[Anatomic study and CT angiography with 3D reconstructions of the pulmonary arterial tree]. / Etude anatomique et angioscanographique avec reconstructions 3D de l'arbre artériel pulmonaire.

AIM OF THE STUDY: To prove in vivo and on cadaveric lungs, the constancy of the collateral type of distribution for the right and left pulmonary arteries as described in classical books and modern studies; to estimate the frequency of the main branches observed and define an arterial tree of reference set up with the most common branches for reading the CT pulmonary angiographies. PATIENTS AND METHODS: Sixty three-dimensional reconstructions of pulmonary arterial trees (right: 30; left: 30) using the Volume Rendering Technique (VRT) performed from CT angiographic studies of 30 patients without bronchial, arterial or pulmonary pathology. Dissection of 16 pulmonary arteries from eight fresh cadavers injected with latex. Finally, 76 pulmonary arteries (right: 38; left: 38) were examined. RESULTS: The most common division of the pulmonary artery is a collateral distribution but in seven cases from 38 (18.4%) at right and one case from 38 (2.6%) at left the artery ended in two or three terminal lobar trunks which provided the segmental arteries. The mediastinal artery for the upper right lobe was always found, with a complementary scissural artery in 89.5% of cases; a middle lobar trunk was observed in 22 of the 38 right lungs (57.9%). On the left tree, four different but usually not coexisting mediastinal arteries were identified for the upper lobe, three for the culmen and one for the lingula; six various scissural arteries were noted, three for the culmen and three for the lingula; the segment 6 received one or two segmental arteries, exceptionally three. An arterial tree of reference could be defined for both sides. CONCLUSION: The division in terminal lobar trunks of the pulmonary arteries is a variation demonstrated for the first time. The data obtained from 3D reconstruction imaging in vivo are in conformity with the results of studies performed on injected cadaveric lungs for this point and to define the arterial tree of reference.

The island hemisoleus flap on distal vascular pedicle: anatomical bases and clinical applications.

The coverage of skin defects of the ankle and of the distal fourth of the leg remains a difficult problem despite progress in reconstructive surgery. The aim of our study was to establish an arterial map of the lateral head of the soleus muscle, to compare it with the existing data in order to investigate the possibility of raising a fibular artery-based pedicle island reverse flow flap. It has the theoretical advantage over its medial counterpart of sparing the main arterial axis of the leg and foot. The anatomical study was undertaken on 15 fresh cadavers, 8 left and 7 right randomly chosen lower extremities from different subjects. For each calf, the following measurements were obtained: fibular length from the fibular head to the tip of the lateral malleolus; length of the lateral head of the soleus from its most proximal insertion point on the fibula to the most proximal part of the ending of the muscle belly on the Achilles tendon; width of the lateral head of the soleus; distance between the origin of the fibular artery and the tip of the fibular head; number and height of the pedicles for the lateral soleus, taking as reference their origin from the fibular artery. The mean dimensions of the muscle belly of the lateral soleus were 218 mm in length (between 160 and 270) and 73 mm in width (58-95). In all the examined lower extremities, we found a main pedicle for the lateral soleus emerging from the fibular artery; and in all cases the blood supply of the proximal part of the muscle was of a segmental distribution by way of multiple branches originating from the fibular artery. Then the flaps were raised with a distal pivot point represented by the perforating branch of the fibular artery. In all the cases, the flap would have covered an ankle or a dorsal foot defect up to the metatarsal heads.

[Transmaxillary approach to the skull base: surgical anatomy and guidelines]. / Voie d'abord transmaxillaire de la base du crâne : anatomie chirurgicale et repères.

BACKGROUND: A surgical and anatomic approach to the skull base using the transmaxillary route is presented. This route is well-known and used for a long time for sinus conditions. METHOD: This study was performed on injected cadavers. This study describes step by step this approach in microsurgical conditions following a vital lead: the infraorbital nerve. RESULTS: Anatomical landmarks are located in order to avoid complications. These complications are on one hand, hemorrhages by vascular lesions and on the other, definitive nerve palsy. CONCLUSION: Several skull base approaches exist, transfacial routes produce cosmetic damages. This route preserves the functional anatomy of the nose because it preserves the integrity of the lateral wall of the nasal cavity.

[Numerical variants and congenital fusions of carpal bones]. / Variations numériques et synostoses congénitales des os du carpe.

The number of carpal bones may be increased or decreased by the fact of anatomical variants or true congenital anomalies. Numerical increment arises from additional or from split bones. Over twenty accessory carpal bones have been described but the commonest are the os centrale carpi, the os radiale externum, the triangular bone and the styloideum bone. Additional carpal bones usually result from a failure of fusion of their ossification centers. A congenital origin is not clearly established for all these ossicles. The scaphoid and lunate may split into two or three bones and several cases of bipartite hamulus of the hamatum have been reported. A carpus with only seven bones results from the congenital absence of a normal bone, which mainly affects the scaphoid, lunate and triquetrum, or from a synostosis between two carpal bones, usually the lunate and triquetrum. Congenital fusions originate from an absence of joint cavitation into the embryo and chondrification of the joint interzone. Numerical carpal variants are uncommon as independent entities but occur with a relative high frequency in association with complex malformations of the hand. These anomalies are detectable on plain radiographs of the wrist, but CT-scan and MR-Imaging are useful to differentiate bipartite and accessory bones from carpal fractures or posttraumatic injuries, carpal fusions having to be distinguished from bony ankylosis.

The morphometric study of the sacrospinal and sacrotuberal ligaments correlated with the morphometry of the pelvis.

Perineal neuralgias may be considered as nerve entrapment syndromes, which have been anatomically poorly studied. The pudendal nerve could be compressed between the sacrospinal and the sacrotuberal ligaments. This study tries to find a correlation between the pelvis and the lumbosacral junction morphometry, and sacrospinal and sacrotuberal ligaments morphometry. We did an anatomical study of eight anatomic specimens, and we performed the measures by using the computed tomography scanner. No correlations were found.

[Persistence of the stapedial artery: three cases]. / Persistance de l'artère stapédienne: à propos de trois observations.

The authors report three cases of persistence of the stapedial artery, discovered by computed tomography examination. For two cases, a clinical symptomatology was present but probably related to the association with an aberrant carotid artery in the middle ear; the only case of isolated persistence of the stapedial artery was asymptomatic. Direct visualisation of the abnormal artery was possible on the C. T. scans in two cases and a collateral sign as a larger tympanic part of the facial canal was found in the third case inducing a MRI. The incidence of this anomaly is 0.48 per cent from 1,045 dissections of temporal bones but it is generally clinically unrecognized. The hyoïdo-stapedial artery appears and develops at the 7-18 mm embryonic stages. Partial or complete persistence have been described associated with no regression or no division of the ventral pharyngeal artery.

[Right-sided duplication of the inferior vena cava]. / Duplication droite de la veine cave inférieure.

An infrarenal duplication of the inferior vena cava with both channels lying on the right side of the aorta was fortuitously found during an abdominal Computed Tomography performed on a 52 year-old woman. Only two same cases seem to be reported in the literature. This very uncommon abnormality probably results from persistence of the infra-renal part of the right subcardinal vein. Radiologists have to be aware of this right-sided ipsilateral duplication for it may be a trap in abdominal imaging as well as "classical" inferior vena cava duplication located on both sides of the abdominal aorta.

Two rare anomalies of the left renal vein.

Two uncommon anatomical variations of the left renal vein were found on dissected specimens: a circumaortic venous ring and a retro-aortic bifid left renal vein. The first anomaly results from a persistence of the embryonic renal venous collar. The second one would be related to a particular pattern of left inferior vena cava. Both abnormalities have to be known for they may be undetected or be misleading in imaging. Other clinical implications are also considered.

Dorsal pancreas agenesis: computed tomography appearance with three-dimensional volume rendering reconstruction.

We report a case of a very rare congenital variant consisting in a dorsal (or left) pancreas agenesis due to the lack of development of the dorsal embryonic bud of the gland. This variant is characterized using helical computed tomography (CT). Three-dimensional (3D) computed tomography reconstruction, especially using the volume rendering technique, is very helpful for assessing this entity, which it is important to recognize due to its potential clinical implication (diabetes mellitus). Associated variants of abdominal vessels were also clearly seen in our patient with this technique, including a hepatomesenteric trunk and left retro-aortic renal vein.

Pedicle island flaps of latissimus dorsi. Applications in surgical repair of ruptures of the rotator cuff.

There are considerable problems in repair of major ruptures of the rotator cuff tendons particularly those of the supra and infraspinatus mm. The Gerber technique only transfers the tendinous insertion of the latissimus dorsi onto the greater tuberosity in massive cuff ruptures. We have extended this approach. In 12 shoulders, we studied the feasibility of a latissimus dorsi transfer harvested to fit and bearing muscle and tendon detached at its two extremities and transposed as a neurovascular island. The muscular part is transferred to the infra or supraspinous fossae and the tendon to the greater tuberosity with the aim of reactivating the infra and supraspinatus muscles. The lateral bundle of the latissimus dorsi is always transferable on its neurovascular pedicle into the infraspinous fossa, even into the supraspinous fossa, or into both if transfer is used as a bilobed flap. This anatomical work allowed a parallel study of the different possibilities of transposing the neurovascular pedicle, which might limit the technique, and also to determine the most appropriate surgical approach.

Celiac-bimesenteric trunk: anatomic and radiologic description--case report.

The authors report the case of a 39-year-old man with a common origin of three arteries-the celiac, superior mesenteric, and inferior mesenteric arteries-that has not been described previously in the literature, to their knowledge. This variant, which they call the celiac-bimesenteric trunk, is documented with a selective angiogram, and an embryologic explanation is offered.

[Ultrasonic features of congenital anomalies of the gallbladder]. / Aspects échographiques des anomalies congénitales de la vésicule biliaire.

Congenital anomalies of the gallbladder (GB) correspond to the ultimate manifestation of the wide range of anatomical variations that may affect the GB. Anomalies may be numerical: duplication, accessory GB, and, rarely, agenesis. Anomalies of position are more common: ectopic GB, floating or wandering GB. Morphological anomalies (septations) are the most common GB anomalies. Most of these anomalies may result in pitfalls at US imaging.

[Anatomic variability and congenital anomalies of the gallbladder: ultrasonographic study of 1823 patients]. / Variabilité anatomique et anomalies congénitales de la vésicule biliaire: étude échographique sur 1823 patients.

The authors report the results from the ultrasonographic exploration of the gallbladder performed on 1823 patients. They found morphologic variations and abnormalities in more than 33% of gallbladders, topographic ones in about 3.5% of observations and only 3 cases of real duplication of the gallbladder. Folds and septa may induce traps during echographic examination.

Arterial and neural relations at the posterior and lateral aspects of the medullo-spinal junction.

The authors report the results of a series of 59 microdissections of the region of the foramen magnum. These dissections were made under the strict conditions of a surgical approach using an operating microscope. The major anatomic structures of the medullo-spinal junction are arranged mainly at its lateral aspect. The customary surgical approaches to the posterior cranial fossa give ready access to the cerebello- and latero-medullary cisterns. The description of the neurovascular structures contained therein assumes a particular importance because of the relative frequency of lesions developing at this level. This study deals particularly with the vertebral a. (VA), the inferior posterior cerebellar a. (IPCA), the cranial nn. IX (glossopharyngeal n.), X (vagus n.), XIc and XIs (cranial and spinal accessory n.) and XII (hypoglossal n.). The anatomy of this posterior and lateral region is characterised by the contrast between the relatively uniform course of the VA and the variable course of the IPCA, a true guideline whose very irregular arrangement accounts for the diversity of its relations with the last four cranial nn.

Anatomical basis of a fascio-cutaneous pedicle flap based on the infero-lateral collateral artery of the leg.

An anatomical study of 30 cases has been performed on the vascularisation of the distal third of the antero-lateral compartment of the leg, with particular reference to the relations of the infero-lateral collateral artery of the anterior tibial artery, the perforating branch of the peroneal artery, and the antero-lateral malleolar artery. A fascio-cutaneous pedicle flap based on the infero-lateral collateral artery is described noting that the superior, anterior, and posterior limits are similar to those of the lateral supramalleolar flap of Masquelet. The inferior limit of this new flap is 15 mm distal to the site of emergence of the perforating branch of the peroneal artery. The advantages of this flap are; a large surface area for cover, antegrade vascularisation, and no significant vascular sacrifice. The distal half of the calf can be covered both medially and posteriorly as well as the proximal half of the dorsum of the foot, the medial and lateral arch areas, the perimalleolar region, and the region behind the Achilles tendon. The flap requires the presence of the infero-lateral collateral artery of the tibialis anterior which can be confirmed either peroperatively or preoperatively by angiography.

The "anatomic" view of the suprarenals in medical imaging.

Based on coordinates derived from three series of anatomic sections, the authors propose a view for tomographic investigation, applicable in MRI and ultrasound, which reconstructs the ideal image of the suprarenal gland in its quadrilateral as described by Testut. This "anatomic" view is 45 degrees vertical and oblique, intermediate between the sagittal and frontal views, which it can advantageously replace. A new aspect of suprarenal tomography, recalling the image of a triskele, is described in the context of this view.

Thoracoscopic dissection of the esophagus in human cadavers.

A technique for thoracoscopic dissection of the esophagus is described which gives a large and magnified view of the pleural cavity, the mediastinum, and the esophagus. This technique was developed on human cadavers which gives excellent technical resources for learning and practicing endoscopic surgical anatomy of the esophagus. It avoids the need to change the position of the patient to perform a total thoracoabdominal esophagectomy via a triple surgical approach.

[Juxta- or trans-condylar lateral extension of the posterior suboccipital approach. Anatomical study, surgical aspects]. / L'extension latérale juxta- ou transcondylienne de la voie sous-occipitale postérieure. Etude anatomique, intérêt chirurgical.

In order to improve the surgical approach to tumors and aneurysms of the anterior or antero-lateral aspect of the foramen magnum, some authors have proposed a lateral extension of the posterior sub-occipital approach to the occipital condyle including in some cases its partial or complete resection. The evaluation of this close medio-condylar or trans-condylar suboccipital approach has been performed on eight coloured-latex injected specimens in the conditions of a microsurgical operation. The extra- and intradural steps have been studied so as to define the optimal position of the patient's head and the surgeon and to precise the accessible anatomical structures: Vertebral artery (and its control), Cranial nerves IX, X, XI & XII, Posterior-inferior cerebellar artery and collaterals, Vertebro-basilar junction, antero-lateral aspect of the brain stem and spinal cord. Depending on the extent of the condylar resection, the lateral extension of the posterior sub-occipital approach may be defined as minimal, moderate or large. Based on anatomical and surgical constations it appears that a complete resection of the occipital condyle (resulting in occipito-cervical instability) should be reserved for those very extensive lesions. Yet a partial drilling of the condyle provides a better angle of approach, minimises the hazards of retraction of nervous structures and enables the surgeon to take the best advantage of the dissection and control of the vertebral artery.

Anatomical basis of neurotisation of the median nerve in the hand by the radial nerve.

The sensory sequelae after lesions of the median nerve cause difficulties in treatment since few sensory transfers are available. Neurotisation of the median by sensory branches of the radial nerve have aroused little interest although they have already been used by some authors after anastomosis at the wrist or through the first or second interosseous spaces. Based on what was originally a purely anatomic study, our interest was directed to the possibilities of performing more distal neurotisation for the treatment of sensory disorders of limited extent. The chief object was to obtain faster sensory reinnervation. 30 hands were dissected and a radial branch was defined as suitable for neurotisation whose diameter approximated that of its palmar digital homolog. Only those findings constantly observed in analysis of the hands studied were taken into account. It is therefore possible to reliably define the type and site of the routes of approach as well as the sensory branches suitable for neurotisation.