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Clinical Anatomy 1:63-70 (1988)
Presented at the Fourth Annual Meeting of the American
Association of Clinical Anatomists, June 4-5,1987, Toronto,
Ontario, Canada
AMADIO, Peter C. Department of Orthopedics, Mayo
Clinic and Mayo Foundation, Rochester, Minnesota.
Anatomical variations of the median nerve within
the carpal tunnel.
Anatomical variations of the median nerve within the carpal
tunnel are not uncommon and may have great clinical significance both with regard to ensuring appropriate decompression
and avoidance of iatrogenic injury. In a personal consecutive
series of 275 carpal tunnel releases, the most common abnormality noted was perforation of the transverse carpal ligament
by the thenar motor branch, in 35 cases. Two separate motor
branches were identified in 8 cases and three separate motor
branches were identified in 3 cases. Nine cases of high division
of the median nerve were identified, one of which also included an abnormal path of the radial division within the
substance of the transverse carpal ligament. In seven cases the
palmar cutaneous branch of the median nerve arose distally
and passed through the transverse carpal ligament. Additional
anomalies encountered included persistent median artery in 7
cases usually associated with high division of the median
nerve; prominent palmaris brevis muscle in three cases, accessory abductor digiti quinti in two cases, and a palmaris profundus in one case. Many surgical incisions have been
recommended for treatment of carpal tunnel syndrome, some
of which do not involve complete exposure of the median
nerve in the distal forearm and proximal palm. Based on the
number and variety of anatomical variations encountered,
complete exposure of the median nerve from the distal foream
to the mid palm is recommended, in order to ensure adequate
visualizationof potential variations in median nerve branching
and adequate identification of other anatomical anomalies.
ARENSON, Anna Mane. Sunnybrook Medical
Centre, Department of Radiology, Toronto, Ontario,
Canada. Vascular landmarks as a guide to diagnosis
of disease in the pancreas and para-aortic region:
CT and ultrasound demonstration.
The great vessels of the abdomen are well accepted landmarks
for the localization of the pancreas using computed tomography or ultrasound as diagnostic modalities. This paper will
demonstrate the ability to diagnose diseases of the pancreas as
well as celiac region, duodenum and retroperitoneum using
vascular landmarks.
R.E. FALK and J.A. FALK, Division of Plastic and
0 1988 Alan R. Liss, Inc.
Neurosurgery, University of Toronto, Toronto, Ontario. Evaluation of regeneration across peripheral
nerve allografts in rats immunosuppressed with cyclosporin A.
Management of the large peripheral nerve deficit continues to
be a problem for the reconstructive surgeon. The potential use
of nerve allografts could expand the reconstructive potential
for patients with major nerve injuries.
In the rat model, the minimal effective dosage of Cyclosporin A (CsA) necessary to prevent nerve allograft rejection
was determined in Lewis (RTl') recipients of ACI (RT1')
nerve allografts by a combination of immunological and histological assessments. This dosage of CsA, 5 mgikgiday used
was in the same donorirecipientcombination to determine the
quality of nerve regeneration across nerve allografts vs control
Seventyfive Lewis rats were the recipients of 3 cm nerve
allografts from ACI donors or syngeneic nerve grafts (autografts) from identical Lewis donors. Nerve grafts were microneurosurgically repaired to the transected sciatic nerve of the
recipient in the midthigh using 10-0 epineurial sutures. These
animals were divided into CsA treated and untreated groups.
Animals were evaluated serially by sciatic function index (SFI)
determination and at 14 weeks by electrophysiological,histological and morphological assessments. Sciatic nerve function
in CsA immunosuppressed recipients of nerve allografts was
significantly superior by functional (CsA treated allograft, SFI
= -54.2 + / - 19.4; control allograft, SFI = -82.4 +/13.5; p<O.Ol), electrophysiological (CsA treated allograft,
nerve conduction velocity (NCV) = 19.55 +/-2.69 m/sec;
allograft control, NCV = 11.68 +/-3.37 mlsec; p<O.M)l)
and histological criteria to that of untreated allograft recipients
and indistinguishable from that of control autograft recipients.
In addition, the rate of nerve regeneration as assessed by SFI
determination was significantly faster in the early stages of
regeneration. Morphometric data will be available for presentation at the meeting.
Sponsored by Dr. Keith Moore, Department of Anatomy,
University of Toronto, Toronto, Ontario M5S 7A8
Supported by the Medical Research Council of Canada
and the Physician's Services Incorporated
COHEN, Ian T., Division of Pediatric Surgery, UIIversity of Massachusetts Medical Center, Worcester,
Massachusetts. Esophageal atresia and tracheo-
esophageal fistula.
Esophageal atresia and tracheoesophageal fistula is a complex
congenital anomaly of the upper gastrointestinal and respiratory tract of the neonate which has taxed the skill and ingenuity
of pediatric surgeons for many years. This anomaly is lethal if
untreated. It causes morbidity by obstructing the upper esophagus with obvious nutritional sequelae, and by allowing aspiration of reflux into the tracheo-bronchial tree causing
aspiration pneumonia. The purpose of this presentation will be
to illustrate how a knowledge of the embryology and anatomy
of this region is absolutely essential to the understanding and
treatment of this difficult problem.
The embryologic explanation for the five subtypes of
esophageal atresia and tracheoesophageal fistula will be described together with the detailed anatomy of this region. The
clinical, radiologic and operative details of six patients with
this anomaly will be described. Four of these infants were of
the common variety with an esophageal atresia and distal
tracheoesophageal fistula. One had a rarer variety consisting
of an isolated esophageal atresia with no fistulae, and an
associated high imperforate anus. The last was an example of
an extremely rare variety consisting of an esophageal atresia
with both upper and lower fistulae. The embryologic explanation for each of these varieties, their incidence and rationale
for treatment will be described.
During the course of this presentation it will be shown
how the embryology and anatomy provide logical explanations
for the following: 1) early diagnosis including diagnosis in
utero. 2) staging of the operative repair based on prognostic
clinical subgroups. 3) the technique of the standard extrapleural surgical repair. 4) recognition and treatment of vexing
complications such as recurrent tracheoesophageal fistula and
gastroesophageal reflux. 5) innovative techniques to deal with
esophageal replacement in the “long-gap’’ esophageal atresia.
6) methods of preventing gastric perforation in premature
infants on ventilator support. 7) theories to explain the association of tracheomalaciawith this anomaly.
DALLEY, Arthur F., I. Department of Anatomy,
Creighton University School of Medicine, Omaha,
Nebraska. Low back pain: Relevant clinical
Low back pain (LBP) is said to be second only to upper
respiratory infection as the most common disease entity of
developed nations. 65% of the population will experience LBP
sufficient to cause them to consult a physician (16 million
ofiice visitslyr. for LBP in the U S . ) andlor miss work. LBP
currently costs the U S . more than $12 billiodyr. With widespread adoption of pre-employment health screening, the impact of LBP-on both society and the individual-is likely to
increase tremendously. Although LBP results in surgery <4%
of the time, 200,000 spine operations are performed annually
in the U S . The success rate of such surgery is less than 50%
in some series, with the most conservative of estimates citing
lack of success 20 to 40% of the time. In spite of the dramatic
development of new diagnostic tools (CT, MRI) and therapeutic techniques (chemonucleolysis,radiofrequency procedures,
etc.), success rates have not changed significantly. In view of
this, a disproportionately small amount of the medical cumculum is devoted to the study of the back. While this coverage
has been adequate for passage of NBME examinations, it
generally falls far short of providing an anatomical basis sufficient for understanding either the primary causes of LBP or
the rationale of current therapies. This presentation will outline
several relevant anatomical concepts, concentrating on those
most commonly neglected in gross anatomy, e.g., sources of
back pain, the motion segment or functional spinal unit (FSU)
and its significance, and sites of stenosis.
and Manuel E. MOLINA. Iowa Methodist Medical
Center and Des Moines Veterans Administration Medical Center, Des Moines, Iowa; University of Mississippi School of Medicine, Jackson, Mississippi;
Marshall University School of Medicine, Huntington,
West Virginia. The occurrence and distribution of
valves in the canine hepatic portal system.
To investigate venous segmentation of dog spleens, splenic
tributaries of the splenic vein were isolated, injected with
Batson’s Number 17 compound and placed in 40% KOH to
corrode soft tissues. In 5 of 13 spleens thus injected, some
segments failed to fa,indicating obstruction of certain segmental veins. Upon close observation during the injection
phase, valves were seen through vein walls. Upon reexamination of the vascular casts, valve impressions, both open and
closed, were noted. These observations prompted a survey of
the entire portal system in 10 dogs. Corrosion cast studies
were supplemented by dissection studies and histological sections. Valves were frequent in the small veins (diameter circa
1 m)directly draining an organ or organ segment. However,
many larger veins (diameters up to and exceediig 5 mm) of
this system also contained valves. Typically, valves occur at
or slightly before a confluence, although valve impressions
were occasionally noted where no evidence of vessel confluence could be found. Thus, there is a fundamental anatomic
difference between the portal system of dogs and that of
humans. This should be noted by investigators using dogs as
models for research on the portal system or organs drained by
this system.
FASEL, Jean. Department of Anatomy, University of
Basle, Switzerland (Sponsored by M. ALLGOWER).
The use of plastination technique in a surgeon’s
The plastination technique is a new method for preservation of
biological specimens, developed at the Department of Anatomy of the University of Heidelberg (GFR). This paper presents the use of the method in a surgeon’s training:
a) Treatment: The anatomy relevant to operative procedures is best learned from three dimensional specimens. Prep
arations considering the specific needs of the surgeon were
therefore prepared and plastinated (S10 or PEM technique).
The plastinated specimens proved to be odorfree, dry, resistant
to mechanical stress, with well preserved relief. In contrast to
conventionally preserved specimens they are therefore well
suited for use even in the operating room.
b) Diagnosis: Currently therapy is increasingly based on
radiologic bodyscanning systems. The surgeon therefore needs
to become familiar with sectional anatomy. In view of this,
the authors carried out a CT/MR/plastination(El2 technique)
correlative study. The transparent plastinated slices show the
same physical qualities as mentioned above for the threedimensional specimens. They allow an immediate comparison
of the radiologic and anatomic f i d i g s .
Supported by Freiwillige Akademische Gesellschaft, Basel
FRIEDMAN, Mark H. New Rochelle, New York.
Anatomical basis for the head and neck musculoskeletal examination.
Temporomandibularjoint synovitis, trigger points in the deep
vertical masseter muscle fibers, and masseter muscle tendonitis are diagnosed by palpation at the lower border of the
zygomatic arch. L i h i g and rolling the skin over the angle of
the jaw separates it from muscle fibers; sensitivity to this test
indicates cervical involvement, often demonstrated by increased sensitivity to palpation of the C3 apophyseal joints.
Muscles are evaluated by resistive tension. Local or referred
symptoms produced by isometric contraction indicate muscle
pathology, which is confirmed by palpation of the muscle, if
accessible. This technique is demonstrated for the stemocleidomastoid, lateral and medial pterygoid, temporal, and masseter muscles. Clinical examples are given, such as identifying
headache referred from the masticatory muscles, and distinguishing parotid gland disease from masseter muscle dysfunction. If head pain is present during the examination, manual
traction is applied to separate the neuroforamina. A cessation
of head pain indicates cervical rather than cranial origin.
Range of motion tests are useful to distinguish the upper
cervical spine from the lower cervical spine. Cervical rotation
in full flexion isolates the atlantoaxial joint. Nodding (flexion),
with the head in full extensions to lock the apophyseal joints,
isolates the atlantooccipital joint.
GER, Ralph. Department of Surgery, Winthrop University Hospital, Mineola, New York. The surgical
anatomy of the liver.
Thc intra-hepatic anatomy of the liver, not unlike the surgery
of the liver, is somewhat complicated, so much so, that standard texts in both anatomy and surgery do not cover the
detailed disposition of the intrahepatic structures. For this
information one has to turn to specialized texts and even then
the picture is not easily comprehended. It is suggested that
problems arise from the difficulty in visualizing the structures
in a 3 dimensional plane, as well the difficulty in identifying
the 3 sets of vessels and a set of ducts. This problem can be
partially met by preparing special specimens, painting the
structures rather than injecting them, and viewing them stereoscopically. The 3 dimensional view will then place the
structures in their true relationship, an essential component for
successful surgery. Livers were specially prepared to demonstrate the distributionof the componentsof the Glissonian triad
and the hepatic veins. The lines of the fissures through which
surgical resection is carried out is also demonstrated. These
demonstrationswill be reinforced by liver dissections from the
Basset collection. With regard to extrahepatic structures, disagreement still exists concerning the structure and function of
some of the peritoneal ligaments.
GROSSMAN, John A.I., Roger KHOURI, A. CALDAMONE. Departments of Plastic and Urologic Surgery, Brown University Program in Medicine, Providence, Rhode Island (Sponsored hy R. Ger).
Clarification of the vascular anatomy of dorsal p
nile skin flaps.
One stage repairs of hypospadias and other urethral deformities using local “vascularized” flaps have gained increasing
acceptance over the past two decades. Although the “rich”
vascular supply of the dorsal penile skin and the prepuce have
been well recognized, the precise anatomic basis of these flaps
is poorly understood, thus l i t i n g application of the techniques. Six fresh cadaver specimens were injected with colored latex via the infrared aorta. The dorsal penile skin and
prepuce were dissected using 3 . 5 ~
loupe magnification. The
skin of the dorsum of the penis is perfused almost exclusively
by paired axial extensionsof the external pudental arteries and
veins. These vessels are organized inside a multilaminar loose
areolar layer that includes Dartos muscle and separates the
dorsal penile skin from Buck’s fascia. The normally redundant
and serpentinenature of these vessels allows for great mobility
of the penile skin and has caused their axial nature to be
overlooked or to be mistaken for perforators from dorsal
penile arteries. Contrary to most anatomical texts, no such
perforators from the deeper dorsal penile arteries could be
identified. The skin of the prepuce is highly vascular and we
could identify a triple vascular supply. (1) Terminal arborisation of the two axial vessels perfusing the dorsum, (2) direct
branches of the dorsal penile arteries, (3) perforators from
Buck’s fascia radiating axially underneath the skin of the inner
lamina of the prepuce. The clinical importance of this anatomic arrangement is discussed.
HANNI, Cary L., Richard E. DEAN, Rexford E.
CARROW, Kimberly B. DEAN. Departments of Surgery and Anatomy, Michigan State University, College
of Human Medicine, East Lansing, Michigan. Clinical anatomy for surgical residents. A 10-week
The limited exposure of medical studentsto gross anatomy has
significant bearing on those students who elect a surgical
career. In an effort to address this deficiency, a 10-week, 50
hour clinically oriented surgery anatomy course has been developed for third year surgical residents. The aim of the course
is to provide clinical interpretation of anatomy in the regions
of faceheck, thorax, abdomen, pelvis/inguinal and extremities
as it illuminates the challenges facing a surgeon. Each of the
20, 2% hour laboratory experiences are initiated with a brief
presentation by a member of the surgical faculty who identifies
the surgical complexities of the area, which may include,
unique blood supply, intraorganal lobular anatomy or prohlems of exposure as it relates to operations. The constant
interface with Anatomists facilitates the teaming experience
provided in the laboratory. The relationshipbetween operative
challenges and structural knowledge provides the optimal
learning experience. An organized readmg program, a pre and
post test, as well as weekly quizzes have been developed to
enhance residents’ preparation and to assist in faculty evaluation of their performance. Summative evaluations are given to
participants and their program directors at the completion of
the course.
JEYNES, Brian J. Basic Science Division, Faculty of
Medicine, Memorial University of Newfoundland, St.
John’s, Newfoundland. (Sponsored by K. L. Moore).
Comparison of NET and Congo Red birefringentpositive blood vessel frequency and distribution in
the hippocampal formation of control and Alzheimer brains.
The discrete focal distribution of neurofibdary tangles (NITS)
in the brains of Alzheimer victims is an important but poorly
understood characteristicof the disease. The very high coincidence of congophilic amyloid angiopathy in these patients is
also significant. In this study the distribution and frequency of
these two lesions was examined in detail in the hippocampal
formation of control and Alzheimer patients in order to determine whether any correlationsexist. Coronal sections through
the hippocampal formation of 6 control and 6 Alzheimer brains
were stained with Congo Red for polarized light microscopic
examination. The neuronal, vascular and extracellular frequency and distribution of apple-green birefringent material
was recorded. In control brains there appeared to be an even
antero-posterior distribution of tangles, and comparatively few
positive vessels. However in the Alzheimer tissue there appeared to be a propensity for NFT distribution in the anterior
half of the hippocampus, increased vascular deposition of
briefringent material and, in certain cases, significant paraventricular birefringent material deposition. In the AD cases, the
NFTs sometimes appeared in clusters in discrete regions, and
most of the positive vessels appeared to be large pial vessels.
It is possible that some spatial correlations exist between tangles, positive vessels and specific regions of the hippocampus.
Supported by a grant from the Alzheimer Society of
KHAN, S . Ali, Johanna P. HAGEDOORN and Biaggio RAVO. Department of Urology, State University
of New York, Stony Brook, New York, Department of
Anatomy, New York Medical College, Valhalla, New
York, Department of Surgery, Winthrop University
Hospital, Mineola, New York. Applied surgical anat-
omy of male perineal spaces.
A detailed knowledge of the applied surgical anatomy of the
perineal spaces is extremely important for the practicing urologist and the general surgeon. Based on surgical material and
observations of cadaver dissections, applied surgical anatomy
of these perineal spaces are divided into those located in the
anterior or urogenital triangle, which can be phrased as the
‘Urologist Triangle’ and the posterior or anal triangle, which
can be referred to as the ‘Triangle of General Surgeons.’ The
urogenital triangle has two anatomical spaces, superficial and
deep, the contents and the urological importance of which,
will be examined. A new concept, the ‘Bare Area of the
Urethra,’ a frequent site of the urethral mpture due to unskilled instrumentation, will be introduced. Anal triangle has
several important spaces, their spacial dimensions and fascial
relationships as established by cadaver dissection, will be
explored. Potential pathways that communicate from the pelvis
to the perineum, which serve as sites of unusual hernias and
as routes for the escape of localized biological fluids that may
present in the perineum, will also be examined.
LOCICERO, Joseph, William P. HOYNE, Martha S.
LOCICERO, John H. SANDERS, Jr.. Department of
Surgery, Northwestern University Medical School,
Chicago, IL. Anatomic variations of the phrenic
nerve in the thoracic inlet: Implications for the
cardiothoracic surgeon.
Routine use of the internal thoracic artery (ITA) in coronary
revascularization has prompted surgeons to seek ways to increase its length and mobility while avoiding phrenic nerve
(PN) injury related to dissection of the ITA to its origin. Since
no clear anatomic description of the PN/ITA relationship exists, we investigated the course of the PN through the thoracic
inlet and its proximity to the origin of the ITA in 51 cadavers.
The ITA coursed posterior to anterior as it crossed the subclavian vein, and the PN, passing between the subclavian artery
and vein, was lateral to the origin of the ITA (100%). The
superiorlinferior position of the PN to the ITA is variable. The
PN passed superior and medial to the ITA (66%) but was not
consistent from side to side in the same cadaver. The PN
passed inferior and lateral to the ITA in the right hemithorax
(27%) and in the left (40%).A bilateral superiorimedialrelationship was found in 50% of cadavers and a bilateral inferior/
lateral one in 19%. The surgical implications of this anatomic
finding is that the PN is vulnerable to injury when it is inferior
to the ITA as it passes from lateral to medial through the
thoracic inlet and ITA dissection is camed past the posterior
border of the subclavian vein; one centimeter of soft tissue
will protect the PN if dissection ends at the anterior border of
the vein.
MCKEE, Nancy H., Ralph T. MANKTELOW, Joel
FISH and Scott YOUNG. Department of Surgery,
University of Toronto, Toronto, Ontario. (Sponsored
by Dr. Keith L. Moore). A new look at muscle
anatomy to assure optimal function of a free functioning muscle transplant.
Skeletal muscle loss can be replaced by a non-essential skeletal
muscle from another part of the bcdy. The gracilis muscle is
frequently reattached in the forearm with neurovascular repairs. Once it is reinnervated it can provide finger flexion.
The purpose of this study was to establish the potential of this
muscle to provide separate but controlled movement (e.g.
independent finger flexion). Cadaver and in vitro studies were
used to study the intramuscular neurovascular anatomy.
Through injection, dissection and stimulation studies it has
been established that the gracilis can be separated longitudinally into at least two parts that would have independent neural
control. This potential has been realized in three clinical cases
where independent thumb and finger function has been
Supported by Grant No. MA8076 from the Medical Research Council of Canada.
MENNIN, Stewart P. Department of Anatomy, and
Primary Care Curriculum, School of Medicine, University of New Mexico, Albuquerque, New Mexico.
Parallel tracks: A strategy for change in medical
Medical education faces global criticism for two primary rea-
sons. First, it lacks relevance to the tasks to be performed in
primary health care systems. Second, the explosion of scientific information makes traditional curricula increasingly outmoded as they teach solely what is known today, to the
exclusion of how to learn what will be known tomorrow. Field
tested strategies for change from eight schools using separate
parallel tracks have been analyzed. A core set of strategies and
recommendations has been distilled which are applicable to
implementing changes in established, traditional institutions.
They include the following categories: getting started, cumculum, overcoming resistance, admissions, personnel, program
evaluation, and outcomes. What can we learn from the avaiable data? The impact of a parallel track on a traditional
institution will be analyzed.
MILLER, Leonard B., John BOSTWICK and Carl R.
HARTRAMPF. Departments of Plastic Surgery,
Emory University, Atlanta, Georgia and New England
Deaconess Hospital, Boston, Massachusetts. Anatom-
ical and clinical considerations of the blood supply
to the rectus ahdominis muscle flap in chest wall
The superiorly based rectus abdominis muscle and musculocutaneous flap is useful for breast reconstruction following
mastectomy and closure of dehiscence following median sternotomy. The reliability of these flaps has been fairly good,
however, some occurrences such as unexplained partial and
complete flap losses, episodes of fat necrosis as well as flap
survival after internal thoracic artery interruption in the thorax
and mediastinal irradiation have prompted us to investigate the
blood supply of these flaps in more detail. The arterial blood
supply was studied by several techniques: Review of angiograms of the internal thoracic artery, cadaver dissections and
observation of the vascular anatomy in over 300 clinical dissections. A number of constant and variable features of the
vessel systems supplying the flap were observed. There is a
rich collateral flow in the thorax both from intercostals and
across the midline-explaining flap survival after ITA injury.
The ITA-Superior Epigastric Artery pedicle into the upper
rectus abdominis muscle is variable-a costo-marginal branch
may be significant during mobilization of the flap in this area.
There are variations of the deep epigastric arcade (DEA) and
sometimes poor communication between SEA and DEA. The
segmental blood supply and specific patterns of musculocutaneous perforators can influence the planning and design of the
skin islands.
MOORE, Keith L. Department of Anatomy, Faculty
of Medicine, University of Toronto, Toronto, Ontario.
Anatomical nomenclature and clinical terminology.
Attempts have been made to standardizeanatomical nomenclature since 1895 when the Basle Nomina Anatomica was
published. Since that time there have been various revisions of
the nomenclature, culminating in the fifth edition which was
published in 1983 by the Williams & Wilkins Company. Although Nomina Anatomica is adopted world-wide by Anatomical Associations, not all teachers of anatomy are aware of
its existence. As a result, the same structures are called by
different names in different countries and, to make matters
worse, clicians still prefer to use eponyms such as the foramen of Winslow, instead of the internationally adopted epiploic foramen. However because eponyms are in frequent use
in hospitals, it is best for anatomists to refer to this opening as
the epiploic foramen (foramen of Winslow). Eponyms should
not be used in anatomy because they give no clue to the
location of the structures involved. Who would know that
Wharton’s duct is the submandibular duct? In addition, some
eponyms are historically inaccurate, e.g., Poupart was not the
first person to describe the inguinal ligament (Pouparta’s ligament). Another problem associated with eponyms is that the
same structure is described with different eponyms in other
countries, depending on who they believe was the first to name
the structure. As clinical anatomists, we must strive to use the
correct terminology so that medical students will not have to
learn new terms when they enter their clerkships.
plicated operation. To this end, our surgical residency program
encourages a period of anatomical study in the second year of
training. During such an elective period, an interest in the
variants of the celiac, superior mesenteric, and inferior mesenteric arteries began. Subsequently over the following year
fifty cadavers were dissected and diagrammed. The classic
description of the celiac, superior mesenteric, and inferior
mesenteric arteries was found in only 24%, 18%, and 16%,
respectively. The significance of these data is that they reflect
an abundance of variants which are vital to the operating
surgeon’s knowledge of anatomy. This is especially true in
organ procurement and dissection about the liver hilum where
the viability of a transplanted or native liver might be jeopardized by inadvertent transection of an anomolous vessel, e.g.,
a right hepatic artery from the superior mesenteric artery or a
left hepatic artery from the left gastric artery. The embryologic
hasis and clinical relevance of these variants as well as findings
of other large series are presented.
MYERS, Jay D. and Donald R. CAHILL. Department
of Anatomy, Mayo Medical School, Rochester, Minnesota. The right outflow system of the heart.
The nervous and vascular stmctures of the sellar region were
studied in cadavers and patients. The varieties of chiasma
(normal, prefixed, postfixed) and the measurements of the
optic nerves and chiasma (width, length, height, distance,
angle between optic nerves) were studied in cadavers. Different transfrontal surgical approaches to the sella, according to
the morphology of the chiasma, are discussed. Because of
their importance in transsphenoidal surgery, variations in the
carotid arteries and the cavernous sinus were carefully studied
both in cadavers (with and without contrast material) and in
patients during operations. Pituitary compression by the arotid siphon was found in 18% of cadavers dissections hut
only in 6 % of patients. An intercavernous sinus was found in
front of the pituitary gland in 16% of cadavers and in 9% of
patients. The cranial nerves adjacent to the cavernous sinus
were also studied in the cadavers. Some anatomical variations
may be responsible for difficulties encountered during transsphenoidal surgery and require slight modification in the standard transsphenoidal technique.
This work was supported in part by a financial grant of
the Notre-Dame Hospital (grant no. 6323).
Dissections were performed on both en bloc specimens and
coronal and sagittal sections of the mediastinum, focusing on
the anatomy of the pulmonary outflow system and its relationships. For descriptive purposes we organized the system into
the infundibulum, valve region, pulmonary trunk, and the
right and left pulmonary arteries. Precise definitions of the
boundaries of each region are given. As by convention, the
infundibulum is defined as the smooth outflow tract of the
right ventricle bounded inferiorly by a plane formed through
the crista supraventricularisand the septomarginal trabeculum,
and superiorly by a plane through the lowest extent of the
pulmonary valve sinuses. We paid special attention to the
region around the pulmonary valve and termed it the valve
region. It is defined as a region 1-2 cm in length bounded by
the curved attachments of the cusps of the pulmonary valve.
Although this region is seldom recognized as a separate part
of the pulmonary outflow system, it has important relationships to surrounding structures that include the left coronary
artery and its anterior interventricular branch, the aorta, left
atrium and left auricle. The pulmonary trunk (FT)begins just
T is defined
above the valve region. The distal limit of the I
by two oblique planes that originate at the pulmonary carina
and pass across the orifices of the left and right pulmonary
arteries. The left and right pulmonary arteries end where they
bifurcate into lobar branches. Emphasis is given to the asymmetrical directionality and differential caliber of the left and
right pulmonary arteries. Relationships in each region to surrounding external structures and unique internal features are
NELSON, Thomas M., Raymond POLLAK, Olga
JONASSON and Herand ABCARIAN. Department of
Surgery, University of Illinois, College of Medicine at
Chicago, Chicago, Illinois. Anatomical variants of
the celiac, superior mesenteric, and inferior mesenteric arteries and their clinical relevance.
The classic anatomical description of arterial patterns in the
textbook is the mindset in which many residents and some
surgeons operate. Open eyes, an open mind, and a knowledge
of anatomical variants are necessary for a successful, uncom-
OUAKNINE Georges E. and Hardy Jules Department
of Neurosurgery, HBte-Dieu of Montreal and NotreDame Hospitals. University of Montreal, Quebec,
Canada. Microsurgical anatomy of the pituitary
gland and the sellar region. Part three: The nervous
and vascular structures.
PARKE, Wesley W. Departmentof Anatomy, University of South Dakota School of Medicine, Vermillion,
South Dakota. Mediastinal bronchogenic cysts:
Probable mechanism of development.
Most reports of ectopic pulmonary tissues have attributed their
origin to anomalous outgrowths of the lower foregut that
retained its primitive capacity to differentiate into respiratory
epithelium and parenchyma. During the routine anatomical
dissection of a 93-year-old female cadaver, a large bronchogenic cyst was discovered under the parietal pleura of the right
upper mediastinum. The concave inferior border of this 31.7
gm mass arched over the right lung root with its major arterial
supply being derived from the pericardiacophrenic artery and
the larger veins draining into the left superior intercostal vein.
Because of the location and relationship of this tissue to the
azygos system and lung root, it most probably represents a
vascularly transferred azygos lobe rather than a spearatederivative of the foregut. The mode of origin is consistent with the
variation in the development of the pulmonary appendages that
normally occur in a single species of mammal, the short-tailed
shrew (Blarim brevicauda). Observations of a large series of
lungs in this Insectivore have shown that variants of the un-
usual extrapulmonary bronchial appendages of their right lung
have provided examples of all the major classificationsof lung
anomalies (agenesis, aplasia, hypoplasia, intralobar sequestration, extralobar sequestration and ectopic lung) due to an
inherent plasticity of the developing bronchopulmonary stfuctures in response to spatial changes. Thus the “extra-pulmonary” origin of variant lung tissue is not required.
PECK, David, and Edward A. LUCE. Department of
Anatomy and Department of Surgery, University of
Kentucky, Lexington, Kentucky. An easy and reliable
method for locating the external ramus of the accessory nerve in the posterior triangle of the neck.
Injury to the external ramus of the accessory nerve during
surgery in the posterior triangle of the neck results in a disfiguring and incapacitatingparalysis of the trapezius. To prevent
this, a simple method for locating the ramus was tested by cutdowns on ten cadavers as follows: The anterior border of the
trapezius was palpated and the skin marked at a point three
finger breadths (5 cm) above its clavicular attachment. Another point was marked over the posterior border of the sternocleidomastoid four finger breadths (6.5 cm) below the tip of
the mastoid process. A linejoining the two skin marks overlies
the course of the ramus. The ramus can be quite superficial in
this region, therefore a shallow incision along this line was
followed by blunt dissection of the underlying fascia and the
ramus located at the anterior border of the trapezius three
finger breadths (5 cm) above its clavicular attachment. The
method was successful in all ten cadavers (20 cases) even
though three of these were very obese with short necks. Injury
to the external ramus of the accessory nerve in the posterior
triangle can be avoided using this simple method by locating it
prior to surgery.
PHILLIPS, Lloyd G., Jr. Department of Anatomy and
Surgery, Wright State University School of Medicine,
Dayton, Ohio. The transverse cervical artery: New
origins and pathways.
The transverse cervical artery and its branches, as described
in the classical anatomic literature, is variable enough in its
origin(s), branches and nomenclature that one might be taxed
to fully comprehend its description at first glance. It may have
a complete origin from the thyrocervical trunk in some cases
or may originate incompletely from the third portion of the
subclavian artery proper and the thyrocervical trunk. These
and other known variations in origin and pathways led to a
study of some 74 neck-shoulder cadaver hemispecimens and
38 bilateral neck-shoulder specimens. It was determined that
this artery is far more complex and variable with respect to its
origins and branches than previously imagined. A significant
number of specimens conformed to standard descriptions but
an equally significant number, in combination, presented with
configurations heretofore not known to be described. Some of
the variations and anomalies of origin and distribution are of
potential clinical importance. These variations will be described with the hope of presenting new knowledge to both the
clinical surgeon and to the anatomic academician with the
additional hope that the more significant findings will be absorbed into the standard anatomic literature.
FUTRELL, University of Pittsburgh, Division of
Plastic Surgery, Pittsburgh, Pennsylvania. The versatile subscapular vascular axis: Reconstructive surgeon’s friend.
The major branches of the subscapular artery are (1) the
thoracodorsal artery which supplies the expansive latissimus
dorsi muscle, (2)the circumflex scapular artery which supplies
via the descending and transverse branches the skin and subcutaneous tissue overlying the scapular region, and (3) the
periostd branches of the circumflex scapular artery that supply the lateral border of the scapula. These major branches are
1 mm or greater in diameter and lend themselves to microvascular free tissue transfer. In addition the length of the vascular
axis is 5 cm or longer, thus permitting the flaps to be rotated
as a pedicle flap. One can therefore use only the skin paddle
or the latissimus dorsi muscle or the bone or in any combination based on a single vascular pedicle, the subscapularartery.
The vascular pedicle being constant adds to the reliability of
the flaps. The versatility of the subscapular vascular axis has
been demonstrated by our varied applications in 50 patients
within the last 3 years. No functional deficit at the donor site
has been seen. Summary: The versatile subscapular vascular
axis provides the vascular basis for flaps that can help cover
substantial defects of varying complexity of head and neck,
lower extremity regions and the chest wall.
RANNEY, Donald A. and Richard P. WELLS. Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada. Passive forces influencing
finger movement.
In normal hands the active forces due to muscle contraction
are considered, but little attention has been directed toward
passive resistance offered by soft tissues. Tightness of ligaments determines terminal end points. In the middle range
volar skin and fascia offer some resistance to finger extension
which increases dramatically toward the end point. Also increasing steeply toward the end point is the passive resistance
to stretch of antagonistic muscles. The latter has been measured for the index extrinsic muscles in 3 recently deceased
fresh cadaver hands. Skin and fascial resistance has been
assessed in 75 Canadian and Asian hands to determine the
influence of sex, race and occupation. As occupation was seen
to be by far the greatest determinant of finger stiffness, the
implications of this in tendon transfer for ulnar paralysis will
be discussed.
Departments of Anatomy and Radiology, University
of South Florida College of Medicine, Tampa, Florida. (sponsored by W.R. RICHARDSON). Imaging
anatomy of the cervical spine.
Images of the cervical spine acquired with CT and magnetic
resonance have been compared with gross anatomical sections
in axial, coronal, and sagittal planes. The region may be
divided into 1) an upper occipito-atlanto-axial complex and 2)
the lower C3 to C7 vertebrae. A small fat pad is situated in
the medial concavity of the occipital condyle and a supraodontoid bursa (Trolard) may contain fat, contributing to the variations in imaging of the mipito-atlanto-axial region. Wedgeshaped lateral masses of the atlas articulate with the occipital
condyles above, with the lateral masses of the axis below, and
serve as attachment for the transverse ligament which restricts
the odontoid during flexion. The lower cervical region is
unique in the paucity of epidural fat, long neural canals posterior to the vertebral artery, sloping facet joints, uncovertehral
(Luschka) joints, and relatively small centra. Although the AP diameter of the spinal cord is about 1 cm throughout the
cervical region, the lateral diameter increases in the cervical
enlargement to nearly fill the triangular vertebral canal, increasing vulnerability to small osteophytes and disc hemiations. The major support of the cervical spine is the posterior
muscle masses.
SCHUSTER, Ronald, Gershon EFRON and Adrian
BARBUL. Department of Surgery, Sinai Hospital of
Baltimore, Baltimore, Maryland. The critical point
of Sudek revisited.
In 1907 Sudek promolgated that in order to avoid ischemia of
the rectosigmoid colon following the performance of a rectal
resection, the inferior mesenteric artery be ligated proximal to
the last sigmoid artery. His thesis concerning the critical point
of ligation of the inferior mesenteric artery was based on his
concept of the inadequacy of the anastomotic blood flow b e
tween the last sigmoid artery and the superior rectal artery.
This concept has since been disproved. Notwithstanding the
excellent vascular watershed of the rectosigmoid colon derived
from the inferior mesenteric artery, the marginal artery of
Drummond and the middle rectal branches of the hypogastric
arteries, clinical experience with cases of rectosigmoid gangrene lend credence to Sudek’s observation of the potential
vulnerability of the rectosigmoid blood supply. The factors
responsible for impairment of the blood supply to the rectosigmoid colon with resultant ischemia include severe atherosclerosis, deficiency of the marginal artery anastomosis at the
splenic flexure, and the low flow syndrome. The recognition
and management of this potentially lethal problem will be
and James M. BENNETT. University of Mississippi
School of Medicine; the Des Moines VA and lowa
Methodist Medical Centers; and Marshall University
School of Medicine. Microvascular healing of sutured and stapled small intestinal anastomoses.
Surgical staplers are safe, efficient tools for bowel anastomosis. Enhanced preservation of blood supply to the anastomosis
(evidenced by brisk bleeding distal to the staple line) and
improved healing by primary intention have been claimed.
Although the morphologic sequence of events involved in
capillary ingrowth and wound healing after sutured anastomoses has been well-studied, there is little comparable information available about healing of stapled anastomoses. The
establishment of vascular crossover and the rate of neovascularization after small intestinal anastomosis was studied in 22
dogs. Two inverting end-to-end anastomoses were made in the
proximal jejunum of each dog, using a two-layered suture
technique for one anastomosis and a circular stapler for the
other. Animals were sacrificed at intervals from three to 24
days after surgery. An india-ink and latex mixture was injected
into the mesenteric artery supplying one side of each anastomosis. The appearance of india ink in histologic sections taken
from the opposite side was taken to indicate the establishment
of cross-circulation. Although more inflammation and somewhat greater vasodilatation were noted with sutured anastomoses, vascular crossover and neovascularity occurred rapidly
in both sutured (day 3) and stapled (day 4)anastomoses. No
advantage in the microvascular phase of healing was noted
with use of the circular stapler.
SIM, Franklin H. and Frank J. FRASSICA. Department of Orthopedics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Rotation-plasty of the
lower l i b in the treatment of osteosarcoma: Surgical technique of resection and reconstruction.
Rotation of the lower limb through an arc of 180 degrees for
the treatment of congenital defects and tuberculous arthritis
was first described by Borggreve in 1930, and later popularized by Van Ness in 1950. Recently there has been an increased interest in the application of rotation-plasty in the
treatment of malignant tumors. The purpose of this study is to
describe the complex surgical anatomy and techniqueof reconstruction when large malignant tumors of the distal femur and
proximal tibia are resected utilizing this procedure. Preserva-
tion of the sciatic, tibial, and peroneal nerves is mandatory to
allow successful substitution of the knee joint by the ankle.
When the major vessels are engulfed by tumor, they are
resected and re-anastomosed. In addition, current Mayo Clinic
experience will be reviewed. Rotation-plasty has proved to be
an effective limb-salvage procedure in the adolescent afflicted
with a malignant bone tumor of the lower extremity. Limb
salvage allows these children to lead an active and athletic life.
STURTEVANT, Ruthann P. Departments of Anatomy
and Surgery, Loyola University Medical Center, Maywood, Illinois. Surgical considerations: An effective
emphasis for senior medical students relearning
basic gross anatomy.
A common complaint among clinicians concerns a general
weakness in the basic gross anatomical knowledge seen in
their Residents. In an effort to overcome this problem, we
offer a 4-week specialty oriented advanced gross anatomy
elective to our senior medical students. Regional dissections
appropriate for the medical specialty selected by each student
are augmented by seminars. Following an initial review of
basic gross anatomy, the students observe selected scheduled
surgeries and then attempt to reproduce the same techniques
and approaches on the cadaver. When possible their efforts
are critiqued by the Surgeon or Chief Resident. The students
are expected to analyze clinically relevant sequellae to gross
pathological changes noted in the cadavers. Discussions of
these changes are held with a member of the Pathology department; histological preparations are often used to c o n f m a
presumptive diagnosis. Common deviations from the usual
textbook description of regional vascular patterns are discussed. Particular attention is given to fascial planes, orientation of muscle layers and to relationships of underlying
structures to surface landmarks. Each student prepares a written summary of his observations and analyses of the clinical
findings encountered during the course. The students find this
approach to anatomy for the prospective resident a stimulating
challenge that encourages them to reanalyze and appreciate
many of their experiences during recent clerkships.
TAYLOR, Ian M. and P. Niall BYRNE. Department
of Anatomy and Division of Studies in Medical mucation, University of Toronto, Faculty of Medicine,
Toronto, Ontario (sponsored by K.L. MOORE). The
Toronto medical gross anatomy course.
The new course (19 weeks, 170 hours) was developed because
much of traditional gross anatomy is not clinically useful.
Furthermore, there is much clinical anatomy which usually
receives little or no mention. In addition, it is anatomical
structure rather than function which has been stressed in the
past whereas clinicians generally begin with dysfunction and
then work back towards structure.
The new course is thus heavily oriented towards clinical
usefulness with less emphasis on morphology and much more
on function and its derangements. Lectures (55 hours) in gross
anatomy do not cover basic textbook facts. Instead they are
integratory by showing that certain anatomical facts are useful
in diagnosis and treatment. We continue to dissect. However,
the students (260) are divided into groups of 10 and then into
5 subgroups each of which is given a specific dissection task
to perform within a particular time period. The two dissectors
must then demonstrate their work to the larger group of 10.
The obligation to teach peen ensures high standards of dissection and encourages cooperation. There are 19 hour-long
weekly tutorials during which 2 or 3 clinical problems are
discussed. These emphasize key points in each week’s work.
We also arrange visits to operating rooms and demonstrations
by radiologists.
THOMAS, Jon V. and Donald R. CAHILL. Deparment of Anatomy, Mayo Medical School, Rochester,
Minnesota. Observationson the tricuspid valve.
The purpose of this paper is to provide a supplemental method
for study of the right atrioventricular valve which can be
camed out in the anatomy laboratory while also providing
detailed observations on the leaflets and their chordae tendinae. The dissection method described here is easy and involves
removal of the tricuspid valve after it has been examined by
conventional student dissection in siru. After careful removal,
the valve is placed as a flattened sheet upon a drawing of a
typical valve. This method encourages study of important
features of the valve complex often overlooked in conventional
dissection. Such features include complicated and extensive
insertions of chordae tendinae which range in number from
139 to 174 per valve. The chordae tendinae insert not only into
the free edge of the valve but also into zones of the ventricular
surfaces of the leaflets in great numbers as well. Whereas
Silver and Lam (1970) in a study of fifty normal hearts provided a useful description and classification of the chordae and
the leaflets, the present paper offers additional observations on
the insertions of the chordae, including the widths of the
leaflets and numbers of insertions.
TONI, Roberto, Luigi BOLONDI, Luca FAVERO
and Salvatore MOSCA. Istituto Anatomia Umana &
Clinica Medica I, UniversitA di Bologna and Chieti,
Italy. (Sponsored by R.Ger). Combined ultrasonographidresin injection method to investigate the
segmental intrahepatic venous architecture.
By means of a combined ultrasonographiciresin-injection
method we have investigated the segmental distribution of the
intrahepatic venous vessels in 10 subjects (age range 61
years) whose death was not related to hepatobiliary disease.
The organs were removed from the cadaver after ligature of
the main venous, arterial and biliary branches in order to avoid
penetration of air into the parenchyma, and isolated on a stiff
surface. A catheter was then placed into the portal and/or
hepatic veins under ultrasonographicguidance. Then 200 ml
of 0.9% NaCl were injected slowly through the catheter and
at low pressure in order to expand the venous vessels and
prevent “post-mortem” collapse of the parenchyma; simulta-
neously ultrasonographic scanning was performed to identify
the best scanning planes by which a specific vessel could be
visualized. Furthermore, small air bubbles diffusing from the
main to the tinest branches of the scanned segmental vein
spread over the relative parenchymal segment, allowing identification of its bidmensional extension. Later, using the same
catheter, a perfusion of polyvinilic resin was carried out (1)
and vascular casts of selectively injected segmental venous
terminals were obtained. Finally, comparison between the architecture of the vascular casts and the ultrasonographicfindings provided evidence for the reliability of the method.
Supported by grant n 8614599, Funzion. Comit. 06, Fohdi
40% MPI. (1) Toni R., Favero L., Bolzani R., Roversi R.,
Vezzadini P. IRCS Med Sci 13;605:1985
WAGNER, Marvin, Lowell SETHER, Victor
HAUGHTON, Shiwei YU, and Peters HO. Medical
College of Wisconsin, Department of Anatomy and
Cellular Biology-Radiology-Surgery.
Wisconsin. Correlative MR, CT, cryomicrotomy
study of the intervertebral disc.
The modalities of CT scanning and magnetic resonance imaging have been utilized in the evaluation of disc disease. Our
endeavor was to develop a critique on the usual anatomy found
according to age groups as noted on parasagittal anatomic
sections. We made a correlated study of lumbar discs with
cryomicrotomy, CT scan, and MR. New Born: The nucleus
pulposus occupies a large area relative to the total area of the
whole disc and is sharply demarcated from the surrounding
fibrocmilage and has a MR high signal. Teen Age; The annulus and nucleus is denser and the annulus fibres are courser
and byaliied and the nucleus MR signal is diminished. Fourth
Decade: The demarcation between the annulus and nucleus
less obvious. The nucleus becomes irregular and more dense.
Fifth and Sixth Decade: The fibres of the annulus is more
course. The nucleus is more dense with increased fibrocartlagenous change. Seventh Decade; Distinction between nucleus and annulus becomes difficult. Horizontal fissuring
occurs, with cleft formation. The nucleus is course and fibrocartilagenous. Eighth Decade: The whole intervertebral mass
appears as a uniform plate of tissue.
This work was supported in part by grant from NIH, #1
RO1 AR 33667-01A2.
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