteric trunk. It is a type I coeliacomesenteric trunk which is the most frequent type of this arterial variation in Higashi's classification.

[The left gastroepiploic artery: a splenic origin but a variable birthplace]. / L'artère gastro-omentale gauche : une origine splénique mais un niveau de naissance variable.

The left gastroepiploic artery (LGEA) is rarely described. The aim of this study is to report the fashion of its origin considering the greatly surgical interest of the short gastric vessels in the spleen-preserving distal pancreatectomy with excision of splenic pedicle. About 79 fresh cadaveric pieces we dissect and opacified the LGEA to specify its origin based on the Pinus's classification. We measured the distances between the origin of the LGEA and the terminal division of the splenic artery, the splenic hilus and the great gastric curvature. The LGEA arise from the splenic artery. Dissection underlines a troncular origin (type I) in 20.25% of cases, a distal origin from an inferior polar branch (type II) in 68.35% of cases and an origin from a common spleno-gastroepiploic trunk (type III) in 11.4% of cases. The three distances measured was respectively of 28.7, 25.3 and 31.4mm. The arteriography revealed respectively for the same types 21.21, 51.51 and 27.28%. The vascular disposition of the type III well illustrates the important role of the LGEA for the vascularization of the inferior pole of the spleen. Although the LGEA arise from a polar splenic lower branch in more half of the cases, it is important to know the frequency of the other modalities of its origin. These anatomical variations vascular are to be considered during spleen-preserving distal pancreatectomy with excision of splenic pedicle as well as for gastric esophagoplasty.

[Choledocho-duodenal fistula due to perforating duodenal ulcer disease. Report of 3 cases]. / Fistule choledoco-duodenale par perforation d'ulcere duodenal. A propos de 3 observations.

The authors report three (3) cases of choledoco-duodenal fistula due to perforating duodenal ulcer disease. All of them were male, aged from 35 to 55 years. The ulcer symptomatology summarised the clinical feature. They presented respectively a prestenosis, a stenosis and a chronic ulcer The fistula diagnosis was estasblished at the oesogastro-duodenal radiologic exploration showing an opacification of the common bile duct. The surgical treatment concerned bnly to the ulcer. A gastrectomy of exclusion with digestive continuity re-establishment according to FINSTERER in the pre-stenosis, vagotomy associated to gastrojejunostomy and the pylore closing at both other were performed. After 24, 23 and 5 months follow-up all the patients were disease free; classified VISICK I. Rarely reported among the complications of the duodenal ulcer the choledoco-duodenal fistula is a reality. Currently the majority of the authors recommend the respect of the fistula in the event of surgical operation.

Anatomical basis of neuropathies and damage to the ilioinguinal nerve during repairs of groin hernias. (about 100 dissections).

Surgical access to the inguinal region, notably during hernia repairs, exposes the ilioinguinal nerve to the risk of damage at the origin of the neuralgia. The incidence of these post-operative neuropathies and their medicolegal consequences justify this study about the anatomical variations of the ilioinguinal nerve. With the aim of preventing its damage during repairs of groin hernias and identifying the factors of onset of chronic spontaneous neuropathy of the ilioinguinal nerve, we dissected 100 inguinal regions of 51 fresh adult corpses. The nerve was absent in seven cases and double in one case. Out of the 94 ilioinguinal nerves observed, we analyzed the path in relation to the inguinal ligament and the connections with the walls of the inguinal canal and its content. The ilioinguinal nerve travels along the superficial surface of the internal oblique muscle, passing on average 1.015 cm from the inguinal ligament. In one case, the fibers of the internal oblique muscle spanned it in several places. The nerve was antero-funicular in 78.72% of cases and perforated the fascia of the external oblique in 28.72% of cases. The terminal division took place in the inguinal canal in 86% of cases, with terminal branches that sometimes perforated the fascia of the external oblique. These results enabled us to better understand the etiopathogenic aspects of certain neuropathies of the groin and to propose techniques useful for the protection of the nerve during repairs of groin hernias.

Posterior surgical approaches to the elbow: a simple method of comparison of the articular exposure.

PURPOSE OF THE STUDY: Bilaterotricipital approach, triceps splitting and olecranon osteotomy are the three most common posterior approaches to the elbow. The aim of this study was to propose a simple technique to measure the exposure of distal articular surfaces of the humerus through these posterior surgical approaches. MATERIALS AND METHODS: Each approach was performed on ten cadaver elbows. After the completion of each approach, the visible articular surface was painted yellow. The elbow was then disarticulated. The unexposed articulated surface (by the approach) was painted blue. The painted surfaces were then wrapped using a net with meshes. The articular percentage of exposure was measured by calculating the mesh occupied by each painted surface. RESULTS: The median exposed articular surface for the bilaterotricipital approach, the triceps splitting and the olecranon osteotomy was 26, 37 and 52%, respectively. CONCLUSION: The method is easy to perform and is reproducible.

[Anastomotic method of the gastro-omental arterial circle: interest in the transillumination method at the gastric esophagoplasty]. / Le mode anastomotique du cercle arteriel gastro-omental: interet de la transillumination lors d'une oesophagoplastie gastrique.

The gastroomental (gastroepiploic) arterial circle of the stomach is the main vascular axis of the gastroplasty use as esophagus substitute after esophagectomy. The aim of this anatomoangiographic study is to study the anastomosis between the right and left gastroomental arteries and emphasize interest of the transillumination: an ordinary anatomic method use in surgical practice. We use forty five fresh cadaveric stomach of adult for determine the anastomotic fashion of the arterial circle of the great gastric curvature. About three models of gastric esophagoplasty we verify similarity of vascular transillumination results and we compare with the radiographic exploration. The thickness of the gastrocolic ligament in which progress the gastroomental arterial circle can lead astray for macroscopic determination of anastomotic mode. Thus the type I, II, III and IV which are of 60%, 22,2%, 13,3% and 4,4% at macroscopic observation become 64,1%, 15,4%, 15,4% and 5,1% after arteriographic analysis. Even if the submucosal arteriolar network and the rich parietal anastomosis confer at the stomach the best qualities for esophageal replacement, the multifactorial particularity of success in esophagogastroplasty require identification and preservation of the gastroomental arterial circle. The transillumination which facilitate evaluation of this arterial axis is a simple and accessible process which we advocate.

The arch of the great saphenous vein: anatomical bases for failures and recurrences after surgical treatment of varices in the pelvic limb. About 54 dissections.

The arch of the great saphenous vein presents numerous tributaries. Misappreciation of their anatomical variations might cause recurrence after surgical treatment of varices. We dissected 54 inguino-femoral regions of fresh, black African corpses. Our purpose was to study the anatomical variations in the vein confluents of the arch of the great saphenous vein; its positions in relation to the external pudendal artery; establish palpable anatomical markers for its surgical approach. The conventional type in a 'vein star' shape was not the most frequent. Upper or abdominal common vein produced through the merging of superficial veins of the anterior abdominal wall and genital or internal common vein were more frequent. An anterior saphenous vein was found in 23 cases. The external pudendal artery crossed beneath the arch of the great saphenous vein cross in 56% of cases and previously in 44% of cases. On average, the top of the arch of the great saphenous vein was projected out 10.88 cm from the ventral and cranial iliac spine, 3.83 cm from the pubic tubercle and 4.19 cm from the inguinal ligament. In view of our results, variations are real. Knowing and taking them into account are essential to prevent recurrences after surgical treatment of varices of the pelvic limb.

[About the tributaries of the arch of great saphenous vein. Concerning 40 dissections]. / Les affluents de la crosse de la veine grande saphène. A propos de quarante dissections.

The arch of the great saphenous vein cross receives numerous tributaries from the abdominal wall, male external genitalia and pelvic limbs. These collaterals present many variations relating to their number and mode of anastomosis. Their misappreciation may lead to post operative recurrences after surgical treatment of varices. For a last study of these variations, we dissected 40 inguinofemoral regions in fresh black african corpes. The conventional type in a "vein strar" shape was present in 4 cases. An abdominal common vein produced through the merging of the superficial epigastric and superficial circumflex iliac veins was found in 5 cases. A genital common vein summarising the external pudendal veins was present in 19 cases. In 8 cases the abdominal and genital common vein was simultaneously present. An anterior saphenous vein was found in 15 cases, and a posterior saphenous vein in 5 cases. These results, confirm the importance of anatomic variations. Their knowledge is necessary to avoid recurrences after surgery of varicose veins.

[Cadaveric topography and morphometry of the vermiform appendix]. / Topographie et morphométrie cadavériques de l'appendice vermiculaire.

Our study justified by the frequency of acute appendicitis and the possibility of anatomic variations of the caecoappendicular area attempt to index the topographic variations of the vermiform appendix (v.a.). On 80 fresh native cadavers (62 men and 18 women) without surgical antecedent whose mean age was 36 years (range between 16 and 78 years) we note the morphotype and the height. More over we study the intraperitoneal projection of the Mac Burney point, topography and shape of the cecum and the situation, shape and dimensions of the v.a. We note also the level of implantation of this latter on the cecum, appearance of the mesoappendix and the distance separating the base of the appendix to the ileo-caecal junction. Mac Burney's point permitted to localize appendix in 66%; the cecum has more often than not the form of a bulb (98.7%) and sited in right fossa iliaca. We noted 7 types of topographic disposition; front varieties were more frequent (68.7%) notably the pelvic direction (51.2%) with a medial (72.5%) or a posteromedial (27.5%) establishment on the cecum. The v.a. was more often in the form of worm with a long mesoappendix; his mean length was 106.4 mm (between 65 and 160 mm) and the mean diameter 6.77 mm (range between 4 and 10 mm). The distance which separated the base of the appendix to the ileo-cecal junction varied between 15 to 40 mm with a mean distance of 24.2 mm. Thus in this study, dimensions of the v.a. were very variables. Located in right fossa iliaca he adopted a front topography with pelvic direction and medial establishment on bulbar cecum. In spite of scarcity of ectopic situation of the appendix for which laparoscopic approach is salutary, a similar topographic study during surgical treatment of acute appendicitis will be interesting.

[The pectoralis major flap: anatomic basis and indications in head and neck cancer surgery]. / Le lambeau de pectoralis major: bases anatomiques et indications en chirurgie carcinologique cervico-faciale.

INTRODUCTION: The Pectorals Major Pedicle Flap has been described by ARIYAN in 1979. Authors expound the anatomic basis of this flap and case's experience . MATERIALS AND METHODS: The study carried out in the laboratory concerned 14 corpses (11 men and 3 women). Concerning Clinical cases, from January 1st 1994 to December 31st 2003, 26 patients have had a pectoralis major flap in the Otorhinolaryngology and Head and Neck department of the University of Dakar. RESULTS: The average year was 51 and the sex ratio was 2 women (7.69%)out of 24 men (92.31%). We repaired the pharyngostoma in 20 cases, the oropharynx in 3 cases, the mucosal defect in the mouth in 2 cases and the parotid gland in 1 case. The pectoralis major flap was favourable in 9 cases . We noted 8 cases of partial necrosis and 5 cases of total necrosis. Four (4) cases of death were to be deplored in post operative immediate. CONCLUSION: Reconstruction by pectoralis major flap is scarce in our practice. The improvement of the results goes through the indications choice and the acquisition of more efficient technical stools.

[Anatomoradiological correlation of the hypothenar hammer syndrome]. / Corrélation anatomo-radiologique du syndrome du marteau hypothénarien.

Hypothenar hammer syndrome is all the clinical ischemic secondary manifestations in a stenose even one occlusion of traumatic origin of the distal portion of the ulnar artery. Our objective was to underline anatomical substratum of this lesion and to emphasize the interest of the angio M.R.I. in the diagnosis of this syndrome. The radioanatomical study of the distal portion of the ulnar artery were on 10 fresh corpses of both sexes free of traumatic hurt of upperlimb. On 6 anatomical details injected with latex colored with red Congo, three were dissected to the fresh state to the anterior faces of the distal third of the forearm, the wrist and the palmar face of the hand. The three others were subjected to transverse anatomical cuts of carp after freezing. An arterial opacification by injection of lead minium with radioscopic control followed by a radiography in face incidence was realised on 12 upperlimb. The 3 modes of this anatomoradiographic analysis objectivized the nearness of the carpal distal segment of ulnar artery and the hook of the hamate bone. On 7 carps the ulnar artery passed in the balance of the hooked bone, in 5 cases it followed the radial hillside and in twice the artery was mediale. Four details were not exploited for quality reasons of injection or radiographic incidence. By the fact that the carpal portion of ulnar artery be situated in the sagittal plan of the hook or that it be medial or lateral it always passed near this osseous anvil. This anatomical arrangement objectivized well in a transversal plan by the angio magnetic resonance imagering predisposes this arterial segment to the parictal hurts of traumatic origin responsible of stenose in the long-term.