The cutaneous nerves encountered during laparoscopic repair of inguinal hernia: new anatomical findings for the surgeon.

BACKGROUND: With an incidence rate of 2%, injury to the nerves of the lumbar plexus is the most common complication of laparoscopic hernioplasty, particularly when the transabdominal preperitoneal (TAPP) technique is used. METHODS: The course of the genitofemoral nerve, lateral femoral cutaneous nerve, and ilioinguinal nerve within the operation site was investigated in 53 adult dissecting-room bodies. Their relationship to the deep inguinal ring, iliopubic tract, and anterior superior iliac spine was also examined. RESULTS: Both the femoral and genital branches of the genitofemoral nerve may penetrate the abdominal wall lateral to the deep ring and cranial to the iliopubic tract. The lateral femoral cutaneous nerve and the ilioinguinal nerve may run immediately lateral to the anterior superior iliac spine. CONCLUSION: Contrary to the previously accepted opinion, dissection and the placement of staples either cranial to the iliopubic tract or lateral to the anterior superior iliac spine can result in injury to the nerves.

[The venae cavae and their major inflow. Anastomotic valve relations and endothelial abnormalities]. / Die Vv. cavae und ihre grossen Zuflüsse. Mündungsnahe Klappenverhältnisse und Endothelverwerfungen.

The site and condition of the valves at the junctions of the venae cavae and their tributaries were determined, abnormal endothelial structures identified and the vessel calibre measured in sections through the superior venae cavae of 122 and of the inferior venae cavae of 107 adults. A scale diagram of the venae cavae shows variations of the valve position and occurrence of abnormal endothelial structures in the brachiocephalic veins and the inferior vena cava. These structures might present a hazard for central venous catheterization and introduction of a vena cava filter.

The portal bifurcation and the termination of the hepatic veins: an anatomical investigation into the projection of the ultrasonographically important hepatic vessels onto the anterior body wall.

An investigation was carried out on 50 cadavers, in which the projection onto the anterior abdominal wall of the following vascular points was examined: the portal bifurcation, the direction of the course of the right and left branches of the portal vein and the terminal course of the hepatic veins near their entry into the inferior vena cava (IVC). The results are related to a transverse axis passing through the apex of the xiphoid process and the median plane in the supine position. The average position of the portal bifurcation is projected onto a point between a vertical line passing through the midpoint of the right hemithoracic width and a horizontal line passing through a point on the midclavicular line (MCL) corresponding to 57% of the height of the liver measured upwards from its inferior margin. The axis of the prehepatic course of the portal vein makes an angle of about 50 degrees, open downwards, with a vertical line drawn through the apex of the internal angle of the portal bifurcation. A line parallel to the course of the right and left branches of the portal vein is projected on to a surface line cranial to the right costochondral margin, which runs upwards at an angle of approximately 20 degrees towards the apex of the xiphoid process. The termination of the three great hepatic veins is projected at about the level of the xiphisternal joint, one sternal width to the right of the midline. Close to the IVC, the right hepatic vein runs upwards and medially at an angle of between 20 degrees and 30 degrees with the transverse plane.(ABSTRACT TRUNCATED AT 250 WORDS)

[Disorders of microcirculation in colon anastomoses and their significance for the pathogenesis of suture dehiscence]. / Mikrozirkulationsstörungen bei Colonanastomosen und ihre Bedeutung für die Pathogenese der Nahtinsuffizienz.

In this morphologic experimental study in the rabbit disturbances in the microcirculation at the site of colonic anastomoses were found in all suture techniques employed. They are caused by resection, intraoperative traumatization, the suture technique, and, secondarily, by abscess formation on the anastomosis. The suture-induced disturbances of the microcirculation lead to necroses of the mucosa, partial and complete necroses of the inverted cuff, and transmural necroses with destruction of the sero-serous contact zone. For the pathogenesis of anastomotic dehiscence only transmural and extensive complete necroses of the anastomotic bulge, including the serosal contact, are important. They result in transmural abscess formations which correspond to microscopic small secondary anastomotic leakages.

The iliohypogastric and ilioinguinal nerves. Distribution in the abdominal wall, danger areas in surgical incisions in the inguinal and pubic regions and reflected visceral pain in their dermatomes.

The courses of the iliohypogastric and ilioinguinal nerves were studied in 44 adult human cadavers, in order to clarify their relations to incisions in the abdominal wall in appendectomy, inguinal hernial repair, caesarean section and lumbar nephrectomy. If either of these nerves is trapped during suturing of the abdominal layers, especially after inguinal hernia repair and appendectomy typical nerve irritation in the inguinal region is observed. To avoid cutting the anterior branches of the iliohypogastric and ilioinguinal nerves in appendectomy, incisions should be placed at a distance of not less than 3 cm from the anterior superior iliac spine. In inguinal hernial repair, after the external oblique aponeurosis has been opened, the ilioinguinal nerve should be displaced from the spermatic cord cranially. In performing a lower paramedian incision (Lennander) and Pfannenstiel's suprapubic incision, the iliohypogastric nerve will be spared if the incision passes at least 5 cm cranial to the inguinal ligament. During oblique lumbar incision for nephrectomy (Bergmann-Israel) the iliohypogastric nerve can easily be found in the middle third of the lateral margin of the quadratus lumborum muscle. The nerve should be displaced carefully downwards. Positional changes of the kidney or ureter, perinephric inflammation, etc. are often referred to the skin areas (Head, Mackenzie) of the iliohypogastric and ilioinguinal nerves.

[Course and anastomoses of the large hepatic veins to main structures on the liver surface]. / Verlauf und Mündungen der grossen Lebervenen zu Leitstrukturen an der Leberoberfläche.

The upper liver veins of fifty adult people were dissected from their orifices up to their second ramifications. The courses of the hepatic veins to the main portal fissure and umbilical fissure were determined. Three large upper hepatic veins can be expected in 74%, an accessory one occurs in 26%. The three or four upper hepatic veins join V. cava inferior by two (66%) or three (34%) common terminal branches (length 0.9 cm). Mean diameters of right hepatic vein 1.5 cm, middle hepatic and left hepatic veins 1 cm, accessory upper hepatic vein 0.6 cm. The course of the middle hepatic vein to "cava-gallbladder-line" was determined. The most common vein of the umbilical fissure joins the left, occasionally the middle hepatic vein. The intrahepatic distribution of the liver veins was projected to the surface of the liver considering the typical resection lines. We recommend the following anatomical way of proceeding: right extended and left lateral lobectomy remain right to lig. falciforme hepatis; right lobectomy 1 cm right, left lobectomy 1 cm left to "cava-gallbladder-line".

[Pericardiac puncture. The most favorable anatomical approach (author's transl)]. / Die Herzbeutelpunktion. Der anatomisch günstigste Zugangsweg.

On the basis of pericardiac punctures in 105 prepared patients and of pericardiac preparation in 92 adults, a simple low-risk method of epigastric pericardiac puncture is described. The needle is pushed at 33 degrees to the front level in about 1/2 cm below the left costoxiphoid angle and directed towards the right acromion. At a depth of about 4.5 cm the needle penetrates the pericardium. The left internal thoracic artery, the pericardial vessels, the arteria marginalis dextra and the anterior interventricular artery are usually more than 2 cm distant from the needle. When the pericardial infusion is small, the tip of the needle may come relatively close to the right coronary artery (1.3 +/- 1 cm).

[Morphological aspect of the development of stenosis and suture insufficiency in the common bile duct after choledochotomy and biliary anastomoses]. / Morphologische Gesichtspunkte zur Entstehung von Stenosen und Nahtinsuffizienzen am Ductus choledochus nach Choledochotomie und bilio-biliären Anastomosen.

The formation of stenosis following choledochotomy, common duct injury and repair can be observed frequently. A severe complication following a common duct repair, which can almost span a defect of about 3 cm, is the insufficient suture. An insufficient blood supply of the suture margins and a seam which is standing under tension are quoted as reasons for insufficient suture. The extra- and intramural distribution of arterial blood supply of the superior part of common bile duct is described. The results are based on preparations of 25 dissections and further 6 dissections following to another special arterial injection method. The "main-streets" of arterial blood supply of the common bile duct are described and hints are given to the surgeon, how to avoid stenosis or ischemic margins following anastomosis of the common duct.

[Anatomical directions for the placement of central venous catheters]. / Anatomische Hinweise zur Anlage von zentralen Venenkathetern.

Based on approximately 70 dissection studies, the topographical situation of the central veins forming the superior vena cava is described. Actual problems and complications following punctures of central veins are commented upon, from the morphological point of view.

[Non-resecting surgery for gastroduodenal ulcer. II. Indication and technique (author's transl)]. / Die nicht-resezierende Chirurgie des Gastro-Duodenal-Ulkus. II. Indikation und Technik

The indication for the non-resecting combination method arises if the presence of genuine ulcer disease is confirmed by complete diagnostic measures (history, roentgenologic examination, endoscopy, secretion analysis and possibly psychic testing). An extended indication exists for erosive gastritis with hypersecretion, for hiatal hernia with reflux esophagitis (Berman's syndrome), for cardiospasm and prophylaxis of hemorrhage. The technique yields permanent curative results if a complete selective proximal vagotomy is combined with a pyloroplasty suitable in form and function. This is also true for duodenal ulcer. In 22% of cases of gastric ulcer, selective vagotomy with antrectomy is necessary.

[Animal-experiment studies on the pathogenesis of peptic ulcer in the newborn]. / Tierexperimentelle Untersuchungen zur Pathogenese des peptischen Ulcus beim Neugeborenen.

Gastric secretion was studied in 188 fetuses of 28 pregnant dogs near term. Baseline secretory values were determined and gastric secretion was stimulated in additional fetuses with histamine, insulin, or gastrin. A significant increase in volume, acidity and pepsin output was observed in fetuses stimulated during the last week of gestation. Following maternal stimulation the placental transfer of histamine, insulin, and gastrin are demonstrated.

[Frequency of the retroaortic left renal vein in adults (author's transl)]. / Uber die Häufigkeit der linken retroaortären Nierenvene bei Erwachsenen

In 231 adults the frequency and the pattern of the retroaortic left renal vein were studied. We observed a retroaortic left renal vein in 9.09% ("renal collar" in 5.62%, single retroaortic left renal vein in 3.46%. According to our results and to the findings in the literature a retroaortic left renal vein can be expected in 13.67% ("renal collar" in 9.53%, single retroaortic left renal vein in 4.13%).