Paracervical Block or Uterosacral Ligament Infiltration for Benign Minimally Invasive Hysterectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this study was to estimate the efficacy of preemptive paracervical block or uterosacral ligament infiltration in reducing postoperative pain and opioid consumption after benign minimally invasive hysterectomy. DATA SOURCES: We searched MEDLINE, Cochrane Library, Embase, ClinicalTrials.gov, and Google Scholar from inception until February 2020. METHODS OF STUDY SELECTION: We identified randomized placebo-controlled trials assessing the primary outcome of pain and opioid consumption after paracervical block or uterosacral infiltration in benign laparoscopic, vaginal, or robotic hysterectomy. Two investigators evaluated studies for risk of bias and quality of evidence. TABULATION, INTEGRATION, AND RESULTS: We reviewed 219 abstracts; 6 studies met the inclusion criteria: 3 using paracervical block (2 vaginal and 1 laparoscopic) and 3 using uterosacral ligament infiltration (all vaginal). Two studies were included in the meta-analysis (both vaginal hysterectomy). Because of lack of numerical data, or comparison, the other 4 studies are reported in narrative form. Three controlled trials reported a moderate benefit from paracervical block up to 8 hours after vaginal and 4 hours after laparoscopic surgery. Meta-analysis could not be performed because of the lack of numerical data for pooling results or the lack of a laparoscopic hysterectomy comparison group. Three trials reported that uterosacral infiltration decreases pain up to 6 hours after vaginal hysterectomy, and meta-analysis pooling the results of 2 of these studies demonstrated improvement in pain up to 4 hours on a 0- to 100-mm visual analog scale for pain (-19.97 mm; 95% confidence interval, -29.02 to -10.91; P < 0.000). Five trials reported a moderate reduction in cumulative opioid use within 24 hours after vaginal surgery for both paracervical block and uterosacral infiltration. Meta-analysis was not performed for paracervical block because only 1 trial provided suitable data for pooling. Meta-analysis pooling the results of 2 trials of uterosacral infiltration demonstrated opioid consumption of 20.73 morphine milligram equivalents less compared with controls (95% confidence interval, -23.54 to -17.91; P < 0.000). CONCLUSIONS: There were a total of 6 randomized placebo-controlled studies evaluated in this study. Although a meta-analysis was unable to be performed for all studies because of lack of comparison groups or numerical data, there is evidence that preemptive uterosacral ligament infiltration may reduce postoperative pain and opioid consumption after vaginal hysterectomy. Our study does not allow us to make any substantive conclusions on the use of paracervical block in vaginal hysterectomy or the use of either type of injection in laparoscopic or robotic hysterectomy.

The Effects of Mechanical Scale on Neural Control and the Regulation of Joint Stability.

Recent work has demonstrated how the size of an animal can affect neural control strategies, showing that passive viscoelastic limb properties have a significant role in determining limb movements in small animals but are less important in large animals. We extend that work to consider effects of mechanical scaling on the maintenance of joint integrity; i.e., the prevention of aberrant contact forces within joints that might lead to joint dislocation or cartilage degradation. We first performed a literature review to evaluate how properties of ligaments responsible for joint integrity scale with animal size. Although we found that the cross-sectional area of the anterior cruciate ligament generally scaled with animal size, as expected, the effects of scale on the ligament's mechanical properties were less clear, suggesting potential adaptations in passive contributions to the maintenance of joint integrity across species. We then analyzed how the neural control of joint stability is altered by body scale. We show how neural control strategies change across mechanical scales, how this scaling is affected by passive muscle properties and the cost function used to specify muscle activations, and the consequences of scaling on internal joint contact forces. This work provides insights into how scale affects the regulation of joint integrity by both passive and active processes and provides directions for studies examining how this regulation might be accomplished by neural systems.

Nerve-sparing in Gynecology.

OBJECTIVE: To demonstrate identification and dissection of the pelvic autonomic nerves in gynecologic surgery. DESIGN: Identification on the right and left pelvic pelvises, dissection and preservation of the inferior hypogastric plexus in deep endometriosis, and dissection and preservation of the pelvic autonomic nerves in radical hysterectomy. SETTING: Academic center. INTERVENTIONS: Robotic excision of the pelvic peritoneum, excision of deep endometriosis in the uterosacral ligaments, and radical hysterectomy. CONCLUSION: Pelvic autonomic nerves are easy to identify with the magnification provided with an endoscopic camera. They should be dissected and preserved whenever possible because of their important function.

The fascial connections of the pectineal ligament.

In clinical settings, the pectineal ligament forms a basic landmark for surgical approaches. However, to date, the detailed fascial topography of this ligament is not well understood. The aim of this study was to describe the morphology of the pectineal ligament including its fascial connections to surrounding structures. The spatial-topographical relations of 10 fresh and embalmed specimens were dissected, stained, slice plastinated, and analyzed macroscopically, and in three cases histological approaches were also used. The pectineal ligament is attached ventrally and superiorly to the pectineus muscle, connected to the inguinal ligament by the lacunar ligament and to the tendinous origin of rectus abdominis muscle and the iliopubic tract. It forms a site of origin for the internal obturator muscle, and throughout its curved course, the ligament attaches to both the fasciae of iliopsoas and the internal obturator muscle. However, dorsally, these fasciae pass free from the bone, while the pectineal ligament itself is adhered to it. The organ fasciae are seen apart from the pectineal ligament and its connections. The pectineal ligament seems to form a connective tissue junction between the anterior and medial compartment of the thigh. This ligament, however, is free to other compartments arisen from the embryonal gut and to the urogenital ridge. These features of the pectineal ligament are important to consider during orthopedic and trauma surgical approaches, in gynecology, hernia and incontinence surgery, and in operations for pelvic floor and neovaginal reconstructions. Clin. Anat. 32:961-969, 2019. © 2019 Wiley Periodicals, Inc.

Selective ablation of ligament of Marshall inhibits ventricular arrhythmias during acute myocardial infarction: Possible mechanisms.

INTRODUCTION: Our recent study found that selective ablation of the distal part of the ligament of Marshall (LOMLSPV ) could suppress ventricular arrhythmias (VAs) during acute myocardial infarction (AMI). This study was to investigate the possible underlying mechanisms. METHODS: Dogs were randomly divided into the sham-operated group (SO; n = 6), AMI group (AMI; n = 8) and the group undergoing LOMLSPV ablation ahead of AMI (LOMD+AMI; n = 8). Incidence of VAs, serum levels of malondialdehyde (MDA) and superoxide dismutase (SOD), expression of connexin (Cx43), Bcl-2, Bax, caspase-3, tumor necrosis factor (TNF)-α, interleukin-6 (IL-6), and high mobility group box (HMGB)1 were compared. Anatomic and immunostaining examinations of LOM LSPV were performed. RESULTS: Compared with the AMI group, incidence of VAs was reduced in the LOMD+AMI group. Compared with the SO group, Cx43, SOD, and Bcl-2 were decreased, MDA, Bax, caspase-3, TNF-α, IL-6, and HMGB1 were increased in the MI group, and all the alterations were significantly restrained in the LOMD+AMI group. A visual nerve fiber communication between the left stellate ganglion (LSG) and LOM and abundant sympathetic nerve bundles distribution in LOMLSPV were revealed. CONCLUSIONS: LOMLSPV ablation could suppress VAs during AMI. The possible mechanism may be associated with disconnection of the sympathetic conduit from LSG to the ventricles. Preservation of Cx43, inhibition of cardiac oxidative stress, apoptosis, and inflammation may be involved.

Histological changes in the proximal suspensory ligament after neurectomy of the deep branch of the lateral palmar nerve of horses with induced proximal suspensory desmitis.

Proximal suspensory desmitis (PSD) is a common cause of lameness in the pelvic limb, but could also affect the thoracic limb of competing and non-competing horses. Most horses diagnosed with PSD in a thoracic limb respond to rest followed by controlled exercise, but in a small percentage of affected horses, lameness persists. In one study, four horses chronically lame because of PSD in a thoracic limb became sound after neurectomy of the deep branch of the lateral palmar nerve (DBLPaN), which innervates the proximal aspect of the suspensory ligament (SL; Guasco et al., 2013). Whether neurectomy of the DBLPaN results in changes in the SL that might predispose the horse to re-injury is not known. The aim of this study was to describe the findings observed during quantitative lameness evaluation, gross and histological examination of the proximal portion of the suspensory ligament (SL) of the thoracic limbs of eight horses after neurectomy of the DBLPaN performed after inducing unilateral PSD by injecting collagenase into the proximal portion of the SL. The clinical response to neurectomy was resolution of lameness in all horses. Muscle fibers of the denervated ligaments presented atrophy and were infiltrated with fat and connective tissue, thereby reducing the strength and elasticity of the ligament.

Vagal nerve endings in visceral pleura and triangular ligaments of the rat lung.

The inner thoracic cavity is lined by the parietal pleura, and the lung lobes are covered by the visceral pleura. The parietal and visceral plurae form the pleural cavity that has negative pressure within to enable normal respiration. The lung tissues are bilaterally innervated by vagal and spinal nerves, including sensory and motor components. This complicated innervation pattern has made it difficult to discern the vagal vs. spinal processes in the pulmonary visceral pleura. With and without vagotomy, we identified vagal nerve fibres and endings distributed extensively in the visceral pleura ('P'-type nerve endings) and triangular ligaments ('L'-type nerve endings) by injecting wheat germ agglutinin-horseradish peroxidase as a tracer into the nucleus of solitary tract or nodose ganglion of male Sprague-Dawley rats. We found the hilar and non-hilar vagal pulmonary pleural innervation pathways. In the hilar pathway, vagal sub-branches enter the hilum and follow the pleural sheet to give off the terminal arborizations. In the non-hilar pathway, vagal sub-branches run caudally along the oesophagus and either directly enter the ventral-middle-mediastinal left lobe or follow the triangular ligaments to enter the left and inferior lobe. Both vagi innervate: (i) the superior, middle and accessory lobes on the ventral surfaces that face the heart; (ii) the dorsal-rostral superior lobe; (iii) the dorsal-caudal left lobe; and (iv) the left triangular ligament. Innervated only by the left vagus is: (i) the ventral-rostral and dorsal-rostral left lobe via the hilar pathway; (ii) the ventral-middle-mediastinal left lobe and the dorsal accessory lobe that face the left lobe via the non-hilar pathway; and (iii) the ventral-rostral inferior lobe that faces the heart. Innervated only by the right vagus, via the non-hilar pathway, is: (i) the inferior (ventral and dorsal) and left (ventral only) lobe in the area near the triangular ligament; (ii) the dorsal-middle-mediastinal left lobe; and (iii) the right triangular ligament. Other regions innervated with unknown vagal pathways include: (i) the middle lobe that faces the superior and inferior lobe; (ii) the rostral-mediastinal inferior lobe that faces the middle lobe; and (iii) the ventral accessory lobe that faces the diaphragm. Our study demonstrated that most areas that face the dorsal thoracic cavity have no vagal innervation, whereas the interlobar and heart-facing areas are bilaterally or unilaterally innervated with a left-rostral vs. right-caudal lateralized innervation pattern. This innervation pattern may account for the fact that the respiratory regulation in rats has a lateralized right-side dominant pattern.

Laparoscopic Nerve-Sparing Radical Hysterectomy for Cervical Carcinoma: Emphasis on Nerve Content in Removed Cardinal Ligaments.

OBJECTIVE: To evaluate the histopathology of autonomic nerve removal within the cardinal ligaments (CLs), patients' postoperative urinary function, and the feasibility and safety of laparoscopic nerve-sparing radical hysterectomy (LNSRH) for treatment of early-stage cervical cancer. METHODS: Perioperative and postoperative parameters were compared between patients with biopsy-proven, early-stage cervical carcinoma treated with LNSRH (n = 64) versus those treated with laparoscopic radical hysterectomy (LRH, n = 42) in a retrospective study. Nerves within CLs were identified by hematoxylin-eosin staining. Rates of the following complications were compared: bladder function, sexual dysfunction, and defecation problems. RESULTS: Duration of surgery, intraoperative blood loss, duration of hospitalization, and morbidity did not differ significantly between the LNSRH and LRH groups. Patients who underwent LNSRH had a significantly earlier return of bladder and bowel functions, with an average time to achieve residual urine of 50 mL or less of 10.22 days and a mean first defecation time of 3.58 days. Nerves were observed mainly in the CLs of the LRH group. Disease-free survival rate did not differ between the LNSRH (90.6%) and LRH (88.1%) groups (P = 0.643). CONCLUSIONS: The LNSRH is a safe, feasible, and easy procedure for trained laparoscopic surgeons. Patients who underwent LNSRH had a more satisfactory quality of life than patients who underwent LRH.

Comprehensive anatomical and immunohistochemical review of the innervation of the human spine and joints with application to an improved understanding of back pain.

BACKGROUND: Pain of spinal origin contributes significantly to cervical, thoracic, and lower back pain presentations. Such pain originates in the nerve fibers supplying the joints or the surrounding ligaments and intervertebral discs. Although there has been little detailed discussion of spinal bony innervation patterns in the literature, the clinical implications of these patterns are anatomically and medically significant. METHODS: The present review provides a detailed analysis of the innervation of the spine, identifying the unique features of each part via online search engines. CONCLUSIONS: The clinical implications of these various studies lie in the importance of the innervation patterns for the mechanism of spinal pain. Immunohistochemical studies have provided further evidence regarding the nature of the innervation of the spine.

Allogeneic versus autologous derived cell sources for use in engineered bone-ligament-bone grafts in sheep anterior cruciate ligament repair.

The use of autografts versus allografts for anterior cruciate ligament (ACL) reconstruction is controversial. The current popular options for ACL reconstruction are patellar tendon or hamstring autografts, yet advances in allograft technologies have made allogeneic grafts a favorable option for repair tissue. Despite this, the mismatched biomechanical properties and risk of osteoarthritis resulting from the current graft technologies have prompted the investigation of new tissue sources for ACL reconstruction. Previous work by our lab has demonstrated that tissue-engineered bone-ligament-bone (BLB) constructs generated from an allogeneic cell source develop structural and functional properties similar to those of native ACL and vascular and neural structures that exceed those of autologous patellar tendon grafts. In this study, we investigated the effectiveness of our tissue-engineered ligament constructs fabricated from autologous versus allogeneic cell sources. Our preliminary results demonstrate that 6 months postimplantation, our tissue-engineered auto- and allogeneic BLB grafts show similar histological and mechanical outcomes indicating that the autologous grafts are a viable option for ACL reconstruction. These data indicate that our tissue-engineered autologous ligament graft could be used in clinical situations where immune rejection and disease transmission may preclude allograft use.

Anatomic observation of the running space of the suprascapular nerve at the suprascapular notch in the same direction as the nerve.

PURPOSE: The configuration of suprascapular notch was previously analysed from the anteroposterior viewing. However, the approach direction of the suprascapular nerve (SSN) to the inlet of the suprascapular notch is consistently craniocaudal and mediolateral. We propose a new method to observe the suprascapular notch according to the running course of the SSN. We reviewed the anatomic characteristics of the suprascapular notch in relation to the nerve. METHODS: In 30 formalin-fixed cadaveric shoulders, the morphology of the suprascapular notch and the attachments of the superior transverse scapular ligament (STSL) were examined from both the anteroposterior and the nerve approach direction. The dimensions of the opening of the SSN passage were measured. RESULTS: By observing from the nerve approach direction, the inlet of the suprascapular notch was recognized to be a space-bordered by the medial wall of the coracoid process, the deep fascia of subscapularis, and the STSL. The STSL formed a sheet-like structure, which ran parallel to the nerve and also to the deep fascia of subscapularis. The attachment of the ligament to the coracoid process was located at the posteromedial corner rather than the medial side. CONCLUSION: Based on the present study, the space between the STSL and deep fascia of the subscapularis formed the space for the nerve to run through. As a clinical implication, this new method to assess the suprascapular notch in the nerve approach direction might develop the imaging techniques for evaluation of SSN entrapment.

Ultrastructure and innervation of thumb carpometacarpal ligaments in surgical patients with osteoarthritis.

BACKGROUND: The complex configuration of the thumb carpometacarpal (CMC-1) joint relies on musculotendinous and ligamentous support for precise circumduction. Ligament innervation contributes to joint stability and proprioception. Evidence suggests abnormal ligament innervation is associated with osteoarthritis (OA) in large joints; however, little is known about CMC-1 ligament innervation characteristics in patients with OA. We studied the dorsal radial ligament (DRL) and the anterior oblique ligament (AOL), ligaments with a reported divergent presence of mechanoreceptors in nonosteoarthritic joints. QUESTIONS/PURPOSES: This study's purposes were (1) to examine the ultrastructural architecture of CMC-1 ligaments in surgical patients with OA; (2) to describe innervation, specifically looking at mechanoreceptors, of these ligaments using immunohistochemical techniques and compare the AOL and DRL in terms of innervation; and (3) to determine whether there is a correlation between age and mechanoreceptor density. METHODS: The AOL and DRL were harvested from 11 patients with OA during trapeziectomy (10 women, one man; mean age, 67 years). The 22 ligaments were sectioned in paraffin and analyzed using immunoflourescent triple staining microscopy. RESULTS: In contrast to the organized collagen bundles of the DRL, the AOL appeared to be composed of disorganized connective tissue with few collagen fibers and little innervation. Mechanoreceptors were identified in CMC-1 ligaments of all patients with OA. The DRL was significantly more innervated than the AOL. There was no significant correlation between innervation of the DRL and AOL and patient age. CONCLUSIONS: The dense collagen structure and rich innervation of the DRL in patients with OA suggest that the DRL has an important proprioceptive and stabilizing role. CLINICAL RELEVANCE: Ligament innervation may correlate with proprioceptive and neuromuscular changes in OA pathophysiology and consequently support further investigation of innervation in disease prevention and treatment strategies.

Finger position alters the median nerve properties within the carpal tunnel: a pre-post MRI comparison study.

PURPOSE: The purpose of this study was to compare the properties of the median nerve and the flexor retinaculum within the carpal tunnel with Magnetic Resonance Imaging (MRI) under two conditions: (a) fingers extended, and (b) fingers in an isometric squeeze grip. METHODS: Thirty-Four volunteers participated in this experimental study. The flexor retinaculum and median nerve characteristics were measured during both conditions using MRI. RESULTS: The isometric squeeze grip condition resulted in significant palmar bowing of the flexor retinaculum (t = 7.67, p<.001), a significant flattening-ratio of the median nerve (t = 4.308, p<.001), and no significant decrease in the cross-sectional area of the median nerve (t = 2.508, p = 0.017). CONCLUSION: The isometric squeeze grip condition resulted in anatomical deformations within the carpal tunnel, possibly explained by the lumbrical muscles incursion into the carpal tunnel during finger flexion.

Anatomy and histology of the transverse humeral ligament.

The classic literature describes the transverse humeral ligament (THL) as a distinct anatomic structure with a role in biceps tendon stability; however, recent literature suggests that it is not a distinct anatomic structure. The purpose of this study was to evaluate the gross and microscopic anatomy of the THL, including a specific investigation of the histology of this ligament. Thirty frozen, embalmed cadaveric specimens were dissected to determine the gross anatomy of the THL. Seven specimens were evaluated histologically for the presence of mechanoreceptors and free nerve endings. Two tissue layers were identified in the area described as the THL. In the deep layer, fibers of the subscapularis tendon were found to span the bicipital groove with contributions from the coracohumeral ligament and the supraspinatus tendon. Superficial to this layer was a fibrous fascial covering consisting of distinct bands of tissue. Neurohistology staining revealed the presence of free nerve endings but no mechanoreceptors. This study's findings demonstrate that the THL is a distinct structure continuous with the rotator cuff tendons and the coracohumeral ligament. The finding of free nerve endings in the THL suggests a potential role as a shoulder pain generator.

Distribution of lymphatic tissues and autonomic nerves in supporting ligaments around the cervix uteri.

To investigate the distribution of lymphatic tissues and nerves in the supporting ligaments around the cervix uteri for their tomographical relationship, 9 adult female cadavers were used in this study. Following the incision of all supporting ligaments around the cervix, hematoxylin and esosin (H&E) and immunohistochemical staining of various sections of these ligaments was performed to enable the distribution of lymph tissues and autonomic nerves to be observed. Four lymph nodes were identified in three cadaver specimens. Three lymph nodes were present at a distance of 2.0 cm from the cervix in the cranial side of the cardinal ligaments (CLs), and one lymph node was located at a distance of 4.0 cm from the cervix in the cranial side of the uterosacral ligament (USL). The lymphatic vessels were dispersed in the CLs, scattered in the cervical side of the USLs, and occasionally distributed in the vesicouterine ligaments (VULs). In the CLs, parasympathetic nerves were located at the pelvic lateral wall and went downwards and medially into the cervix, while sympathetic fibers were located in the middle and lower parts of the ligaments. In the USLs, the autonomic nerves, which consisted primarily of sympathetic fibers, went downwards and laterally from the pelvic wall to the cervix. In the VULs, parasympathetic and sympathetic nerves were located in the inner sides of the vesical veins in the deep layers of the ligaments. It is concluded that there are few lymphatic tissues in the supporting ligaments around the cervix uteri, and that nerve­sparing radical hysterectomy (NSRH) may be a safe method for the treatment of early­stage cervical cancer.

The bifid anterior coracoscapular ligament: a new morphological variation and its potential clinical implications.

The suprascapular notch (SSN) is the most common site of compression and injury of the suprascapular nerve (SN), which results in a neuropathy known as SN entrapment. The SSN is enclosed from the top by the superior transverse scapular ligament (STSL), creating a tunnel for the SN. On both sides of the SSN, below the STSL, the anterior coracoscapular ligament is found. This fibrous band can potentially narrow the opening and contribute to the occurrence of suprascapular entrapment syndrome. This study presents the first case of a bifid anterior coracoscapular ligament coexisting with an atypical SN course, which has never been described in the literature before. Knowledge of such anatomical variations can be helpful in arthroscopic and open procedures of the suprascapular region and confirms the safety of operative decompression for entrapment of the SN.

[Anatomic and surgical study of the recurrent laryngeal nerve and its involvement with the ligament of Berry]. / Estudo das relações anatomocirúrgicas entre os nervos laríngeos recorrentes e o ligamento de Berry.

OBJECTIVE: To study the anatomical relations of the recurrent laryngeal nerve (RLN) with the ligament of Berry (LB), and point out the different ways of presenting the relationship between these two structures. METHODS: We conducted a study with anterior cervical dissection of 22 corpses, in the years 2009 and 2010, with attention towards the frequency of presentation of anatomical relations between the NLR and Berry ligament, with the following classification: Type I or intraligamentary: the nerve and / or its branches were visualized in the ligament substance conjunctiva; Type IIA or lateral: nerve and / or its branches lateral to the ligament; Type IIB or lateral paraligamentary: nerve and / or its side branches and in contact with the ligament without penetrating it; Type III or medial: nerve and / or its branches visualized after complete dissection of the ligament, in lateral-medial position. RESULTS: The study analyzed 41 RLNs, which comprised eight (19.5%) of type I, 20 (48.8%) Type II, five (12.2%) Type IIB and eight (19.5%) type III. Of the 19 (86.3%) RLNs dissected bilaterally in the same cadaver, 11 (57.8%) displayed a classification in one side of the neck different from the one of the other side. CONCLUSION: Due to its proximity to the RLN and the anatomical variability, the Berry ligament should not be considered a reliable parameter for repair and preservation of the recurrent laryngeal nerve. Hence, the indiscriminate latero-medial dissection of the ligament is not recommended without direct visualization of the nerve.

Morphometric study and anatomical variations of the medial ligament of the talocrural joint / Estudio morfométrico y variaciones anatómicas del ligamento medial de la articulación talocrural

The aim of this study was to perform a descriptive study of the morphology, anatomical variations and morphometry of medial talocrural (or deltoid) ligament. We dissected 27 lower limbs obtained from amputations without histories of age, sex or disease. The measurements were made with a caliper, compass and ruler, expressing the results in millimeters. We described the superficial layer morphology of the medial ligament, measuring the size and ligament's thickness. For the deep layer we described and measured the length (l), width (w) and thickness (t). Results: Superficial layer: trapezoid form=66.7 percent (anterior margin=30.5 mm; posterior margin=27.6 mm; top margin=22.6 mm; bottom margin=50.5 mm), rectangular form=19 percent (anterior margin=19.3 mm; posterior margin=27.2 mm; top margin=24.4 mm; bottom margin=29.8 mm), triangular form=14.3 percent (anterior margin=37 mm; posterior margin=37.8 mm; bottom margin=48.3 mm). The average thickness of the superficial layer was 3.6 mm. Deep layer of the medial ligament: l=6.9 mm, w=11 mm, t=5.7 mm; presented rectangular form in 100 percent. In 76.2 percent of the specimens, the deep layer was covered completely by the superficial layer; however, in 23.8 percent the coverage is incomplete, showing the deep layer by posterior angle. The literature is contradictory regarding the anatomy and variations of the medial ligament of the ankle. There are important differences in morphology, attachments, subdivisions and relationships between the two layers of the deltoid ligament. Conclusions: We found significant anatomical variations in the morphology and the relationship between the superficial and deep layers of the deltoid ligament.

El objetivo fue realizar un estudio descriptivo de la morfología, variaciones anatómicas y la morfometría del ligamento talocrural medial (o deltoídeo). Se disecaron 27 miembros inferiores obtenidos de amputaciones sin antecedentes de edad, sexo, ni morbilidad. Las mediciones se realizaron con un pie de metro, regla y compás, expresando los resultados en milímetros. Se describió la morfología del ligamento medial en su capa superficial, midiendo el tamaño y grosor del ligamento. Para la capa profunda se describió y midió la longitud (l), ancho (a) y espesor (e). Resultados: En la capa superficial se observó: forma trapezoidal = 66,7 por ciento (margen anterior = 30,5 mm; margen posterior = 27,6 mm; margen superior = 22,6 mm; margen inferior = 50,5 mm), forma rectangular= 19 por ciento (margen anterior = 19,3 mm; margen posterior = 27,2 mm, margen superior = 24,4 mm; margen inferior = 29,8 mm), forma triangular = 14,3 por ciento (margen anterior=37 mm, margen posterior = 37,8 mm; margen inferior = 48,3 mm). El espesor promedio de la capa superficial fue de 3,6 mm. La capa profunda del ligamento medial: l = 6.9 mm, a = 11 mm, e = 5,7 mm, presentó forma rectangular en el 100 por ciento de los casos. En el 76,2 por ciento de las muestras, la capa profunda estaba completamente cubierta por la capa superficial, sin embargo, en 23,8 por ciento la cobertura fue incompleta, mostrando la capa profunda por el ángulo posterior. La literatura es contradictoria respecto a la anatomía y variaciones del ligamento medial del tobillo. Existen importantes diferencias en su morfología, inserciones, subdivisiones y las relaciones entre las dos capas del ligamento deltoídeo. Conclusiones: Se encontraron importantes variaciones anatómicas en la morfología y la relación entre las capas superficial y profunda del ligamento deltoídeo.

Classical and nerve-sparing radical hysterectomy: an evaluation of the nerve trauma in cardinal ligament.

OBJECTIVES: This study evaluated histopathology and clinical outcome of autonomic nerve trauma and vessels removal within the cardinal ligament (CL) during nerve-sparing radical hysterectomy (NSRH) compared with radical hysterectomy (RH). METHODS: 25 women with FIGO stage Ib1-IIa cervical cancer underwent RH (n=13) or NSRH (n=12). Removed CLs lengths were measured. Biopsies were collected from the proximal, middle and distal segment of CLs and fixed. Different markers were used for immunohistochemisty analysis: tyrosine hydroxylase for sympathetic nerves; vasoactive intestinal polypeptide for parasympathetic nerves; CD34 for blood vessels; and D2-40 for lymphatic vessels. The volume density (Vv), a parameter of biological stereology, was used to quantitatively measure CL components, while post-operative functions, such as defecation, micturition and two-year disease free survival in RH and NSRH groups were compared. RESULTS: The nerves mainly existed in the middle and distal segments of CLs. The Vv was greater in RH compared with NSRH for both sympathetic and parasympathetic nerve markers (P<0.05), while the Vv of blood and lymphatic vessels were same in the two groups. Average time to achieve residual urine≤50ml and first defecation were shorter in NSRH than in RH (P<0.05). CONCLUSIONS: Less autonomic nerves within CL are transected in NSRH than in RH, while blood/lymphatic vessels are efficiently removed in both treatments. Compared to RH, NSRH decreases iatrogenic injury, which leads to reduced post-operative co-morbidities, with ensure the same radicality.

Anatomy of the lateral ligaments of the rectum: a controversial point of view.

The existence and composition of the lateral ligaments of the rectum (LLR) are still the subjects of anatomical confusion and surgical misconception up to now. Since Miles proposed abdominoperineal excision as radical surgery for rectal cancer, the identification by "hooking them on the finger" has been accepted by many surgeons with no doubt; clamping, dividing and ligating are considered to be essential procedures in mobilization of the rectum in many surgical textbooks. But in cadaveric studies, many anatomists could not find LLR described by the textbooks, and more and more surgeons also failed to find LLR during the proctectomy according to the principle of total mesorectal excision. The anatomy of LLR has diverse descriptions in literatures. According to our clinical observations, the traditional anatomical structures of LLR do exist; LLR are constant dense connective bundles which are located in either lateral side of the lower part of the rectum, run between rectal visceral fascia and pelvic parietal fascia above the levator ani, and covered by superior fascia of pelvic diaphragm. They are pathways of blood vessels and nerve fibers toward the rectum and lymphatic vessels from the lower rectum toward the iliac lymph nodes.