[A 51-year-old woman with upper abdominal pain]

A 51-year-old woman presented to the emergency room with upper abdominal pain and elevated infection parameters. No abnormalities were found during gastroscopy. A CT scan demonstrated perigastricappendagitis. Perigastricappendagitis is a rare infarction of a fatty appendix of the perigastric ligaments. It is a benign and self-limiting disease.

Falciform ligament appendagitis after Roux-en-Y bypass surgery mimicking acute cholecystitis

Fatty falciform ligament appendage torsion (F-FLAT) is a rare type of intraperitoneal focal fat infarction that involves torsion of a fatty appendage of the falciform ligament. It may cause severe pain, mimicking an acute abdomen, but is typically self-limited and does not require hospitalisation or surgery. As a type of intraperitoneal focal fat infarction, it shares many of the same physiological, clinical and radiological features of epiploic appendagitis. To our knowledge, F-FLAT has not previously been reported in a patient following a laparoscopic Roux-en-Y gastric bypass surgery. Identifying falciform ligament appendagitis is critical because it can prevent unnecessary hospitalisation, follow-up studies and surgery.

Evaluation of the vessels of the cardinal ligament by transrectal ultrasonography with color Doppler imaging

PURPOSE

Radical hysterectomy is the standard treatment for early-stage cervical cancer. Although during surgery the vessels of the cardinal ligament are divided one by one until the splanchnic nerve is identified before they are dissected, there are individual differences in the numbers of vessels. In this preliminary study, we evaluated the accuracy of preoperative detection of the vessels of the cardinal ligament by transrectal sonography with color Doppler imaging (TR-CDUS) with respect to the number of vessels detected intraoperatively.

METHODS

We included patients that underwent radical hysterectomy for cervical cancer in our hospital. The vessels of the cardinal ligament were detected preoperatively by TR-CDUS. Radical hysterectomy was subsequently performed and the number of vessels found at surgery was recorded.

RESULTS

A total of 21 patients were included. The median number of the left vessels detected by TR-CDUS and intraoperatively were 2 (range, 1-4) and 2 (range, 1-5), respectively. The median numbers of the right vessels detected were 3 (range, 2-4) and 3 (range, 2-4), respectively. The accuracy rates were 90.5% for the left cardinal ligament, 85.7% for the right ligament, and 81.0% for both cardinal ligaments.

CONCLUSIONS

The results suggest that TR-CDUS may be useful for preoperative detection of the number of the vessels of the cardinal ligament.

Comparative study of the neuropeptide-Y sympathetic nerves in endometriotic involved and noninvolved sacrouterine ligaments in women with pelvic endometriosis

STUDY OBJECTIVE

To show the relationship between the neuropeptide-Y pelvic sympathetic nerves and neoangiogenesis in the development of endometriosis

DESIGN

Prospective study.

SETTING

Academic community teaching hospital.

PATIENTS

Fifteen consecutive women with unilateral endometriotic infiltration of the sacrouterine ligaments.

INTERVENTIONS

A laparoscopic excision/biopsy of involved and noninvolved parts of the sacrouterine ligaments were taken. The sections were incubated with the neuronal marker rabbit polyclonal anti-protein gene product 9.5 and rabbit polyclonal anti-neuropeptide-Y. We made a comparative study on the distribution of nerve fibers and their relationship to the vessels on intact and endometriotic involved tissue.

MEASUREMENTS AND MAIN RESULTS

The results show that a large amount of nerves are present around the blood vessels in the endometriosis samples, and a large number of these nerves are neuropeptide-Y sympathetic nerves. Adrenergic fibers are also present in the intact control subjects, however, in significantly smaller amounts.

CONCLUSION

This finding shows a strong relationship between the neuropeptide-Y sympathetic pelvic nerves and the neoangiogenesis required for the development of endometriosis.

[Hemomicrocirculation channel and mastocyte population in outer oblique aponeurosis stomach muscles and uterus ligament in women with small pelvic organ prolapses]

The aim of the research was histochemical and morphometric investigation of microcirculation channel and study of mastocytes in outer oblique aponeurosis stomach muscles and sacrouterine ligaments. The study was carried out on 36 patients with small pelvic organs prolapse and on 22 patients without such. Patients with different forms and severity of small pelvic organs prolapse displayed the reduction of aponeurosis microcirculatory channel, sacrouterine and round ligament of the uterus (p<0.05) in contrast to women without small pelvic organs prolapse. It was found that outer oblique aponeurosis stomach muscles in patients contains large amount of labrocytes, which degranulate with statistically significant intensiveness, in contrast to women without prolapses (p<0.05). The state of microcirculation channel and local aponeurosis secretor regulator apparatus of the outer oblique aponeurosis stomach muscles and the sacrouterine ligaments must be considered in choosing the most suitable method of suspension and fixations of small pelvic organs prolapse.

The vascular portion of the cardinal ligament: surgical significance during radical hysterectomy for cervical cancer

OBJECTIVE

The objective of the study was to analyze the histopathologic content of the vascular portion of the cardinal ligament in patients undergoing radical hysterectomy for cervical cancer.

STUDY DESIGN

The vascular portion of the cardinal ligament was completely removed during radical hysterectomy. The maximum cervical diameter and length of the vascular ligament were measured on the fresh specimen. After inking, the pathologist separated and embedded the entire vascular segment from each side. Microscopic examination followed.

RESULTS

Eighty-four patients were available for analysis. The mean cervical diameter was 3.9 cm (2-8), whereas the mean vascular segment length on the right and left sides were 4 cm (1-10) and 3.8 cm (1-7), respectively. Mean number of vascular segment lymph nodes were as follows: medial right = 0.7 (0-4), medial left = 0.6 (0-5), lateral right = 0.4 (0-3), and lateral left = 0.6 (0-6). Mean diameter of medial and lateral lymph nodes were 2 mm (0.25-8) and 3.3 mm (0.25-16), respectively. The length of the vascular segment correlated inversely with maximum cervical diameter. Thirty-one percent (26 of 84) had positive pelvic side wall lymph nodes. Fourteen patients had positive vascular segment lymph nodes (1 positive = 7, more than 1 positive = 7). Three of 7 patients had bilateral positive vascular segment lymph nodes; all 7 had microscopic disease in the paravaginal soft tissue, and all 7 had positive pelvic side wall lymph nodes (6 of 7 bilateral). Including the 14 patients, a total of 19 had nodal or nonnodal microscopic disease in the vascular segment. Of these, 7 had disease in the lateral half of the vascular ligament. Histologic sectioning revealed nerve twigs and/or scattered ganglia in the vascular segment but no large nerve trunks.

CONCLUSION

Among a population of women with high-risk, early-stage cervical cancer, the lateral vascular segment of the cardinal ligament contained metastatic disease in a substantial number of patients. This segment contains no major nerve trunks. When radical hysterectomy is chosen as primary treatment for such patients, the vascular segment of the cardinal ligament should be completely excised.

A common celiacomesenteric trunk, and a brief review of the literature

The authors report a rare variation, a common celiacomesenteric trunk, which was observed during routine dissection of an 89-year-old Japanese female cadaver in the laboratory of the Anatomy Department. The trunk gave rise to left gastric, common hepatic, splenic and superior mesenteric arteries. The developmental significance of this variation is discussed with a brief review of the literature.

Hepatic Pseudolesion Around the Falciform Ligament

PURPOSE

The aim of this study was to determine the prevalence and aberrant venous supply (inferior veins of Sappey) of hypoattenuating hepatic pseudolesions seen around the falciform ligament on portal-dominant phase multidetector computed tomography (MDCT) and the frequency of fatty infiltration of these pseudolesions on chemical-shift magnetic resonance imaging.

MATERIALS AND METHODS

Portal-dominant phase abdominal MDCT examinations of 728 patients were evaluated for the presence of a pseudolesion around the falciform ligament, and those with a presumed pseudolesion underwent chemical-shift magnetic resonance imaging to detect the fatty infiltration. Reconstructed MDCT images were investigated for the presence of an inferior vein of Sappey, and 30 patients without a pseudolesion were evaluated as a control group.

RESULTS

A total of 160 pseudolesions were detected around the falciform ligament in 146 (20%) patients. The longest diameter of the pseudolesions was in the craniocaudal direction in most patients (61%). An inferior vein of Sappey supplying these pseudolesions was depicted in 40 (27%) patients, and it was highly significant (P = 0.001) compared with the controls for the presence of a pseudolesion around the falciform ligament. Fatty infiltration was found in 47 (29%) patients.

CONCLUSIONS

Hepatic pseudolesions around the falciform ligament are frequently encountered on portal-dominant phase MDCT images. Detection of craniocaudal extension, inferior veins of Sappey, and fatty infiltration of these pseudolesions, which were firstly described in this article, with the largest subject group based on cross-sectional imaging, might be valuable in excluding true tumors.

Use of the round ligament of the liver to decrease pancreatic fistulas: a novel technique

BACKGROUND

The reported pancreatic anastomosis fistula rate for pancreaticoduodenectomy, distal pancreatectomy, or enucleation is 2% to 27%. We hypothesized that reinforcement with a vascular pedicle would decrease the number of fistulas. We report a novel technique: the use of the round ligament of the liver to reinforce the pancreatic anastomosis after resection.

STUDY DESIGN

Patients undergoing resection from January 1, 2000 until August 8, 2005, at a tertiary referral center, were followed in a retrospective cohort study. The round ligament of the liver was disconnected from the abdominal wall, from the umbilicus to the liver. After pancreatic resection, it was sutured to the anastomosis or closure. A pancreatic fistula was defined as follows: Jackson-Pratt (JP) drainage>50 mL/d, after the fifth postoperative day, with amylase>3 times the serum level; reexploration for a fistula; postoperative pseudocyst; or death from sepsis with a presumed fistula.

RESULTS

In 95 patients, we were able to mobilize the round ligament and use it as a vascular pedicle. The overall fistula rate for the series was 5.3% (5 of 95) and for pancreaticoduodenectomy it was 8.8% (5 of 57). There were no fistulas within the distal pancreatectomy and enucleation group (n=38). Importantly, there was no mortality from pancreatic fistula in the studied patients and no need for operative intervention for a fistula.

CONCLUSIONS

We present a novel technique to prevent pancreatic fistula. Although randomized trials are necessary, it appears that the use of the round ligament as a vascular pedicle for reinforcing the pancreatic anastomoses and resections results in a very low number of pancreatic fistulas.

Primary torsion of the falciform ligament: Computed tomography and ultrasound findings

Torsion of the free end of the falciform ligament is an extremely rare cause of localized peritonitis. A surgically proven case is presented here, with ultrasound and CT findings and a review of the published work.

Anatomical consequences of “open-book” pelvic ring disruption. A cadaver experimental study

"Open-book" pelvic fractures associate a diastasis and/or a fracture of the pubic rami with a posterior pelvic disruption of the sacro-iliac joint. These uni or bilateral lesions are potentially lethal mainly due to associated injuries and massive pelvic hemorrhage. The most frequently injured arteries are parietal branch of the commune, internal or external arteries because of their proximity to the bone, the sacro-iliac joint and the inferior ligaments of the pelvis. The pelvic bone dislocation and the increase of pelvic volume facilitate blood effusion. The aim of this study was to determine, on a cadaver fracture model, the direct anatomical consequences of "open-book" pelvic fracture on the ilio-lumbar pedicle and the pelvic cavity volume.

MATERIALS AND METHODS

Bilateral open-book pelvic ring injuries were created in ten non-embalmed cadaver specimens by directly disrupting the pubic symphysis, the right and the left sacro-iliac joints. Pelvic volume was determined after total pelvic exenteration. Consequences of this fracture on vascular parietal network, nervous pelvic trunk and pelvic cavity volume were studied.

RESULTS

The mean volume of the pelvic cavity after complete visceral exenteration was 872.5 cm(3) (extremes 580-756 cm(3)). The average increase of pelvic volume was 20.8% after 5 cm of pubic diastasis. In all cases, because of a transversal disposition of the ilio-lumbar pedicle with regard to the sacro-iliac joint, reproduction of the open-book fracture caused a venous dilaceration of the ilio-lumbar vein in 12 cases after 5 cm of pubic diastasis (12/20=60%). No arterial dilaceration was observed on the ilio-lumbar artery, but this artery was put in tension.

CONCLUSION

Open-book fractures create an increase of pelvic volume that facilitates blood diffusion from parietal pelvic vascular network. Ilio-lumbar pedicle seems to be very vulnerable in this type of fracture because of its relations to the sacro-iliac joint and its transversal disposition with regard to this joint.

On some structural features of ovarian ligaments in domestic animals

The vascular and nerve components of ovarian ligaments (proper and suspensory) of the sheep, cow and the donkey were examined in order to investigate the presence of blood flow-regulator endovasal devices, artero-venous anastomoses, free and/or encapsulated nerve endings and ganglion cells. Both the ligaments of the investigated species showed the presence of endovasal devices (valvular apparati, intimal and polypoid cushions) and artero-venous anastomoses, the latter structurally ascribed to the first and second type of Conti and Bucciante's classification. Moreover, although not constantly, both the examined districts showed an autonomic nerve support, while four Ruffini's corpuscles were found in the suspensory ligament just in one sheep.

Anatomical study on the morphology and blood supply of the falciform ligament and its clinical significance

The purpose of this study was to understand the clinical significance of the morphology and blood supply of the falciform ligament in laparoscopic surgery. The structure, blood vessel distribution and anastomoses of the falciform ligament were observed in 20 cases of living laparoscopy, 30 cadaveric specimens injected with latex and five cadaveric specimens with Indian ink and hyaline. The falciform ligament was formed by two sides of peritoneum and its length, largest and smallest width were 8.3+/-1.6 cm, 4.9+/-0.8 cm and 1.1+/-0.3 cm, respectively. The left inferior phrenic artery and middle segment artery of the liver formed a vessel that arched and gave off 6-12 branches to the falciform ligament. The veins of the falciform ligament drained into the left inferior phrenic vein, and were not accompanied by any artery. In conclusion, the vessels of the falciform ligament anastomose with multiple vessels and form a significant pathway of the collateral circulation in the liver. The falciform ligament is an important landmark in laparoscopic surgery.

Transverse ligament of the knee in humans

The purpose of this study was to trace the histological structure of the transverse ligament of the knee and its relation to the inferior lateral genicular artery. Investigations were carried out on 20 lower limbs (10 males, and 10 females) from the Department of Anatomy. It was found that close to the attachment of the transverse ligament to the menisci, bundles of fibres pass in vertical, oblique and horizontal directions, occupying a wide area on the anterior margin of the menisci. These fibres intermingle with bundles of the fibrocartilage of the menisci. In the area of the lateral attachment the inferior lateral genicular artery passes anteriorly to the transverse ligament, giving off numerous branches to the ligament. The medial part of the transverse ligament presents a thick rounded structure, surrounded by loose connective tissue. The fibres are arranged irregularly in bundles running horizontally on a tortuous course and with single spindle-like cells with darkly stained nuclei. The cells are not found at the ends of the ligament. Numerous blood vessels are observed between the bundles of fibres and on the periphery of the ligament.

US and CT diagnosis of a twisted lipomatous appendage of the falciform ligament

Pathologic conditions of the falciform ligament leading to surgical intervention are extremely uncommon. We report a case of twisted lipomatous appendage of this ligament, demonstrated by US and CT. To our knowledge, there have been no previous reports of this entity. The extraperitoneal nature of the lesion was found by realtime sonography, but CT only was able to characterize its lipomatous nature and relationship with the falciform ligament. This lesion should be considered in the differential diagnosis of intra-abdominal focal fat infarction (IFFI), a recent vocable essentially regrouping infarction of omentum and epiploic appendages.

[A new method of cholecystectomy]

On the basis of the results of specially performed investigations on 47 complexes of the liver with extrahepatic bile ducts and gallbladder, a new method of cholecystectomy has been developed. In the clinic, 132 patients were operated on for cholelithiasis, acute and chronic cholecystitis. In performance of subserous cholecystectomy, a danger of injuring the vessels of the hepatoduodenal ligament is excluded, its adequate blood supply and that of hepatic parenchyma adjacent to the gallbladder is preserved.

Vascular injuries within the hepatoduodenal ligament: recognition by laparoscopic color Doppler ultrasound

BACKGROUND

Lesions of vascular structures are rare but serious complications of laparoscopic cholecystectomy. The purpose of this blind randomized animal study was to investigate the possibility of detecting different vascular lesions within the hepatoduodenal ligament using laparoscopic color Doppler ultrasound (LCDU).

METHODS

Twenty-four lesions of the hepatic artery and portal vein were created laparoscopically in six farmer pigs using titanium clips. The following injuries were studied: (a) partial occlusion of the hepatic artery (eight cases), (b) complete occlusion of the hepatic artery (eight cases), (c) partial occlusion of the portal vein (eight cases). There were also eight cases without lesions of the vascular vessels. The order in which the injuries were created was randomly assigned. The study was performed in a blind fashion. Recognition of the injuries was attempted with LCDU.

RESULTS

All injuries were recognized correctly by LCDU. There were no false positive results. The clips were reliably located. Using color Doppler imaging, partial occlusions of the hepatic artery and portal vein were visualized by changes of the blood flow from laminar to turbulent behind the clip. Complete occlusion of the hepatic artery was recognized as a complete cessation of the colored blood flow.

CONCLUSION

LCDU is a very efficient tool for visualizing vascular structures and evaluating the bloodstream. Partial or complete vascular occlusion by clips that may occur as a result of difficult dissection during laparoscopic cholecystectomy can be visualized reliably using this technique.

[Idiopathic segmental fatty tissue necrosis of the ligamentum teres hepatis. Variation on a theme...]

INTRODUCTION

Idiopathic segmental infarction of the peritonealized intra-abdominal fatty tissue is a rare cause of acute abdominal distress. Patients are operated for by suspected acute appendicitis or cholecystitis, and the true diagnosis is made intraoperatively.

METHODS

A 32-year-old woman was admitted to our hospital with a 2-day history of pain in the right upper abdomen. Clinical presentation suggested acute cholecystitis, but laboratory evaluation and sonography revealed no pathological findings. Because of a distinctly palpable and very painful epigastric tumor 2 x 3 x 3 cm, a CT scan was performed, that showed a clearly circumscribed mass in the ligamentum teres hepatis with hyperattenuating, infiltrating streaks. Laparoscopy was performed, and a tumor was found, that was adherent to the stomach's antrum and could easily be resected. Twenty-four hours after surgery the patient only felt slight discomfort and could be dismissed on the second day. Pathology report revealed a hemorrhagic infarction of the fatty tissue, which can be histologically found in idiopathic segmental necrosis of the greater omenum or the appendices epiploicae.

CONCLUSIONS

Laparoscopy is an excellent diagnostic tool and also has therapeutic possibilities. Resection of the necrotic tissue ensures faster recovery and pain control and should be performed to prevent complications such as bacterial superinfection with formation of an abscess or spontaneous bleeding.

Hepatic falciform ligament artery: angiographic anatomy and clinical importance

The hepatic falciform ligament artery (HFLA) was evaluated by angiography and also by dissections. Based on the findings, the mechanism of the post-chemoembolization skin rash was studied. A total of 340 liver cirrhosis patients who underwent hepatic artery chemoembolization for hepatocellular carcinoma were reviewed in terms of the angiographic incidence of the HFLA, variations in its origin, and the incidence of skin rash. The HFLA was demonstrated in 26 (7.6%) of the 340 patients on angiography. Two HFLAs were observed in one patient. The origin was the middle hepatic artery (A4) in 16 cases, the superior branch of the middle hepatic artery in three, the inferior branch of the middle hepatic artery in two, the inferior branch of the left hepatic artery (A3) in three, and the confluence of A3 and A4 in three cases. There were no patients who developed post-chemoembolization skin rash. Two cadavers were dissected to investigate the anastomosis between the HFLA and the subcutaneous artery. Two different anastomoses were found: (1) direct and (2) via the ensiform branch of the internal thoracic artery. These were located at the lower and upper part of the falciform ligament, respectively. The distribution of a chemotherapeutic agent through these anastomoses is the likely cause of post-chemoembolization skin rash. If prophylactic embolization of the proximal portion of the HFLA using a metallic coil is performed, the skin rash will be prevented.

An anatomic approach to pelvic hemorrhage during sacrospinous ligament fixation of the vaginal vault

OBJECTIVE

To examine the current clinical problem of life-threatening hemorrhage during sacrospinous vaginal vault suspension, define a management solution, and validate current anatomic knowledge of the area involved.

METHODS

Ten cadaveric female pelves were dissected from a posterior gluteal approach and from an abdominal approach. The vascularity of the region of the sacrospinous ligament was mapped.

RESULTS

There are multiple and varied collateral vascular supplies and anastomoses in the region of the sacrospinous ligament and buttock, including: 1) superior gluteal, 2) inferior gluteal, 3) internal pudendal, 4) vertebral, 5) middle sacral, 6) lateral sacral, and 7) external iliac via the circumflex femoral artery system. Anastomoses occurred in all pelves examined. The frequency of each type of anastomosis varied from 20-100%.

CONCLUSION

Surgical ligation of the internal iliac artery would not likely curb massive hemorrhage during sacrospinous ligament fixation, except in certain cases of internal pudendal vascular injury. The inferior gluteal artery is probably the most commonly injured vessel in sacrospinous ligament suspension because of its location. Inferior gluteal vessel injury should be approached by the use of packing and vascular clips or packing and arterial embolization. These latter approaches should be of primary consideration in the control of hemorrhage at the time of sacrospinous ligament fixation.

Nerve and vessel supplying ligamentous suspension of the mammary gland

Anatomical findings from 28 breast specimens of female corpses have shown a thin horizontal fibrous septum, originating from the pectoral fascia along the level of the fifth rib, heading toward the nipple. This fibrous septum lies in between a cranial and a caudal vascular network, and being mesentery-like, it is responsible for the supply of the nipple areola complex. The cranial vascular sheet is supplied by the thoracoacromial artery and a branch of the lateral thoracic artery, whereas the caudal sheet is supplied by perforating branches from anastomoses of intercostal arteries. The fibrous septum is also a guiding structure for the main supplying nerve of the nipple. At its borders the septum curves upward into a vertical medial and lateral ligament, which attach the breast to the sternum and the lateral edge of pectoralis minor. These ligaments also contain a regular nerve and vascular supply. In their total, the fibrous septum and its ligaments form a sling of dense connective tissue that acts as a brassiere-like suspensory system. These two structures, the fibrous sling and the vascular and nervous membranes attached to it, are consistent anatomical findings, which have not been described before. Their knowledge could be of value and relevance in clinical application.

Microsurgical anatomy of the suboccipital segment of the vertebral artery

The craniocervical regions of seven cadavers (14 sides) injected with silicone rubber were dissected under a Zeiss OPMI surgical microscope. The present study provides a detailed description of the suboccipital segment of the vertebral artery, with particular attention to its loops, branches, supporting osteofibrous structures, adjacent nerves, and surrounding venous structures. Several ligaments fixating the vertebral artery to surrounding structures, which have not been described in previous anatomical studies, were found. The authors propose an anatomically based subdivision of the suboccipital segment of the vertebral artery into five subsegments: infraforaminal, foraminal, supraforaminal, horizontal, and intramembranous. Measurements of surgically and clinically important features were obtained. Surgical approaches to this region are suggested based on a more informed understanding of the local anatomy.

Functional and clinical anatomy of the posterior insertion of the human vocal ligament

The suggested methods of the formation of intubation granuloma as well as carcinoma invasion in the area of posterior vocal ligament insertion have been controversial. One reason for divergent opinions is possibly based on different judgements of morphology in this region. The present study analyzed structures of the vocal ligament and vocalis muscle insertion at the vocal process by means of histological, immunohistochemical and electron microscopic methods. Investigations were performed in three planes on the vocal cords of 22 men and 19 women (aged 21-97 years). Inside the insertion zone of the vocal ligament at the vocal process three structures could be distinguished: hyaline cartilage at the base of arytenoid cartilage, elastic cartilage at its apex and the posterior elastic nodule in front of them. No perichondrium could be seen around the elastic nodule. In elastic nodules type I and type III collagen fibrils as well as elastic fibers formed a scissor-like meshwork around large fibroblasts. The vocalis muscle inserted at the perichondrium in the lateral part of the arytenoid skeleton by short tendons. At the insertion zone blood vessels of the vocalis muscle penetrated the perichondrium and reached the cartilaginous matrix. At the beginning of osteogenesis, the blood vessels connected with intraosseous blood vessels of the arytenoid. Connective tissue cells of the insertion zone and extracellular matrix components formed by these cells fulfilled a biomechanical function by equalizing the different elastic moduli of tendon, cartilage or bone. The lack of perichondrium around the lengthened posterior elastic nodule made formation of intubation granulomas caused by perichondritis in this area impossible. Loosened perichondrium or periosteum in the area of the insertion of the vocalis muscle at the vocal process, ossification and associated vascularization of the arytenoid skeleton permitted invasion of carcinomas into the arytenoid.

Anatomic bases of the vascularized hepatic teres ligament flap

The hepatic ligamentum teres was investigated in 30 adult specimens. The ligament represents a fibrous remnant of the umbilical v. and a small irregular lumen still exists in the ligament in adult life. The ligament is supplied by one set of independent round ligament a. and paraumbilical vv. Since the proximal segment of the ligament is easily mobilised and since the ligamentous a. originates from the right hepatic a. near the hilum, a proximal vascularized pedicle flap of the ligamentum teres has been recommended. Surgical repair of the extrahepatic bile duct using a vascularized pedicle flap of the ligamentum teres has been carried out successfully in 12 patients.

Tendons and ligaments--an overview

The structure, range of functions, blood supply, nerve supply, biochemical composition and development of tendons and ligaments are reviewed. The importance of their cells is often overlooked because of the obvious role of the extracellular matrix (ECM) in determining the physical properties of tendons and ligaments. However, it is emphasised that tendon and ligament cells have elaborate cell processes that form a three dimensional network extending throughout the extracellular matrix. The cells communicate with each other via gap junctions that could form the basis of an important load sensing system allowing the tendon to modify its ECM. Tendons and ligaments have three specialised regions along their length-the myotendinous junction, the region where tendons change direction by wrapping around bony pulleys and the enthesis (bony insertion site). The myotendinous junction is a common site of muscle strains and pulls, the wrap-around region is frequently fibrocartilaginous and a common site for degenerative change, and the enthesis may be fibrous or fibrocartilaginous according to location, and is a common site for degenerative changes or 'enthesopathies'. Enthesis fibrocartilage is just one of a series of protective devices reducing wear and tear at insertion sites. Consideration is also given to the structure and function of tendon sheaths and to the dramatic effects of exercise and deprivation on tendons and ligaments-exercise strengthens, but even relatively short periods of immobilisation can dramatically weaken tendons and ligaments.

Endothelin-A receptors mediate vasoconstriction of capillaries in the spiral ligament

The purpose of this study was to determine whether endothelin-1 (ET-1), endothelin-2 (ET-2) or endothelin-3 (ET-3) alter the vascular diameter of capillaries in the spiral ligament. Changes in vascular tone were measured in capillaries from the isolated spiral ligament in vitro. Capillaries were occluded on one end and opened on the other end. Red blood cells trapped in the capillaries served as markers for a luminal volume defined by the red cell itself, the capillary wall and the occluder. Movement of the red cell toward the open end was taken as evidence for vasoconstriction and movement of the red cell toward the occluder was taken as evidence for vasodilation. The inner diameter of the capillaries was 7.0 microm and decreased maximally by a factor of 0.8 in response to ET-1 and ET-2 (both 10(-8) M). Vasoconstriction induced by ET-1 and ET-2 was concentration-dependent in the range between 10(-12) and 10(-8) M whereas ET-3 (10(-8) M) had no effect. The EC50s for ET-1 and ET-2 were 1.2 x 10(-10) M and 1.4 x 10(-9) M, respectively. Thus, the potency order was ET-1 > ET-2 >> ET-3. Vasoconstriction induced by ET-1 and ET-2 was completely inhibited by the competitive antagonist 10(-6) M BQ-123 (cyclic D-Asp-L-Pro-D-Val-L-Leu-D-Trp). Vasoconstriction induced by ET-1 or ET-2 continued for more than 1 min after removal of agonist from the perfusate. Rapid vasodilation of capillaries preconstricted by ET-1 was observed in response to 10(-3) M sodium nitroprusside. Sodium nitroprusside, however, had no significant effect on the vascular diameter of resting capillaries. These results demonstrate that capillaries in the spiral ligament can constrict and the endothelin-mediated vasoconstriction occurs via ET(A) receptors.

Intraoperative US diagnosis of pylephlebitis (portal vein thrombosis) as a complication of appendicitis: a case report

We report a case of infectious thrombosis of the superior mesenteric vein (pylephlebitis) that was suspected preoperatively with computed tomography and confirmed at intraoperative ultrasonography as confined to the extrahepatic portal vein and superior mesenteric vein. Intraoperative ultrasonography revealed intraluminal echogenic thrombus material in the dilated superior mesenteric and extrahepatic portal veins, slightly dilated open splenic vein, and numerous venous collaterals in the hepatoduodenal ligament. When preoperative imaging studies are inconclusive, intraoperative sonography can confirm the correct diagnosis of pylephlebitis and may give valuable information about the extent of the thrombosis.

Spatial heterogeneity of the effects of calcitonin gene-related peptide (CGRP) on the microvasculature of ligaments in the rabbit knee joint

1. Experiments were performed in anaesthetized rabbits to examine the effects of calcitonin gene-related peptide (CGRP) and the CGRP antagonist CGRP8-37 on blood flow to the medial collateral ligament of the knee joint. 2. Topical application of CGRP (10(-13) to 10(-9) mol) to the exposed external surface of eight knee joints resulted in dose-dependent dilatation of vessels in both the ligament and the joint capsule. The magnitude of this response varied significantly in different regions of the medial collateral ligament, with the 10(-9) mol dose of CGRP giving the maximum response (101.5 +/- 25.3% increase) at the femoral insertion site of the medial collateral ligament and lowest (23.1 +/- 8.8%) at the tibial insertion site. 3. Topical application of CGRP8-37 (0.1, 1 and 10 nmol) produced dose-dependent constriction of vessels in the ligament and the joint capsule in five knees, with a trend towards the greatest effect occurring at the femoral insertion site (45.8 +/- 8.1% reduction in blood flow). With the 10 nmol dose, the vasoconstrictor response at the femoral insertion site differed significantly (P<0.05) from the responses obtained at the tibial insertion and joint capsule sites. 4. Topical application of CGRP8-37 (0.1, 1 and 10 nmol) to four chronically denervated knees produced substantially smaller vasoconstrictor responses at all sites. At the femoral insertion site, where 10 nmol CGRP8-37 normally produces a 45.8 +/- 8.1% reduction in blood flow (n=8), ten days following denervation this response was reduced to 6.5 +/- 6.1%, this difference being significant (P=0.01). 5. Adrenaline was applied topically to augment blood vessel tone, in order to establish how effectively co-administration of CGRP would offset this increase in tone. Adrenaline (10(-10) mol) produced vasoconstriction at all sites (n=6). In the capsule this vasoconstriction was virtually abolished when CGRP (10(-9) mol) was co-administered with adrenaline but in the ligament vasodilatation occurred at all sites. This vasodilatation was significantly greater at the femoral insertion site compared to the tibial insertion and mid ligament sites (P<0.05 for both) and the capsule (P<0.01). 6. Topical application of substance P (10(-10) or 10(-9) mol) failed to elicit dilatation of ligament blood vessels. 7. These results suggest that endogenous CGRP may play an important role in regulating blood flow to different structures in and around the knee joint.

Coloured microsphere assessment of blood flow to knee ligaments in adult rabbits: effects of injury

Coloured microspheres were used to determine standardized blood flow in an established model of medial collateral ligament injury in the adult rabbit knee. Resting blood flow in the ligament was ascertained to be on the order of 0.68 +/- 0.08 ml/min/100 g (mean +/- SEM) in normal rabbit knees, although errors in flow estimates of this magnitude may be quite high. In healing medial collateral ligament, however, flow had increased markedly 3 weeks after injury (21.45 +/- 5.48 ml/min/100 g). Flows in sham-operated control medial collateral ligaments were not significantly increased compared with those in control normal ligaments. Six weeks after injury, blood flow in the ligament remained elevated (16.90 +/- 3.20 ml/min/100 g) and was similarly elevated in other neighbouring joint tissues (i.e., ipsilateral synovial fat pad). The increase in flow to ipsilateral noninjured articular tissues did not persist beyond 6 weeks, but flow in the healing medial collateral ligament scar tended to remain elevated after 17 weeks (4.20 +/- 1.79 ml/min/100 g), although this did not achieve statistical significance. We conclude from these data that it is possible to measure the increase in blood flow in injured and healing articular tissues using the coloured microspheres technique and that ligament injury is a potent stimulus for increasing blood flow. Coloured microsphere measurements of blood flow to joint connective tissues may offer a valuable approach to future investigations of joint injury and arthritis.

Total laparoscopic proctocolectomy and laparoscopy-assisted proctocolectomy for inflammatory bowel disease: operative technique and preliminary report

We present the operative technique of laparoscopic proctocolectomy along with the clinical course of the first four patients to undergo this procedure. The operation was conducted through five 12-mm ports. In total laparoscopic proctocolectomy, the dissection began with the sigmoid, left colon, and rectum. The gastrocolic ligament was opened at the level of the midtransverse colon and dissected along with the transverse mesocolon toward the splenic flexure. The attachments and vessels of the right side of the gastrocolic ligament and the right colon were taken last. This sequence was followed because gradual mobilization of the colon displaced all structures in the middle of the abdomen and obscured vision. The specimen was extracted through the anus. In laparoscopy-assisted proctocolectomy, it was necessary to incise only the white line of Toldt of the ascending and descending colon, mobilize the hepatic and splenic flexures, and ligate the vessels of the gastrocolic ligament. Then the vessels of the mesentery were ligated near the bowel wall through a 6.5-cm midline subumbilical incision from which the abdominal colon was also extracted. The rectum was then completely dissected and sectioned at 10-15 cm from the anus, everted, and resected at the dentate line. Mean operative time was 7 h, 18 min, and average blood loss was 493 ml. One patient had urinary retention. Return to liquid diet took a mean of 4 days. Average postoperative stay, which depended on full return of bladder function and teaching of stoma care, was 10 days.

Vascular supply of the tendon of the equine deep digital flexor muscle within the digital sheath

The vascular and microvascular anatomy of the equine deep digital flexor tendon (DDFT) within the digital sheath was studied by injecting the vasculature with either colored latex or barium sulphate for radiographic, microangiographic, histologic, and computed tomographic (CT) evaluation. Consecutive 4-mm thick two-dimensional CT slice data were reconstructed to 3-dimensional volumetric images to enhance spatial evaluation of the blood supply. Gross dissection and angiographic studies identified three major vascular sources. Above the fetlock, the DDFT was supplied by either a branch of the medial palmar artery (Arteriae digitalis palmaris communis II) or a branch of the medial palmar digital artery (A. digitalis [palmaris propria III] medialis). Below the fetlock, the DDFT was supplied by branches from the lateral and medial palmar branches to the proximal phalanx (Ramus palmaris phalangis proximalis). The most distal aspect of the tendon received small branches from the medial and lateral palmar digital arteries. Using histology and microangigraphy we observed an extensive and uniform intratendinous vascular network above and below the fetlock, with a relatively avascular region of tendon palmar to the fetlock. The most distal 2.0 to 2.5 cm of the tendon within the sheath was heavily infiltrated with fibrocartilage along its dorsal aspect.

Collagen production and maturation at the experimental ligament defect stimulated by pulsing electromagnetic fields in rabbits

Eighty rabbits receiving the square resection (4 x 4 mm) of both patellar ligaments in full thickness at their center were divided into 4 groups, and each group (20 rabbits) were electromagnetically stimulated with different magnetic intensities, 0 (control group), 2, 10, or 50 gauss (G), for 6 hr daily. Pulse frequency and pulse width were 10 Hz and 25 microseconds, respectively. Five animals of each group were sacrificed weekly from 1st to 4th week after operation and the defect tissue was collected for biochemical and ultrastructural evaluations. Before sacrificing, the blood flow of the central portion of patellar defects were measured. Significant increases in blood flow at the defect were observed in 50 G group compared to those of other groups from 2 to 4 weeks after operation. The collagen content in PEMFs groups showed a significant increase compared to that of control group. Furthermore, those increases were higher according to the increase in magnetic intensity. Electronmicroscopically, massive developmental rough endoplasmic reticulum was seen in the fibroblasts at 2 weeks after operation in 50 G group compared to other groups, which suggests the more active collagen production in this group. These results suggest that PEMFs enhanced the blood flow and increased the fibroblasts at the defect. At the same time, PEMFs directly stimulated the collagen production from the fibroblasts, thus accelerate the healing process of the ligament.

The vascular and neuronal composition of the lateral ligament of the rectum and the rectosacral fascia

Detailed dissections were performed on 83 pelvic halves from 45 cadavers in order to obtain more accurate data on the composition of the lateral ligament of the rectum and the rectosacral fascia. The middle rectal artery was observed in only 18 out of 81 spcimens (22.2%). The lateral ligament of the rectum was divided into lateral and medial portions, according to the positional relationship to the pelvic plexus. The lateral part consisted of a superoanterior and an inferoposterior subdivision. The main component of the former was the middle rectal artery, while the pelvic splanchnic nerves were contained in the latter. Both compoents can be considered to contribute to the formation of the medial part, although the middle rectal vessels were not always present. The medial part consisted of the rectal branches from the pelvic plexus and their connective tissue. The rectosacral fascia was formed by dense connective tissue between the posterior wall of the rectum and the third and fourth sacral vertebrae. The main components of the fascia were branches of the lateral and median sacral vessels and the sacral splanchnic nerves which arose directly from the sacral sympathetic ganglia.

Replacing the medial collateral ligament with an allogenic tendon graft. An experimental canine study

In order to determine whether an allogeneic tendon could be used to replace an extra-articular ligament, the right medial collateral ligament from 11 adult dogs was replaced with a fresh-frozen allogeneic patellar tendon. At each of 3, 6, 15, 30 and 52 weeks postoperatively, one dog was killed for micro-angiographical and histological studies; at 52 weeks the remaining six dogs were killed for tensile testing. Micro-angiograms showed that the allogeneic tendon was revascularised with infiltration of the mesenchymal cells from the surrounding tissues and both ends of the graft. Histologically, the alignment of the fibroblasts and collagen bundles became more regular over time, without any immunological rejection. A biomechanical study performed at 52 weeks found no significant difference in stiffness or ultimate load between normal and reconstructed ligaments. Fresh-frozen allogeneic tendons are therefore considered useful for extra-articular ligament reconstruction.

Dose-dependent variations in blood flow evaluation of canine nerve, nerve graft, tendon, and ligament tissue by the radiolabeled-microsphere technique

This study evaluates the dose-dependent accuracy of the radionuclide-labeled microsphere technique for blood flow evaluation in nerve, tendon, and ligament. In eight dogs, blood flows were determined for nerve, nerve graft, tendon, and ligament tissue by simultaneous injection of high- and low-dose microspheres with different radiolabels. The results demonstrated no significant differences in blood flow as measured from the small number of microspheres (less than 400) and the high number (more than 400) for nerve and tendon tissue. For nerve tissue, microsphere counts of 50 to 100, 100 to 200, 200 to 300, and more than 300 produced mean percentage errors of 12.74% (n = 5, SEM = 4.52), 5.45% (n = 13, SEM = 1.22), 10.22% (n = 6, SEM = 4.37), and 17.08% (n = 12, SEM = 3.30), respectively. For tendon tissue, the same microsphere subdivisions had mean percentage errors of 7.47% (n = 4, SEM = 2.66), 3.63% (n = 6, SEM = 1.34), 15.54% (n = 4, SEM = 4.43), and 12.91% (n = 1), respectively. For ligament tissue, percentage errors were consistently higher; microsphere counts of 30 to 100, 100 to 200, and 200 to 300 produced mean errors of 20.14% (n = 4, SEM = 6.38), 18.66% (n = 4, SEM = 6.24), and 25.78% (n = 2, SEM = 1.97), respectively. Although there was no direct relationship between percentage error and number of microspheres retrieved, we suggest that microsphere counts in the range of 100 to 200 should be considered acceptable for nerve and tendon in the canine. Ligament tissue seems to be less well suited to the microsphere technique; however, further study is warranted.

Identification of a patent paraumbilical vein by using Doppler sonography: importance in the diagnosis of portal hypertension

The aim of this study was to determine if the addition of pulsed Doppler imaging to conventional sonography allows discrimination between true paraumbilical veins of portal hypertension and the apparent vein sometimes seen in the ligamentum teres in normal subjects. Conventional sonography and Doppler sonography of the ligamentum teres were performed in 33 normal subjects and in 39 patients with portal hypertension due to chronic liver disease. An apparent ligamentum teres vessel (i.e., hypoechoic channel) was identified on sonograms in 32 (97%) normal subjects (diameter 0.6-1.9 mm) and in 35 (90%) patients with portal hypertension (diameter 1.1-22 mm). In the portal hypertension group, the apparent vessel had a diameter of greater than 3 mm in only 20 patients (51%), but in 32 patients (82%) it was shown on Doppler examination to be a patent paraumbilical vein (i.e., hepatofugal venous signal). A patent paraumbilical vein on duplex Doppler sonography is therefore a specific sign of portal hypertension. The addition of Doppler imaging to conventional sonographic examination significantly increases the sensitivity for the diagnosis of portal hypertension by demonstration of a paraumbilical vein.

[Hemo- and lymphomicrocirculatory bed of the broad ligament of the uterus in the presence of collateral circulation]

Structural adaptation of the vascular bed in the broad ligament of the dog uterus has been studied at various time of the experimental phlebohypertension. Restitution of the circulation after the posterior vena cava occulsion occurs phasically. The venous collateralies are not formed at one time and it is connected with the venous pressure level in the inferiocaval system and with some changes in the construction of the microcirculatory bed. Basing on the morphometry data, a general equation has been derived which reflects dynamics of the microangiological parameters and demonstrates unidirectionness of the adaptive reactions in the vascular bed at the disturbed venous circulation. Using principles of the system-structural analysis and the mathematical graph theory, we consider the microcirculatory system of the broad ligament of the uterus as a graph-system and study the reorganization of the microcirculatory network at a venous congestion. Realization of the compensatory possibilities is reached in the microcirculatory bed by a changed relationships in the number of the intervascular connections. The latter are estimated according to the graph-schemes of the microvascular bed. Morphokinetics of the connections between the vessels is characterized by widening or narrowing the borders of the "adaptive norm" and by changing the microangioarchitectonics. At the same time, there is noted formation of specialized microhemoangioconstructions. Morphofunctional state of the lymphatic system is connected with reorganization of the angioarchitectonics. This is certain manifestation of the law of the lymphatic and blood beds "synergism". Thus, the structural changes of the vascular bed are aimed to support a certain hemodynamic level.

The role of blood vessels within the ligamentum teres in Perthes' disease

In order to examine the significance of the blood flow through the ligamentum teres in Perthes' disease, intraosseous venography was performed on 81 hips. During the initial stages of the disease, the FCV was visualized in 40% of the hips examined, decreasing to 15% during the reparative stage. Moreover, the size of the FCV tended to decrease as the disease progressed. In venograms obtained in the early stage, several abnormalities were found in the morphology and course of the vein. Based on these findings, it appears that the blood vessels within the ligamentum teres play a compensatory role in reestablishing blood flow to the femoral head following the pronounced disturbance in blood circulation that is characteristic of the initial stages of Perthes' disease.

Physical activity and hypophysectomy on the aerobic capacity of ligaments and tendons

Traditionally, ligaments and tendons (L and T) have been regarded as metabolically inert structures. However, sufficient biochemical evidence on the metabolism of collagen has indicated that such a concept is no longer tenable. To determine whether L and T respond to increased or decreased levels of chronic exercise, studies were undertaken to measure their aerobic capacities. For comparative purposes, similar measurements were obtained from liver and skeletal muscles secured from normal and hypophysectomized male rats. Oxygen consumption and cytochrome oxidase (CO) activity was recorded from cell suspensions that had been prepared with the inclusion of collagenase and with elastase added to the medium. The O2 results showed that L and T had values that were approximately 10 times lower than liver tissue and 7.5 times less than the means from skeletal muscles. Hypophysectomy caused marked reductions in O2 uptake of liver and muscle tissues; but had no impact on L and T. When CO activity of these connective tissues were evaluated, immobilization and hypophysectomy caused significant reductions that ranged from -36% to -59% respectively. Training, on the other hand, resulted in increases of less than 10% in the activity of this enzyme within L and T while being elevated in muscle tissue by 58%. It was concluded that the metabolic activity of L and T was lowered with decreased levels of physical activity but it was unclear why chronic exercise did not produce the opposite effect.

Falciform ligament. A possible twist?

Abdominal pain radiating to the right upper quadrant, producing peritoneal signs, developed in a 30-year-old pregnant woman. At surgery, she was found to have an infarction of the falciform ligament that was excised.

The arterial supply of the developing proximal end of the human femur

By means of perfusion studies, an analysis was made of the arterial supply to the proximal end of the femur in 150 specimens from autopsied fetuses and children, aged from twenty-six weeks of gestation to fourteen years and eight months old. All died of diseases which did not involve the hip joint. Two anastomotic rings were found: an extracapsular one formed by the medial and lateral femoral circumflex arteries, and a subsynovial intra-articular ring at the articular cartilage-neck junction. The intra-articular rings in males were discontinuous more often than in females. A three-plane analysis of totally-cleared specimens demonstrated that the epiphyseal plate constituted an absolute barrier to blood flow between the epiphysis and metaphysis in all but two of the 124 barium sulphate-perfused specimens examined. A smaller number of ascending cervical arteries crossed the anterior and medial surfaces of the mid-neck in the specimens from three to ten-year-old white children than in those from newborn to two-year-old white and black children. This finding may be important for the etiology of Legg-Perthes disease. No differences with respect to age, sex, or race were found in the arteries of the ligamentum teres.