Damage to the inguino-femoral nerves in the treatment of hernias. An anatomical hazard of traditional and laparoscopic techniques

Laparoscopic techniques currently constitute an alternative proposed for the repair of hernias of the inguinofemoral region. Nerve injuries have led some teams to recommend technical principles based on the anatomical relations of these nerves with the subperitoneal fascia transversalis and inguinal fossae. An anatomical study consisting of dissection of nonembalmed cadavres, allowed, after evisceration, dissection of the lumbar plexus and its terminal branches, particularly those supplying the inguinofemoral region: iliohypogastric and ilio-inguinal nerves, the genitofemoral nerve, the femoral nerve and the lateral cutaneous nerve of the thigh. Via transperitoneal laparoscopy, the posterior surface of the anterior abdominal wall is centered on the deep inguinal ring, containing testicular vessels and the vas deferens. This deep inguinal ring receives the genitofemoral nerve. Medially, the anterior parietal peritoneum describes three folds formed by the outline of the epigastric artery, umbilical artery and urachus on the midline. The outline of Hesselbach's ligament separates the deep inguinal ring from Hesselbach's triangle, the zone of weakness of direct inguinal hernia. The iliac psoas muscle pass laterally underneath the inguinal ligament, while the external iliac vessels, subsequently becoming the femoral vessels, are located medially. Pectineal ligament lies on the posterior surface of the femoral ring between the umbilical artery and the epigastric artery. Installation of an abdominal wall prosthesis, either transperitoneally or retroperitoneally, must be centered on the deep inguinal ring, and its solid sutures are located medially to the pectineal ligament and anterior abdominal wall. On the other hand, the nerves at risk of being damaged are situated laterally: the ilio-inguinal and ilio-hypogastric nerves in the plane between external oblique and internal oblique above the anterior superior iliac spine, lateral cutaneous nerve of the thigh under the inguinal ligament close to the anterior superior iliac spine, genitofemoral nerve with the spermatic cord in the deep inguinal ring and femoral nerve underneath the inguinal ligament with the psoas muscle lateral to the external iliac artery. No stapling must be performed under the plane of the inguinal ligament to avoid damage to the femoral vessels and lateral to the deep inguinal ring to avoid nerve damage.     

Twenty-two years of office and outpatient laparoscopy: current techniques and why I chose them

Since 1972 I have introduced the following technical modifications in outpatient laparoscopy under local anesthesia to improve safety, economy, and patient acceptability: avoiding the insufflating needle and sharp trocar in favor of open abdominal entry, using the Hasson cannula; introducing room air for insufflation instead of nitrous oxide or carbon dioxide; using the Hulka clip in place of tubal coagulation; making a single-incision, open surgical entry through the central umbilical fossa in obese patients; and completing fascial penetration with a blunt hemostat or Kelly clamp to minimize the risk of bowel or vessel injury.     

Prepubic dermoid sinus: possible variant of dorsal urethral duplication (Stephens type 3)

The authors present the case of 4-month-old girl with a midline prepubic sinus extending from the skin overlying the pubis to the superior surface of the bladder, and continuing to the umbilicus via the median umbilical ligament. The distal portion of the exicised sinus was surrounded by concentric bundles of collagen and smooth muscle with minimal inflammatory infiltrates, which suggests a developmental origin. According to Stephens' classification, the sinus appears to be a variant of dorsal urethral duplication of Stephens type 3.     

Paxillin

Umbilical arterial catheters in the high position reduce the lumen of the aorta and may thereby impair blood supply to the intestine. Thirty-two preterm and three term infants were studied with an umbilical arterial catheter by colour and duplex Doppler sonography. The diameter of the aorta at the level of the coeliac axis was measured to calculate the reduction of the cross-sectional area of the aorta by the catheter. Blood-flow velocities were measured in the coeliac axis, the superior mesenteric artery and the anterior cerebral artery before and after removal of the catheter. The umbilical arterial catheter reduced the cross-sectional area of the aorta by 3.4-27.2% (mean 10.1%). There was no difference between blood-flow velocities in the coeliac axis and the superior mesenteric artery before and after removal of the umbilical arterial catheter, indicating that the catheter did not impair blood supply to the intestine.     

A biomechanical evaluation of graft loading characteristics for anterior cervical discectomy and fusion. A comparison of traditional and reverse grafting techniques

STUDY DESIGN: A biomechanical study of graft loading characteristics for anterior cervical discectomy and fusion comparing the amount and location of transmitted forces. OBJECTIVES: To evaluate the difference between traditional iliac grafting and reverse iliac grafting used for anterior cervical discectomy and fusion in the amount and location of forces applied to the grafts. SUMMARY OF BACKGROUND DATA: Traditional fusion after anterior cervical discectomy involves placing a tricortical iliac crest strut into the disc space with the cortical portion facing anteriorly and the cancellous portion posteriorly. Recently, reverse iliac grafting has been introduced in which the cortical portion is placed in the posterior disc space and the cancellous portion in the anterior disc space. There is no biomechanical or clinical study showing an advantage of using one technique over the other. This study is the first to produce data supporting one technique as biomechanically superior. METHODS: Five fresh cadaveric cervical spines were tested using pressure-sensitive film placed between the bone graft and the vertebral endplate after an anterior discectomy was performed. A 10-pound load was applied to the cervical spine at predetermined sagittal positions. Recordings were made at neutral, 10 degrees of flexion, and 10 degrees and 20 degrees of extension after traditional and reverse iliac grafting. RESULTS: Graft forces were identical in both traditional and reverse grafting in the location and amount of force applied. Total force increased to the maximum in flexion and gradually decreased in more extended positions. The location of the forces was completely anterior with flexion, moving to the posterior portion of the graft with positions of extension. With 10 degrees of flexion, the load applied to the grafts was 20.4 N. In the neutral position, the load was 12 N. The loads decreased further with extension with forces of 11 N in 10 degrees extension, and 4 N in 20 degrees of extension. CONCLUSIONS: The optimal position of the tricortical iliac graft for an anterior cervical fusion is with the stronger cortical portion placed in the anterior disc space and the weaker cancellous portion placed in the posterior disc space. In this traditional position, the graft will best resist the loads applied to the cervical spine, preventing graft collapse.     

The pathomechanics of compression injuries in the cervical spine. Nondestructive and destructive investigative methods

Biomechanical analysis using nondestructive and destructive investigative methods was performed to evaluate the mechanisms of cervical compression injuries. These injuries produce two basic modes of failure: 1) anterior dislocation; and 2) rupture of the anterior ligamentous complex of the vertebral body. Distribution of these two failure patterns was determined by the initial cervical spine position; translational alignment did not have a significant effect. Different results were observed between spines positioned in flexion and extension, indicating that the most important factor determining the mode of failure was rotational alignment in the sagittal plane.     

Imaging of the umbilicus and periumbilical region

Umbilical disorders can be classified according to embryonic remnants contained in the umbilicus, including the urachus, omphalomesenteric duct, and round ligament of the liver; the extraperitoneal paravesical spaces; the umbilical ring; and the umbilicus itself. Only one of the five types of congenital urachal abnormalities (urachal cyst) is common. All anomalies associated with the omphalomesenteric duct are rare except the Meckel diverticulum, which is the most common congenital abnormality of the gastrointestinal tract. The round ligament contains the remnant of the umbilical vein, which in the presence of portal hypertension, may open, recanalize, and form a portosystemic collateral vessel. Extraperitoneal paravesical spaces that run from the umbilicus to the bladder may contain fluid collections. The umbilical ring and the umbilicus may give rise to many masses, including omphalocele, gastroschisis, various hernias, inflammatory and suppurative processes, and neoplasms. Clinical manifestations of umbilical disorders are usually nonspecific; use of cross-sectional imaging can help identify most of these entities because of their typical locations and distributions in continuity with the urinary bladder and the umbilicus and guide therapy. Understanding the anatomy and the differential diagnosis of umbilical disorders is key to arriving at a correct diagnosis and proper patient treatment.     

Clinical pictures of hemiblock and fascicular block. Diagnosis and clinical significance

In intraventricular conducting defects distal the bundle of His we see different forms, i.e. left anterior and left posterior hemiblock, left bundle branch block and right bundle branch block. The left anterior hemiblock is electrocardiographically responsible for a left axis deviation, the left posteriof hemiblock for a vertical axis or right axis deviation. If there is in addition to a hemiblock a right bundle branch block, it is called a bifascicular block. Are at the same time all three fascicles concerned, there will be a trifascicular block, i.e. a complete atrioventricular block, the so-called peripheral form. The common cause of fascicular blocks is coronary heart disease. Because of the possible progressing of the disease patients need further surveillance and eventually therapy.     

Cytotoxic action of 2-deoxy-D-glucose tetraacetate upon human lymphocytes, fibroblasts and melanoma cells

Obesity can play a significant role in chronic diseases, sudden unexpected death, and morbid obesity may be important as a cause of death for forensic pathologists. Our study attempted to determine if there is a correlation between panniculus measurements and body mass index (BMI) since BMI has been used in most studies to categorize obesity. Using data obtained from a review of 524 adult autopsies conducted at the University of Michigan from 1990 to 1992 we were able to show a correlation between both thoracic and abdominal panniculus and BMI (r2 = 0.335 and 0.296 respectively) which is statistically significant (p = 10(-47) and 10(-41) respectively). A prospective study confirmed the correlation (r2 = 0.552 for thoracic and 0.436 for abdominal panniculus) when the measurements were taken at the xyphoid process and 3 cm below the umbilicus. Using these data we calculated a panniculus index (PI) which is equal to the thoracic + abdominal panniculus in centimeters divided by the square of the height (in meters). The PI strongly correlated with BMI and was able to predict obesity. Using a BMI cutoff of 39 for morbid obesity, a PI value of 4.07 for females and 3.25 for males predicted morbid obesity with the probability of a false positive less than or equal to 2.5%. Mild and severe obesity could also be determined using the PI. Based on these data we've concluded that a concise mathematical relationship does exist between BMI and panniculus measurements. Therefore panniculus measurements can be used either as a surrogate measurement of morbid obesity or to support BMI calculations.     

Yucatan pig: an optimal hairless model for a true random cutaneous flap

Porcine models have been used extensively for skin flap research because of the established similarity between the cutaneous blood supply of the swine and humans. The Yucatan minipig provides an excellent model for researching the properties of random cutaneous flaps, offering several advantages over other breeds of swine. In this study, a total of 67 random cutaneous dorsal flank flaps measuring 4 x 14 cm were raised on nine Yucatan minipigs. The mean survival length (10.03 +/- 1.60 cm) of the nondelayed flaps was greater than others reported in the literature. The well-defined plane between the subcutaneous tissue and the panniculus carnosus facilitated flap elevation consistently above the level of the panniculus carnosus thereby ensuring the creation of a true random cutaneous flap. Furthermore, the hairless nature of the skin, particularly beneficial in studying chemical peels, permits easy visualization and monitoring of any external skin changes. These advantages make the Yucatan minipig a more desirable alternative to other breeds of swine for use in skin flap research.     

High frequency of allelic imbalance at chromosome region 16q22-23 in human breast cancer: correlation with high PgR and low S phase

PURPOSE: The validity and reproducibility of an instrumented dynamic examination method to measure sacroiliac (SI) joint stiffness was tested in vitro. METHODS: Four embalmed human female pelvises were excitated by a pelvic vibrator. A color Doppler imaging (CDI) scanner was used to image the amplitude of vibrations at different sites of the pelvis. Vibrations were applied to the anterior superior iliac spines unilaterally and were received by CDI all over the ipsilateral SI region. Three different stability conditions were created in the SI joints: no intervention, screwed and ligaments cut. Test results were quantified by taking the minimum threshold levels of the bones. The relative difference of vibration intensity between ipsilateral ilium and sacrum at each stability condition is accepted as the stiffness level for the SI joint. RESULTS: Statistics showed high reproducibility and significant differences between the stability conditions. Dynamic testing based on the use of vibrations provides visible and quantifiable intra- and inter-individual differences between SI joint stiffnesses. CONCLUSIONS: This new method is objective and reproducible. Future in vivo application is promising since there are no technical and safety restrictions.     

Depth microhardness of glass ionomer cements

As limited studies have been done on surface morphology of Gnathostoma, adult specimens and eggs of four kinds of species in Japan were compared by scanning electron microscopy. Worms had a subglobular head-bulb which was armed with 7-10 rows of cephalic hooks. Mutidigitate cuticular spines were spaced unevenly on transverse cuticular striations on the anterior half of the body. The lengths of the spines were variable with tridentate spines longer than bidentate ones, These tridantate spines became one of the species specific characteristics. The posterior half of the bodies of G. doloresi and G. hispidum were covered densely with long unidentate spines which were gradually shorter towards the posterior ends. Ventral sides of male terminals had different shape of papillae which so called small and caudal ones in species. Eggs recovered from the uteri of female worms were covered with cuticular pits of different sizes, shapes and depths in species.     

Second-order vestibular neuron morphology of the extra-MLF anterior canal pathway in the cat

Second-order vestibular neurons form the central links of the vestibulo-oculomotor three-neuron arcs that mediate compensatory eye movements. Most of the axons that provide for vertical vestibulo-ocular reflexes ascend in the medial longitudinal fasciculus (MLF) toward target neurons in the oculomotor and trochlear nuclei. We have now determined the morphology of individual excitatory second-order neurons of the anterior semicircular canal system that course outside the MLF to the oculomotor nucleus. The data were obtained by the intracellular horseradish peroxidase method. Cell somata of the extra-MLF anterior canal neurons were located in the superior vestibular nucleus. The main axon ascended through the deep reticular formation beneath the brachium conjunctivum to the rostral extent of the nucleus reticularis tegmenti pontis, where it crossed the midline. The main axon continued its trajectory to the caudal edge of the red nucleus from where it coursed back toward the oculomotor nucleus. Within the oculomotor nucleus, collaterals reached superior rectus and inferior oblique motoneurons. Some axon branches recrossed the midline within the oculomotor nucleus and reached the superior rectus motoneuron subdivision on that side. Since these neurons did not give off a collateral toward the spinal cord, they were classified as being of the vestibulo-oculomotor type and are thought to be involved exclusively in eye movement control. The signal content and spatial tuning characteristics of this anterior canal vestibulo-oculomotor neuron class remain to be determined.     

A case of a urachal sinus with umbilical infection

A case of the urachal sinus accompanied by umbilical infection is reported. A 21-day-old female infant was seen at the hospital because of umbilical granuloma, redness and umbilical purulent discharge. The separation of the umbilical cord in her neonate was delayed. IVP and CT examination revealed a urachal diverticulum from the urinary bladder to the umbilicus. The patient was diagnosed to have internal and external urachal sinus. In spite of systemic administration of antibiotic agents, the umbilical infection did not get well. After extruding of the external urachal sinus from the umbilicus, she had not had any symptoms. After 3 months the IVP did not revealed in urachal diverticulum.     

A new lunch box-type method in umbilical reconstruction

A simple and easy technique for reconstruction of the umbilicus was devised, with emphasis on forming walls of the umbilicus and a depression in a caudal direction. A quite satisfactory result was obtained. A permanent and sufficient depression for the umbilicus can be expected as a result of three-dimensional formation of walls.     

Unreferred: a chance to air my prejudices?

STUDY OBJECTIVE: To discern the best method of wound closure after laparoscopy based on patient acceptability of pain, complications, and cosmetic result. DESIGN: Randomized, prospective study. SETTING: A university-affiliated hospital. PATIENTS: Fifty-four women. Interventions. The women received interrupted 3-0 nylon sutures, subcuticular 3-0 polyglactin 910 sutures, or adhesive strips for skin closure. At the umbilical port site the rectus sheath was closed with a single 0 polyglactin suture and then one of the three materials for skin closure. The lateral ports were closed with a combination of these materials, allowing each patient to act as her own control. MEASUREMENTS AND MAIN RESULTS: Pain was significantly less in wounds closed by subcuticular technique than in those closed by either transcutaneous suture or adhesive strips. This was seen for the 5-mm, 10-mm, and umbilical port sites. There was no statistically significant difference in the rate of reported complications or patient satisfaction between subcuticular and transcutaneous wound sites. CONCLUSION: We believe these results support subcuticular methods of wound closure after laparoscopic procedures.     

ACL reconstruction in children with open physes

Flap reconstruction of the vulva and vagina following gynecological ablative procedures has become an integral part of the management of gynecological oncology patients. The benefits of flap reconstruction, including early primary healing, improved cosmesis over skin grafting, and prolonged secondary wound healing, have been well accepted. Additionally, the creation of a neovagina or neovulva often restores the sexual function and positive body image of the patient lost to radical procedures. The gracilis musculocutaneous flap has been used extensively in flap reconstruction but reports of partial flap necrosis and the need for extensive dissection of both thighs have led to alternative flap choices. The rectus musculocutaneous flap, with its hardier cutaneous blood supply, is often too bulky and difficult to inset delicately around the preserved urethral and vaginal cuff. The umbilicus has the required soft tissue, and its conically contoured depression allows for delicate insetting of the rectus abdominis musculocutaneous flap around the urethral cuff. We present 2 patients who underwent vertical rectus musculocutaneous flaps with umbilical soft tissue to restore urinary function and to create a cosmetic nonfunctional vagina.     

Load-bearing capacity of corticocancellous bone grafts in the spine

We investigated the relationship between the densities and areas of commonly used autogenous tricortical bone grafts from the iliac crest and the fibula and their mechanical load-bearing abilities. Intact corticocancellous grafts, seven millimeters thick, were obtained during elective spinal arthrodeses from fifty-six patients: from the anterior part of the pelvis in twenty-four patients, the posterior part of the pelvis in twenty-nine patients, and the fibula in three patients. The apparent densities and cross-sectional areas of the cortical and cancellous bone were measured with use of a specific computed-tomographic technique before the specimens were mechanically tested to failure in uniaxial compression. Specimens from the anterior superior iliac spine were able to bear significantly higher axial loads (average, 3230 newtons; range, 430 to 8112 newtons) than were those from the posterior superior iliac spine (average, 1458 newtons; range, 350 to 4639 newtons) (p < 0.001). The cancellous density was the most significant single factor in the prediction of the load to failure of the grafts from the iliac crest (adjusted r2 = 0.58; p < 0.0001). When all of the physical variables (the cancellous and cortical densities and areas) were entered into a multiple-regression model, the combination of the cortical and cancellous densities and the cortical area was a good predictor (adjusted r2 = 0.68; p < 0.001) of the load to failure. The fibular grafts were stronger than those from the other two sites, but they had the least over-all cross-sectional area and cancellous bone.(ABSTRACT TRUNCATED AT 250 WORDS)     

End-results of experimental gastroschisis created by abdominal wall versus umbilical cord defect

An experimental study was conducted to determine the end-results of two different defects on the anterior abdominal wall: an abdominal wall defect (AWD) versus an umbilical cord defect (UCD) using chick embryos. The AWD was created by leaving an intact skin bridge between the defect and the umbilical cord in group 1; the UCD was created on the umbilical cord near the junction of the skin in group 2. At the end of incubation, the intestines appeared hemorrhagic in the AWD group, but not in the UCD group. During microscopic examination, hemorrhagic areas were observed in the bowel wall and mucosal villi in the AWD group but not in the UCD group. The end-result of the defect causing the physiological umbilical hernia resulted in bowel damage resembling the classic picture of gastroschisis (GS). We conclude that the site of the defect in GS is not the abdominal wall itself, but the physiological umbilical hernia.     

An alternative limb lead system for electrocardiographs in emergency patients

It is occasionally difficult to record the standard 12-lead electrocardiograph (ECG) in emergency patients. The aim of this study was to evaluate the influence on electrocardiographic wave form recordings of moving the location of electrodes from the standard limb lead position to the trunk. The participants were 10 normal subjects and 20 patients with heart disease. In the new lead system, the limb electrodes were placed on the anterior acromial region and the anterior superior iliac spine using adhesive electrodes. Conventional 12-lead ECGs were recorded by the standard and the new lead system simultaneously in the supine position. Wave form analysis was done by an automatic analysis program. Motion artifacts in the recordings were less in the new lead system. The R wave amplitude of the new lead system increased in leads II, III and aVF, and decreased in leads I and aVL. However, the amplitudes of each wave obtained by standard electrocardiography and the new lead system correlated well (y = 1.008x + 2.038, r = 0.99, n = 2,880). In 99.6% of all wave forms, the differences in amplitudes were within 5% of the values of standard recordings. The average of differences in the ST-segment was 2.6 +/- 11.4 microV. The frontal plane QRS axis obtained by the new lead system showed a vertical shift of 7.8 +/- 8.5 degrees (y = 0.94911x + 10.346, r = 0.98, n = 30). The recording errors produced by the new lead system were within the permissible range of variation. The new lead system is a reasonable alternative for recording ECGs if application of the standard lead is difficult in an emergency.