2314750код для вставки
Clinical Anatomy 1:63-70 (1988) Abstracts 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. BAIN, J.R., S.E. MACKINNON, A.R. HUDSON, 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 autografts. 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. 64 Abstracts 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 anatomy. 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. DAWSON, David L., Carol E.H. SCOTT-CONNER, 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 training. 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 Abstracts 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 65 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 course. 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 Canada. KHAN, S . Ali, Johanna P. HAGEDOORN and Biaggio RAVO. Department of Urology, State University 66 Abstracts 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 achieved. 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 education. 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 reconstruction. 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. Abstracts 67 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 discussed. 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- 68 Abstracts 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. RAMASASTRY, Sai S., Mark S. GRANICK and J.W. 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. SCHNITZLEIN, H.N., F.R. MURTAGH, R.A. CLARK, D.R. HILBELINK, and M.L. SILBIGER. 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 Abstracts 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 discussed. SCOTT-CONNER, Carol E.H., David L. DAWSON, 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- 69 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. 70 Abstracts 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 10 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. Milwaukee, 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.