Evolution of microneurosurgical anatomy with special reference to the history of anatomy,surgical anatomy,and microsurgery: historical overview

This article reviews the evolution of microneurosurgical anatomy (MNA) with special reference to the development of anatomy, surgical anatomy, and microsurgery. Anatomy can be said to have started in the ancient Greek era with the work of Hippocrates, Galen, and others as part of the pursuit of natural science. In the sixteenth century, Vesalius made a great contribution in reviving Galenian knowledge while adding new knowledge of human anatomy. Also in the sixteenth century, Ambroise Paré can be said to have started modern surgery. As surgery developed, more detailed anatomical knowledge became necessary for treating complicated diseases. Many noted surgeons at the time were also anatomists eager to spread anatomical knowledge in order to enhance surgical practice. Thus, surgery and anatomy developed together, with advances in each benefiting the other. The concept of surgical anatomy evolved in the eighteenth century and became especially popular in the nineteenth century. In the twentieth century, microsurgery was introduced in various surgical fields, starting with Carl O. Nylen in otology. It flourished and became popularized in the second half of the century, especially in the field of neurosurgery, following Jacobson and Suarez’s success in microvascular anastomosis in animals and subsequent clinical application as developed by M.G. Yasargil and others. Knowledge of surgical anatomy as seen under the operating microscope became important for surgeons to perform microneurosurgical procedures accurately and safely, which led to the fuller development of MNA as conducted by many neurosurgeons, among whom A.L. Rhoton, Jr. might be mentioned as representative.

     

Computer-assisted planning in living donor liver operation

INTRODUCTION: The appropriate recipient/donor match is a prerequisite for successful living donor liver transplantation (LDLT). A precise knowledge of the liver anatomy and the functional liver volume plays a key role in allocating live liver donor candidates. With the new software HepaVision, we obtained information on liver mapping by means of virtual 3-dimensional non-invasive imaging reconstructions and were able to perform a virtual simulation of the liver transsection. Aim of our study was to investigate, whether this new computer technology is advantageous in surgery planning for LDLT. METHODS: From January 2002 until December 2004 355 liver transplantations were performed in our department, of which 36 were LDLT. According to our evaluation protocol 135 potential donors (63 male, 72 female) between 18 to 59 years received preoperatively an all-in-one CT. The acquired data sets were further analysed with the software HepaVision (MeVis, Germany). RESULTS: Of the 135 evaluated donors, we excluded 99 (73 %) from donation based on the HepaVision-data. Reason for exclusion was an inadequate liver volume (70.8 %) or a risk related anatomical anomaly (2.2 %). In the remaining 36 cases a successful graft donation was possible. There were no postoperative complications in the donors and recipients, directly related to a misjudgment of the anatomy or miscalculation of the liver volume. CONCLUSION: The systematic use of HepaVision for surgery planning proved to be indispensable for proper donor selection. A virtual simulation of the liver transsection on 3D-model additionally increased the safety of the operation, consequently decreasing the risk for the donor.     

肝脏膜结构再认识及在腹腔镜肝切除术中的应用

现代外科学的诞生源于对人体解剖学知识的不断积累,而外科学的飞速发展也促进了对脏器精细解剖的深入认识.肝脏作为人体最大的实质性脏器,其独特的双重血供、复杂的肝内脉管结构,使得手术过程中容易发生难以控制的出血.因此,长期以来肝脏手术都是普通外科难度较大的手术之一,需要较长的学习曲线.近30年来,随着腹腔镜肝切除术(LH)的...     

John Hilton (1805-78): anatomist and surgeon

John Hilton was the foremost anatomist of his day. From only humble beginnings he became an anatomy demonstrator at Guy's Hospital. When appointed Surgeon to Guy's Hospital, his meticulous clinical skills, arising from his depth of anatomical knowledge, led him to develop many anatomical principles culminating in a series of lectures on 'Rest and Pain'. For the first time the clinical importance of each was highlighted in surgical practice. By public demand the lectures were published as a book, still in print today, which brought a new emphasis to clinical anatomy that would permeate surgery thereafter. He became President of the Royal College of Surgeons and was Surgeon Extraordinary to Queen Victoria. A substantial review of his life has not been published; with the present decline in anatomical teaching, we can learn much from understanding a surgeon who dedicated his life to anatomy.     

Superiority of laparoscopic rectal surgery: Towards a new era

While laparoscopic colon surgery has been established to some degree over this decade,laparoscopic rectal surgery is not standard yet because of the difficulty of making a clear surgical field,the lack of precise anatomy of the pelvis,immature procedures of rectal transaction and so on.On the other hand,maintaining a clear surgical field via the magnified laparoscopy may allow easier mobilization of the rectum as far as the levetor muscle level and may result less blood loss and less invasiveness.However,some unique techniques to keep a clear surgical field and knowledge about anatomy of the pelvis are required to achieve the above superior operative outcomes.This review article discusses how to keep a clear operative field,removing normally existing abdominal structures,and how to transact the rectum and restore the discontinuity based on anatomical investigations.According to this review,laparoscopic rectal surgery will become a powerful modality to accomplish a more precise procedure which has been technically impossible so far,actually entering a new era.     

Detailed anatomy knowledge: first step to approach petroclival meningiomas through the petrous apex. Anatomy lab experience and surgical series

Petroclival meningiomas are a challenge for neurosurgeons due to the complex anatomy of the region that is rich of vessels and nerves. A perfect and detailed knowledge of the anatomy is very demanding in neurosurgery, especially in skull base surgery. The authors describe the microsurgical anatomy to perform an anterior petrosectomy based on their anatomical and surgical experience and perform a literature review. The temporal bone is the most complex and fascinating bone of skull base. The apex is located in the angle between the greater wing of the sphenoid and the occipital bone. Removing the petrous apex exposes the clivus. The approach directed through the temporal bone in this anatomical area is referred to as an anterior petrosectomy. The area that must be drilled is the rhomboid fossa that is defined by the Kawase, premeatal, and postmeatal triangles. In Division of Neurosurgery - University of Turin, 130 patients, from August 2013 to September 2015, underwent surgical resection of intracranial meningiomas. In this group, we have operated 7 PCMs and 5 of these were approached performing an anterior petrosectomy with good results. In our conclusions, we feel that this surgery require an advanced knowledge of human anatomy and a specialized training in interpretation of radiological and microsurgical anatomy both in the dissection lab and in the operating room.     

Anatomic anterior cruciate ligament reconstruction utilizing the double-bundle technique

The goal of every orthopaedic surgeon should be to restore anatomy as close as possible to normal. Intense research on reconstruction of the anterior cruciate ligament (ACL) and an advancing knowledge of the anatomy and function of the 2 primary bundles of the ACL have led to techniques of ACL reconstruction that more closely restore normal anatomy. Restoring the ACL footprint is one of the most important goals of the surgery, and the choice between anatomic single-bundle and double-bundle ACL reconstruction is determined by the anatomical features of each patient. After reconstruction, the graft undergoes a complex, lengthy process of remodeling; therefore, inappropriate (early), aggressive rehabilitation can lead to graft failure and compromise the patient's outcome. The purpose of this article is to provide an overview of the anatomy and function of the ACL, the methods for anatomic single-bundle and double-bundle ACL reconstruction, and our recommendations for postoperative rehabilitation.     

Salient Anatomical Landmarks of Thyroid and Their Practical Significance in Thyroid Surgery: a Pictorial Review of Thyroid Surgical Anatomy (Revisited)

Thyroid surgery is a prototype of operations requiring thorough knowledge of surgical anatomy. There are many vital and delicate anatomical structures such as recurrent laryngeal nerve, superior laryngeal nerve, parathyroid glands, and distinct fascial planes surrounding the thyroid gland. A protean range of pathologies such as goiter, nodules, thyroiditis, and malignancy distort or alter the location and course of these structures and planes. The distinct vascular supply and high vascularity of thyroid region challenges the surgeon’s expertise. Several pathologies like malignancy, multinodularity, toxicity, and retrosternal extension further compounds this vascular aspect of surgery. Several structures of embryological importance such as pyramidal lobe, tubercle of Zuckerkandl, and ligament of Berry have decisive clinical implications in the surgical management of thyroid disorders. Surgeons attempting thyroidectomy need to have thorough knowledge of embryology and surgical anatomy of the thyroid gland. In this context, we highlight through a pictorial assay the embryological and anatomical aspects of the thyroid gland emphasizing on their clinical and surgical importance.     

Renal artery vascularization in the African black. Report of 44 dissections

Studies on the anatomy of the renal arteries in Black Africans being scarce, the authors have made their contribution to the knowledge of the renal arteries. They have provided a comparison between the anatomy of the renal arteries studied in the literature in relation to a white patient and black patient. It is a prospective study based on the change in the number of the renal arteries of 44 Black Africans' maccabees quite fresh, not yet embalmed that have been dissected in order, as received in the anatomy laboratory of Abidjan. That work has allowed to notice some results that are more or less similar to those revealed in the literature, i.e. in 80% of the cases, the kidney is irrigated by an artery, and in 20% of the cases, we have more than one artery for one kidney. No kidney is vascularized by more than two arteries. These results underline how important it is to have good anatomical knowledge of this region in renal surgery. This is possible thanks to medical imagery and arteriography which helps in preventing operative accidents and in preserving the kidney.     

New focus on anatomy for surgical trainees

The demise of anatomy teaching in the undergraduate medical curriculum has inevitably reduced the general level of applied anatomical knowledge displayed by junior doctors. Initiatives such as the European Working Time Directive have exacerbated the problem by reducing trainees’ opportunities to acquire appropriate anatomical knowledge and clinical skills through workplace training. Medical Schools and postgraduate Colleges and Schools of Surgery must work together to design and deliver quality‐assured courses in core and non‐core anatomy, that cross the undergraduate/postgraduate interface. All medical students should learn a core syllabus of anatomy, agreed by a panel of clinicians and anatomists but delivered according to the pedagogic style favoured by individual Medical Schools. This core will define the anatomy, that all F1 doctors should know, particularly the anatomy associated with clinical procedures: it will be assessed across all years of the undergraduate medical programme. Medical Schools should also offer modules in non‐core surgical and/or radiological anatomy, some of which may be designed and delivered in partnership with Colleges of Surgery and Radiology: these modules would be particularly attractive to students contemplating a career in surgery or interventional radiology, but would not be offered exclusively to this cohort. At present, the inadequate anatomical knowledge of Foundation doctors must be addressed by ensuring that early postgraduate training programmes include explicit, formal teaching in anatomy, for example, the Core Surgical Anatomy course currently being piloted at the Royal College of Surgeons of England.     

Fully automatic anatomical, pathological, and functional segmentation from CT scans for hepatic surgery.

OBJECTIVE: To improve the planning of hepatic surgery, we have developed a fully automatic anatomical, pathological, and functional segmentation of the liver derived from a spiral CT scan. MATERIALS AND METHODS: From a 2 mm-thick enhanced spiral CT scan, the first stage automatically delineates skin, bones, lungs, kidneys, and spleen by combining the use of thresholding, mathematical morphology, and distance maps. Next, a reference 3D model is immersed in the image and automatically deformed to the liver contours. Then an automatic Gaussian fitting on the imaging histogram estimates the intensities of parenchyma, vessels, and lesions. This first result is next improved through an original topological and geometrical analysis, providing an automatic delineation of lesions and veins. Finally, a topological and geometrical analysis based on medical knowledge provides hepatic functional information that is invisible in medical imaging: portal vein labeling and hepatic anatomical segmentation according to the Couinaud classification. RESULTS: Clinical validation performed on more than 30 patients shows that delineation of anatomical structures by this method is often more sensitive and more specific than manual delineation by a radiologist. CONCLUSION: This study describes the methodology used to create the automatic segmentation of the liver with delineation of important anatomical, pathological, and functional structures from a routine CT scan. Using the methods proposed in this study, we have confirmed the accuracy and utility of the creation of a 3D liver model compared with the conventional reading of the CT scan by a radiologist. This work may allow improved preoperative planning of hepatic surgery by more precisely delineating liver pathology and its relationship to normal hepatic structures. In the future, this data may be integrated with computer-assisted surgery and thus represents a first step towards the development of an augmented-reality surgical system.     

Reproposal for Hjortsjo's segmental anatomy on the anterior segment in human liver

BACKGROUND: A minimum, but necessary amount, of cancer-containing liver tissue is to be excised in patients who have poor liver function. To achieve that goal of excision, a limited hepatic resection has been carried out. However, performing subsegmentectomy of the anterior segment according to the conventional segmental anatomy introduced by Healey and Schroy or Couinaud is difficult. Because the transverse border between segments 5 and 8 was drawn as an imaginary line through the right portal vein, there is no anatomical structure indicating this border. HYPOTHESIS: Hjortsjo divided the anterior segment into 2 vertical segments according to the fissure in which a hepatic vein coursed. By including Hjortsjo's concept of segmental anatomy, new procedures will be added to hepatic surgery. DESIGN: Sixty-five cadaveric livers were dissected to confirm Hjortsjo's concept of segmental anatomy by investigating the vertical fissure that divides the anterior segment into 2 areas, concerning the relation between portal segmentation and the hepatic venous system of the anterior segment. RESULTS: The territories of the third-order portal branches of the anterior segment were divided into 2 (ventral and dorsal) areas with a vertical fissure and in its intersubsegmental plane, an independent hepatic vein, or a first-order branch of the middle or the right hepatic vein coursed. CONCLUSIONS: These findings confirmed the certainty of Hjortsjo's concept of segmental anatomy of the anterior segment. This is relevant for developing new procedures in hepatic surgery. Its reproposal is opportune for adding it as another concept to the conventional segmental anatomy.     

肝脏外科的历史和现状

Liver surgery is composed of hepatic anatomy and relevant surgical techniques.The research of hepatic anatomy promotes the development of surgical techniques,and then the science of liver surgery get evolved.The knowledge of the liver anmomy,hepatic functional reserve,capacity to regenerate,and prevention of hemorrhage is essential for a successful hepatectomy.Hepatectomy has advanced remarkably in the past 30 years,but major challenges remain,which include developing more efficient minimally invasive surgical techniques,improving patient selection for any given treatment modality,and eliminating the chance of tumor recurrence,particularly in the liver.     

Identification of gallbladder pedicle anatomy during laparoscopic cholecystectomy

Laparoscopic cholecystectomy is widely accepted nowadays as the gold standard in the treatment of cholelithiasis. This new technique was initially associated with a significant increase in morbidity, and in particular in iatrogenic biliary injuries and arterial haemorrhages, perhaps due to a lack of knowledge of the "laparoscopic anatomy" of the gallbladder pedicle. In this technique the anatomical structures are viewed on a two-dimensional video monitor, and the dissection is performed with long instruments without manual sensitivity. Therefore, the laparoscopic surgeon has to deal with new anatomical views and must be aware of the possible arterial and biliary variants. In this review we describe our technique of laparoscopic cholecystectomy, with particular reference to manoeuvres useful for identifying the various anatomical structures at the gallbladder hilum. In our opinion, it is mandatory to avoid cutting any duct if its identity has yet to be established. For this reason, we pay great attention to the anatomical dissection of Calot's triangle, in order to accurately identify the cystic duct and the cystic artery and any other vascular or biliary structures. Routine intraoperative cholangiography may be useful for identifying the biliary anatomy. When in doubt, the surgeon should not hesitate to convert the procedure to open surgery.     

微创外科时代胆道外科的前程与归宿

Bile duct has great attraction to surgeons due to its special anatomical location,unique biological features and origin of complicate diseases. Minimally invasive surgery,represented by laparoscopic ch...     

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??Recent advances and difficulties in techniques of the complex and extended liver resection CHEN Xiao-ping, HE Song-qing. Hepatic Surgery Center??Tongji Hospital??Tongji Medical College??Huazhong University of Science and Technology??Wuhan430030, China
Abstract Advances in liver surgery have increased the safety of all types of liver resections and have made complex and extended hepatectomy performed successfully with low operative mortality. The progresses achieved are attributable to an improved understanding of hepatic anatomy using computer-aided reconstruction of the tumor zones,vascular and biliary anatomy, intraoperative ultrasound and other new imaging technologies and a better method of vascular clamping, vascular reconstruction and better techniques and instruments to achieve more precise liver transection with a good haemostasis on the cut surface. Preoperative manipulation of the liver volume with hypertrophy of the future liver remnant (portal vein embolization) has made complex and extended hepatectomies feasible. Control bleeding during hepatic resection using low CVP anesthesia with selective vascular inflow and outflow control before parenchymal transection is a safe, reliable and effective approach. Complex combinations of surgery, chemotherapy and local ablation are used in advanced disease, extended the limits of resectability for liver tumors. Hepatic laparoscopic surgery is gaining popularity due to the useful for staging purposes and the availability of new laparoscopic instruments for liver transection. Advances in laparoscopic equipment and techniques and telerobotic surgery will undoubtedly expand the use of the techniques and become the next frontier in hepatic complex resectional surgery.