Kleinrensink, G.J.

Effects of new anti-adhesion polyvinyl alcohol gel on healing of colon anastomoses in rats (Article)

2012-12-01T00:00:00Z

Background: Adhesions follow abdominal surgery with an incidence as high as 95%, resulting in invalidating complications such as bowel obstruction, female infertility, and chronic pain. Searches have been performed for a safe and effective adhesion barrier; however, such barriers have impaired anastomotic site healing. The primary aim of this study was to investigate the effect of a new adhesion barrier, polyvinyl alcohol gel, on healing of colonic anastomoses using a rat model. Methods: Thirty-two Wistar rats were divided in two groups. In all animals, an anastomosis was constructed in the ascending colon. The first group received no adhesion barrier, whereas in the second group, 2mL of polyvinyl alcohol gel (A-Part Gel®; Aesculap AG, Tuttlingen, Germany) was applied circularly around the anastomosis. All animals were sacrificed on the seventh post-operative day, and the abdomen was inspected for signs of anastomotic leakage. The anastomotic bursting pressure, the adhesions around the anastomosis, and the collagen content of the excised anastomosis were measured. Results: No significant differences were observed between the two groups in the incidence of anastomotic leakage, the anastomotic bursting pressure (p=0.08), or the collagen concentration (p=0.91). No significant reduction in amount of adhesions was observed in the rats receiving polyvinyl alcohol gel. Conclusions: This experimental study showed no significant differences in anastomotic leakage, anastomotic bursting pressure, or collagen content of the anastomosis when using the adhesion barrier polyvinyl alcohol around colonic anastomoses. The barrier did not prevent adhesion formation.

CT arthrography of the human knee to measure cartilage quality with low radiation dose (Article)

2012-07-01T00:00:00Z

Objective: Recently, CT arthrography (CTa) was introduced as a non-destructive technique to quantitatively measure cartilage quality in human knees. This study investigated whether this is also possible using lower radiation dose CT protocols. Furthermore, we studied the ability of (lower radiation) CTa to distinguish between local sulphated glycosaminoglycan (sGAG) content differences. Design: Of ten human cadaveric knee joints, six CT scans using different radiation doses (81.33-8.13 mGy) were acquired after intra-articular ioxaglate injection. The capability of CTa to measure overall cartilage quality was determined in seven anatomical regions of interest (ROIs), using equilibrium partitioning of an ionic contrast agent using (EPIC)-microCT (μCT) as reference standard for sGAG content. To test the capability of CTa to spatially distinguish between local differences in sGAG content, we calculated the percentage of pixels incorrectly predicted as having high or low sGAG content by the different CTa protocols. Results: Low radiation dose CTa correlated well with EPIC-μCT in large ROIs (R = 0.78; R2= 0.61; P < 0.0001). CTa can also distinguish between high and low sGAG content within a single slice. However, the percentage of incorrectly predicted quality pixels increases (from 35% to 41%) when less radiation is used. This makes is hard or even impossible to differentiate between spatial differences in sGAG content in the lowest radiation scans. Conclusions: CTa acquired using low radiation exposure, comparable to a regular knee CT, is able to measure overall cartilage quality. Spatial sGAG distribution can also be determined using CTa, however for this purpose a higher radiation dose is necessary. Nevertheless, radiation dose reduction makes CTa suitable for quantitative analysis of cartilage in clinical research.

Calcium scoring in unenhanced and enhanced CT data of the aorta-iliacal arteries: Impact of image acquisition, reconstruction, and analysis parameter settings (Article)

2011-11-01T00:00:00Z

Background: Several studies have been published on the matter of abdominal aortic and iliac calcifications and the association to clinical entities such as diabetes mellitus and renal failure. However, comparing of these studies is questionable since quantification methods for atherosclerosis differ. Purpose: To evaluate the effect of image acquisition settings, reconstruction parameters, and analysis methods on calcium quantification in the abdominal aorta. Material and Methods: Calcium scores were retrospectively determined on standardized abdominal CT scans of 15 patients. Two researchers obtained calcium scores with 10 different lower thresholds (LT) (130, 145, 160, 175, 200, 300, 400, 500, 600, 1000) in CT scans with and without contrast enhancement, with slice thicknesses (ST) varying between 2.0-5.0 mm for the non-contrast-enhanced series and between 1.0-5.0 mm for the contrast-enhanced series. In addition calcium scores obtained with two convolution kernels (B10f, B20f) were compared. Inter-observer variability was calculated. Results: Calcium scoring at higher STs is overestimated compared to smaller STs and this effect was more pronounced with increasing calcium loads. Concerning the convolution kernel, scores obtained with kernel B10f were overestimated compared to kernel B20f. Increase of LT resulted in a decrease of the calcium score and scoring in contrast-enhanced series resulted in higher scores compared to non-contrast-enhanced series. These effects are more apparent in patients with higher calcium loads. Calcium scoring reproducibility with the reference standard is limited for the aorta-iliac trajectory, whereas scoring with the remaining settings is reproducible. Conclusion: Scores obtained with different settings cannot be compared. The inter-observer reproducibility was limited using the reference standard and practical difficulties were substantial. Scoring with higher LT, ST, and contrast enhancement is faster and has less practical difficulties.

Clinically applied CT arthrography to measure the sulphated glycosaminoglycan content of cartilage (Article)

2011-10-01T00:00:00Z

Objective: Similar to delayed gadolinium enhanced MRI of cartilage, it might be possible to image cartilage quality using CT arthrography (CTa). This study assessed the potential of CTa as a clinically applicable tool to evaluate cartilage quality in terms of sulphated glycosaminoglycan content (sGAG) and structural composition of the extra-cellular matrix (ECM). Methods: Eleven human cadaveric knee joints were scanned on a clinical CT scanner. Of each knee joint, a regular non-contrast CT (ncCT) and an ioxaglate injected CTa scan were performed. Mean X-ray attenuation of both scans was compared to identify contrast influx in seven anatomical regions of interest (ROIs). All ROIs were rescanned with contrast-enhanced μCT, which served as the reference standard for sGAG content. Mean X-ray attenuation from both ncCT and CTa were correlated with μCT results and analyzed with linear regression. Additionally, residual values from the linear fit between ncCT and μCT were used as a covariate measure to identify the influence of structural composition of cartilage ECM on contrast diffusion into cartilage in CTa scans. Results: CTa resulted in higher X-ray attenuation in cartilage compared to ncCT scans for all anatomical regions. Furthermore, CTa correlated excellent with reference μCT values (sGAG) (R=0.86; R2=0.73; P<0.0001). When corrected for structural composition of cartilage ECM, this correlation improved substantially (R=0.95; R2=0.90; P<0.0001). Conclusions: Contrast diffusion into articular cartilage detected with CTa correlates with sGAG content and to a lesser extent with structural composition of cartilage ECM. CTa may be clinically applicable to quantitatively measure the quality of articular cartilage.

Introduction of the "Rotterdam mandibular distractor" and a biomechanical skull analysis of mandibular midline distraction (Article)

2011-09-15T00:00:00Z

The Rotterdam mandibular distractor (RMD) is a slim, rigid, boneborne distractor for use in midline distraction of the mandible. We did a biomechanical study to compare the RMD with the Trans Mandibular Distractor-flex (TMD-flex). This included an anatomical biomechanical study that was conducted on 9 dentate human cadaveric heads using both the RMD and the TMD-flex. In the vertical plane less tipping was measured in the RMD group than in the TMD-flex group. Significantly less skeletal tipping was found in the horizontal plane in the RMD group (P = 0.021). There was minimal difference in the intercondylar distance between the groups. As the amount of lateral displacement of the condyle was similar in both groups and there was less rotational movement in the RMD group, the TMD-flex would be expected to increase stress on the temporomandibular joint. As a result of the increased parallel widening in the vertical plane, more basal bone is being created and less relapse is expected using the RMD. The study design involves an in vitro anatomical model and conclusions must be drawn with care. At present clinical studies are under way and results will follow.

Surgical anatomy of the 10th and 11th intercostal, and subcostal nerves: Prevention of damage during lumbotomy (Article)

2011-08-01T00:00:00Z

Purpose: In a descriptive, inventorial anatomical study we mapped the course of the 10th and 11th intercostal nerves, and the subcostal nerve in the abdominal wall to determine a safe zone for lumbotomy. Materials and Methods: We dissected 11 embalmed cadavers, of which 10 were analyzed. The 10th and 11th intercostal nerves, and the subcostal nerve were dissected from the intercostal space to the rectus sheath. Analysis was done using computer assisted surgical anatomy mapping. A safe zone and an incision line with a minimum of nerve crossings were determined. Results: The 10th and 11th intercostal nerves were invariably positioned subcostally. The subcostal nerve lay subcostally but caudal to the rib in 4 specimens. The main branches were located between the internal oblique and transverse abdominal muscles. The nerves branched and extensively varied in the abdominal wall. A straight line extended from the superior surface of the 11th and 12th ribs indicated a zone with lower nerve density. In 5 specimens the 10th and 11th intercostal nerves crossed this line from the superior surface of the 11th rib. In 5 specimens neither the 11th intercostal nerve nor the subcostal nerve crossed this extended line from the superior surface of the 12th rib up to 15 cm from the tip of the rib. Conclusions: Damage is inevitable to branches of the 10th or 11th intercostal nerve, or the subcostal nerve during lumbotomy. However, an incision extending from the superior surface of the 11th or 12th rib is less prone to damage these nerves. Closing the abdominal wall in 3 layers with the transverse abdominal muscle separately might prevent damage to neighboring nerves.

Development of a new trans-oral endoscopic approach for mediastinal surgery based on 'natural orifice surgery': Preclinical studies on surgical technique, feasibility, and safety (Article)

2011-06-01T00:00:00Z

Objective: In recent years, several surgical disciplines adopted endoscopic techniques. Presently, natural orifice approaches are under exploration to reduce surgical access trauma. We have developed a trans-oral endoscopic approach for endoscopic mediastinal surgery and have tested this new technique in preclinical studies for feasibility and safety. Methods: We conducted an experimental anatomical study in fresh-frozen cadavers. By a midline, sublingual incision, we placed an optical scissor through a 6.0-mm trocar in the pretracheal region and created a working space; two additional trocars were placed by bi-vestibular incisions in the oral cavity. We visualized and followed the trachea down to the main bronchi. Paratracheal and subcarinal lymph nodes were resected bilaterally; the specimen could be removed through the midline channel. In an additional animal study in pigs, we tested the feasibility and safety for this surgical approach. Anatomical dissection allowed an estimate of collateral damage. Results: In all cases, we could reach the target region endoscopically, and no conversion was necessary. Landmarks (the brachiocervical trunk, the azygos vein, and the pulmonary artery) were visualized easily and kept intact. A working space in the mediastinum could be established by the insufflation of air at 6-8mmHg. It was possible to harvest the specimen through the midline channel. Anatomical dissection of the cervical access route as well as of the mediastinal region showed no collateral damage. In the animal study, we encountered seroma of the surgical field due to the conditions of the animal model. The other outcomes with respect to pain and food intake were normal until the third postoperative day. No local infections occurred. Intraoperative gas exchange was normal and was not influenced by CO2insufflation with respect to blood gas analysis. Conclusion: These preclinical studies showed that the mediastinum could be reached by a trans-oral endoscopic approach, based on natural orifice surgery. Complete compartment resection of the paratracheal and subcarinal lymph node stations was possible in a well-defined and clearly visible working space. This approach may enhance the extent of mediastinal resections in oncologic surgery.

Calcium score: A new risk factor for colorectal anastomotic leakage (Article)

2011-06-01T00:00:00Z

Background: Anastomotic leakage (AL) is the most feared complication of colorectal surgery. Atherosclerosis is suggested to have a detrimental effect on anastomotic healing. This study aimed to analyze the calcium score, a measure for atherosclerosis, as a risk factor for AL. Study design: The calcium scores of colorectal patients operated on in 2 Dutch university medical centers were determined using a computed tomography scan and calcium scoring software. The aorta, common iliac arteries, internal and external iliac arteries were studied. Additionally, patient- and operation-related factors were scored. Results: A total of 122 patients were included. In patients with AL, calcium scores were significantly higher in the left common iliac artery (561.4 vs 156.0, P =.028), right common iliac artery (542.0 vs 144.4, P =.041), both common iliac arteries together (1,103.3 vs 301.9, P =.046), and the left internal iliac artery (716.3 vs 35.3, P =.044). Conclusions: Patients with higher calcium scores in the iliacal arteries have an increased leakage risk.

Stability of the Elbow Joint: Relevant Anatomy and Clinical Implications of In Vitro Biomechanical Studies (Article)

2011-05-11T00:00:00Z

Abstract: The aim of this literature review is to describe the clinical anatomy of the elbow joint based on information from in vitro biomechanical studies. The clinical consequences of this literature review are described and recommendations are given for the treatment of elbow joint dislocation. The PubMed and EMBASE electronic databases and the Cochrane Central Register of Controlled Trials were searched. Studies were eligible for inclusion if they included observations of the anatomy and biomechanics of the elbow joint in human anatomic specimens. Numerous studies of the kinematics, kinesiology and anatomy of the elbow joint in human anatomic specimens yielded important and interesting implications for trauma and orthopaedic surgeons.

Anatomieonderwijs in Rotterdam: van eikenbast in wijnazijn tot operaties zonder pijn (Inaugural Lecture)

2011-04-28T00:00:00Z

Rede, In verkorte vorm uitgesproken ter gelegenheid van het aanvaarden van het ambt van bijzonder hoogleraar met als leeropdracht Anatomie, in het bijzonder onderwijs in de toegepaste anatomie aan het Erasmus MC, faculteit van de Erasmus Universiteit Rotterdam op 28 april 2011

Comparison of three different pelvic circumferential compression devices: A biomechanical cadaver study (Article)

2011-02-02T00:00:00Z

Background: Pelvic circumferential compression devices are designed to stabilize the pelvic ring and reduce the volume of the pelvis following trauma. It is uncertain whether pelvic circumferential compression devices can be safely applied for all types of pelvic fractures because the effects of the devices on the reduction of fracture fragments are unknown. The aim of this study was to compare the effects of circumferential compression devices on the dynamic realignment and final reduction of the pelvic fractures as a measure of the quality of reduction. Methods: Three circumferential compression devices were evaluated: the Pelvic Binder, the SAM Sling, and the T-POD. In sixteen cadavers, four fracture types were generated according to the Tile classification system. Infrared retroreflective markers were fixed in the different fracture fragments of each pelvis. The circumferential compression device was applied sequentially in a randomized order with gradually increasing forces applied. Fracture fragment movement was studied with use of a three-dimensional infrared video system. Dynamic realignment and final reduction of the fracture fragments during closure of the circumferential compression devices were determined. A factorial repeated-measures analysis of variance with pairwise post hoc comparisons was performed to analyze the differences in pulling force between the circumferential compression devices. Results: In the partially stable and unstable (Tile type-B and C) pelvic fractures, all circumferential compression devices accomplished closure of the pelvic ring and consequently reduced the pelvic volume. No adverse fracture displacement (>5 mm) was observed in these fracture types. The required pulling force to attain complete reduction at the symphysis pubis varied substantially among the three different circumferential compression devices, with a mean (and standard error of the mean) of 43 ± 7 N for the T-POD, 60 ± 9 N for the Pelvic Binder, and 112 ± 10 N for the SAM Sling. Conclusions: The Pelvic Binder, SAM Sling, and T-POD provided sufficient reduction in partially stable and unstable (Tile type-B1 and C) pelvic fractures. No undesirable overreduction was noted. The pulling force that was needed to attain complete reduction of the fracture parts varied significantly among the three devices, with the T-POD requiring the lowest pulling force for fracture reduction. Clinical Relevance: The results of this biomechanical cadaver study suggest that circumferential compression devices can provide early, noninvasive circumferential compression in partially stable and unstable pelvic fractures for advantageous realignment and reduction of these fractures without overreduction. Clinical effectiveness of circumferential compression devices in patients with pelvic ring fractures remains to be determined. Copyright

Anatomy of the distal tibiofibular syndesmosis in adults: A pictorial essay with a multimodality approach (Article)

2010-12-01T00:00:00Z

A syndesmosis is defined as a fibrous joint in which two adjacent bones are linked by a strong membrane or ligaments. This definition also applies for the distal tibiofibular syndesmosis, which is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis and are linked by the distal anterior tibiofibular ligament, the distal posterior tibiofibular ligament, the transverse ligament and the interosseous ligament. Although the syndesmosis is a joint, in the literature the term syndesmotic injury is used to describe injury of the syndesmotic ligaments. In an estimated 1-11% of all ankle sprains, injury of the distal tibiofibular syndesmosis occurs. Forty percent of patients still have complaints of ankle instability 6 months after an ankle sprain. This could be due to widening of the ankle mortise as a result of increased length of the syndesmotic ligaments after acute ankle sprain. As widening of the ankle mortise by 1 mm decreases the contact area of the tibiotalar joint by 42%, this could lead to instability and hence early osteoarthritis of the tibiotalar joint. In fractures of the ankle, syndesmotic injury occurs in about 50% of type Weber B and in all of type Weber C fractures. However, in discussing syndesmotic injury, it seems the exact proximal and distal boundaries of the distal tibiofibular syndesmosis are not well defined. There is no clear statement in the Ashhurst and Bromer etiological, the Lauge-Hansen genetic or the Danis-Weber topographical fracture classification about the exact extent of the syndesmosis. This joint is also not clearly defined in anatomical textbooks, such as Lanz and Wachsmuth. Kelikian and Kelikian postulate that the distal tibiofibular joint begins at the level of origin of the tibiofibular ligaments from the tibia and ends where these ligaments insert into the fibular malleolus. As the syndesmosis of the ankle plays an important role in the stability of the talocrural joint, understanding of the exact anatomy of both the osseous and ligamentous structures is essential in interpreting plain radiographs, CT and MR images, in ankle arthroscopy and in therapeutic management. With this pictorial essay we try to fill the hiatus in anatomic knowledge and provide a detailed anatomic description of the syndesmotic bones with the incisura fibularis, the syndesmotic recess, synovial fold and tibiofibular contact zone and the four syndesmotic ligaments. Each section describes a separate syndesmotic structure, followed by its clinical relevance and discussion of remaining questions.

Stiffer Fixation of the Tibial Double-Tunnel Anterior Cruciate Ligament Complex Versus the Single Tunnel: A Biomechanical Study (Article)

2010-09-01T00:00:00Z

Purpose: The primary objective of this study was to evaluate the difference in graft pullout forces, stiffness, and failure mode of double-bundle anterior cruciate ligament (ACL) reconstruction of the tibial insertion by use of a single tunnel compared with a double-tunnel technique with interference screw fixation. Methods: ACL reconstruction on the tibial side was performed on 40 fresh-frozen porcine knees (mean bone mineral density of 0.64 g/cm2 measured by dual-energy x-ray absorptiometry scan), randomly assigned to the single- or double-tunnel group. Interference screw fixation of the soft-tissue graft was used for both types of tibial reconstruction. Maximum failure load, stiffness, and failure mode were recorded. Results: There was no significant difference in maximum failure load between the single-tunnel group (400 ± 26 N) and double-tunnel group (440 ± 20 N). Stiffness of the tibial tunnel complex was significantly higher in the double-tunnel group (76 ± 3 N/mm) than in the single-tunnel group (62 ± 4 N/mm) (P = .013). All but 2 grafts (38 of 40) failed by slippage of the tendon past the interference screw. Conclusions: There was significantly stiffer fixation of the tibial double-tunnel ACL complex when compared with the single tunnel. Our study did not show a different failure mode for the double-tunnel reconstruction compared with the single-tunnel reconstruction. Clinical Relevance: This study shows a biomechanical advantage with no potential deleterious side effects for fixation of the ACL with a double-tunnel technique on the tibial side.

Surgical anatomy of the floor of the oral cavity and the cervical spaces as a rationale for trans-oral, minimal-invasive endoscopic surgical procedures: results of anatomical studies (Article)

2010-08-01T00:00:00Z

Over the past 10 years, several minimally invasive procedures for thyroid surgery have been developed. Because of extensive dissection in the thoracic and neck region, the name "minimal-invasive" is misleading. The aim of this study was to define a new trans-oral access to the cervical spaces especially to the thyroid on the basis of natural orifice surgery. Three embalmed human specimens were dissected for complete review of the anatomical situation in the cervical region. In additional five fresh frozen human specimens after an experimental trans-oral endoscopic minimally invasive thyroidectomy the anatomical structures of the floor of the oral cavity as well as the anterior neck region were evaluated. It was possible to create a working space under the platysma muscle with respect to the surgical planes of the neck and fascial layers. Within this area, the pretracheal region can be reached and the thyroid gland can be visualized and resected. To access the working space, a trocar for endoscopic view is placed medially in the floor of the oral cavity sublingually. The trocar passes the muscles of the floor of the oral cavity easily without relation to relevant anatomical structures. A first exclusively sublingual approach had to be abandoned because triangulation of the instruments could not be reached. Therefore, the approach was modified by positioning the working trocars in the oral vestibule bilaterally. By this way, a road map for accessing all anterior cervical regions directly under the platysma muscle could be established and anatomical landmarks and areas of possible collateral damage could have been defined. This combined sublingual and bi-vestibular trans-oral endoscopic approach enables an easy access to all structures and spaces of the anterior neck region with respect to anatomical preformed layers neck, even to the thyroid as one of the more distant structures.

Functional outcome after laparoscopic and open incisional hernia repair (Article)

2010-07-01T00:00:00Z

Abstract: Background: The debate about the advantages of laparoscopic versus open incisional hernia repair is still ongoing. The primary outcomes of already published studies are mainly recurrence, pain and quality of life. Data on postoperative abdominal wall function after these corrections is still lacking. In this single center study muscle strength and transverse abdominal muscle thickness were analysed with regard to open and laparoscopic techniques. Methods: Thirty-five patients that underwent open and laparoscopic midline incisional hernia correction were included. Approximation of the rectus muscles was included in some open procedures but never in laparoscopic correction. Twelve healthy subjects without any abdominal operation functioned as a control group. Trunk flexion muscle strength of all operated patients and 12 healthy subjects was studied with the Biodex® isokinetic dynamometer and conventional abdominal muscle trainers for the rectus and oblique abdominal muscles. All patients underwent ultrasound examination of the abdominal wall for analysing transverse abdominal muscle thickness. Results: The mean torque/weight (%) for trunk flexion, measured with the Biodex®, was significantly higher in the control compared with the total patient group. Comparing trunk flexion with the Biodex® after either laparoscopic or open incisional hernia repair showed a trend in favour of the open group after adjusting for gender. The muscle strength measured by the conventional abdominal muscle trainers showed no differences between the operation groups. The transverse abdominal muscle thickness difference between rest and contraction was significantly higher in the open repair group. Conclusions: The isokinetic strength of trunk flexor muscles is reduced after an operation for incisional hernia. There is some evidence that open repair with approximation of the rectus abdominis muscles results in higher muscle strength of the rectus muscles and higher thickness differences between rest and contraction of the transverse abdominis muscles compared to laparoscopic technique.

Isokinetic strength of the trunk Xexor muscles after surgical repair for incisional hernia (Article)

2010-06-01T00:00:00Z

Purpose The repair of incisional hernias can be accomplished by open or laparoscopic techniques. The Biodex® dynamometer measures muscle strength during isokinetic movement. The objectives of this study are to compare the strength of the trunk Xexors between patients who underwent repair for incisional hernia and a control group, and to compare trunk Xexion after two kinds of operative techniques for incisional hernias with and without approximation of the rectus abdominis muscles. Methods The trunk Xexion of 30 patients after different operative techniques for midline incisional hernias and of 12 healthy subjects was studied with the Biodex® isokinetic dynamometer. Results The mean torque/weight (N m/kg) for trunk Xexion was significantly higher in the control group compared to the patient group after incisional hernia repair. A significantly higher peak torque/weight [coefficient 24.45, 95% confidence interval (CI) -0.05; 48.94, P = 0.05] was found in the two-layered suture technique without mesh compared to the laparoscopic technique after adjusting for gender. Conclusions The isokinetic strength of the trunk Xexor muscles is reduced after an operation for incisional hernia. There is some evidence that a two-layered suture repair with approximation of the rectus abdominis muscles results in higher isokinetic strength of the trunk Xexor muscles compared to the laparoscopic technique.

Noninvasive assessment of intra-abdominal pressure by measurement of abdominal wall tension 1 (Article)

2010-05-07T00:00:00Z

Background: Sustained increased intra-abdominal pressure (IAP) has negative effects. Noninvasive IAP measurement could be beneficial to improve monitoring of patients at risk and in whom IAP measurements might be unreliable. We assessed the relation between IAP and abdominal wall tension (AWT) in vitro and in vivo. Materials and methods: The abdomens of 14 corpses were insufflated with air. IAP was measured at intervals up to 20 mm Hg. At each interval, AWT was measured five times at six points. In 42 volunteers, AWT was measured at five points in supine, sitting, and standing positions during various respiratory manoeuvres. Series were repeated in 14 volunteers to measure reproducibility by calculating coefficients of variation (CV). ANOVA was used for analyses. Results: In corpses, all points showed significant correlations between IAP and AWT (P < 0.001 for points 1-4 in the upper abdomen, P = 0.017 for point 5 and P = 0.008 for point 6 in the lower abdomen). Mean slopes were greatest at points across the epigastric region (points 1-3). In vivo measurements showed that AWT was on average 31% higher in men compared to women (P < 0.001), and increased from expiration to inspiration to Valsalva's manoeuvre (all P < 0.001). AWT was highest at points 1 and 2 and in standing position, followed by supine and sitting positions. BMI did not influence AWT. Mean CV of repeated measurements was 14%. Conclusions: AWT reflects IAP. The epigastric region appears most suitable for AWT measurements. Further longitudinal clinical studies are needed to assess usefulness of AWT measurements for monitoring of IAP.

Transoral endoscopic thyroidectomy (Article)

2010-02-01T00:00:00Z

Background: Thyroid surgery is one of the newest fields for application of video-assisted surgery. The majority of approaches must choose between optimizing cosmetic results by hiding scars in the chest and axillary region while maximizing tissue dissection and post-operative pain versus having a visible cervical scar with minimal tissue dissection. In an effort to minimize surgical trauma and to achieve an optimal cosmetic result we investigated the transoral approach to the thyroid. Material and methods: In three cadavers the safety and reproducibility to access and resect the thyroid gland were assessed according to a defined road map. The surgical procedure itself was performed on two further cadavers with the help of one 5 mm trocar and two 3 mm trocars which were introduced bilaterally through the floor of mouth and the oral vestibule. A subplatysmal working space was created by blunt dissection and CO2insufflation to a pressure of 4-6 mmHg. Division of the median raphe of the neck muscles was followed by exposure of the thyroid gland. In the next step the isthmus was transected, the upper pole arteries dissected and divided and the medial thyroid vein cut close to the gland. Thyroid resection was performed from cranial to caudal and the specimen was removed transorally through the 5mm midline incision. Results: Description of landmarks of the surgical steps and dissection of defined anatomic structures could be achieved. Unilateral subtotal thyroid resection could be successfully performed without any additional skin incisions in 59 min. Postoperatively performed anatomical dissection showed intact surrounding structures. Conclusion: Our results demonstrate the feasibility and safety of a transoral access for thyroidectomy. In comparison to other minimally invasive thyroidectomy access procedures, the transoral approach is minimally invasive and at the same time cosmetically optimal.

Abdominal wall paresis as a complication of laparoscopic surgery (Article)

2009-10-01T00:00:00Z

Purpose: Abdominal wall nerve injury as a result of trocar placement for laparoscopic surgery is rare. We intend to discuss causes of abdominal wall paresis as well as relevant anatomy. Methods: A review of the nerve supply of the abdominal wall is illustrated with a rare case of a patient presenting with paresis of the internal oblique muscle due to a trocar lesion of the right iliohypogastric nerve after laparoscopic appendectomy. Results: Trocar placement in the upper lateral abdomen can damage the subcostal nerve (Th12), caudal intercostal nerves (Th7-11) and ventral rami of the thoracic nerves (Th7-12). Trocar placement in the lower abdomen can damage the ilioinguinal (L1 or L2) and iliohypogastric nerves (Th12-L1). Pareses of abdominal muscles due to trocar placement are rare due to overlap in innervation and relatively small sizes of trocar incisions. Conclusion: Knowledge of the anatomy of the abdominal wall is mandatory in order to avoid the injury of important structures during trocar placement.

Feasibility study of three-nerve-recognizing Lichtenstein procedure for inguinal hernia (Article)

2009-10-01T00:00:00Z

Background: Inguinal nerve identification during open inguinal hernia repair is associated with less chronic postoperative pain.However,most Dutch surgeons do not identify all three inguinal nerves when carrying out this procedure. The aim of this study was to evaluate the feasibility of a nerve-recognizing Lichtenstein hernia repair and to measure the extra time required for surgery Methods: Forty patients with primary inguinal hernia were operated on following the nerve-recognizing Lichtenstein hernia repair by four experienced hernia surgeons from four different Dutch teaching hospitals. The additional time needed to identify each individual nerve was recorded, and iatrogenic nerve injuries and anatomical characteristics were registered. Results: Identification of the iliohypogastric and ilioinguinal nerves was each performed within 1 min. Identification of the genital branch of the genitofemoral nerve was notably more difficult but could usually be performed within 2 min. Identification of the cremasteric vein, running parallel to the genital branch, was less comprehensive. The incidence of major anatomical variations was low. Twenty-five per cent of ilioinguinal nerves, however, could not be identified. In five patients inguinal nerves were damaged iatrogenically during standard manoeuvres of the Lichtenstein hernia repair. Conclusion: Three-nerve-recognizing Lichtenstein hernia repair is feasible and non-time consuming if the surgeon has appropriate anatomical knowledge. In view of the low incidence of major anatomical variations, knowledge of standard inguinal nervous anatomy should be adequate. This procedure could enable the surgeon to prevent or recognize iatrogenic nerve damage and offer an opportunity to perform deliberate neurectomy as an alternative to accidental nerve injury. Copyright

Small stitches with small suture distances increase laparotomy closure strength (Article)

2009-09-01T00:00:00Z

Background: There is no conclusive evidence which size of suture stitches and suture distance should be used to prevent burst abdomen and incisional hernia. Methods: Thirty-eight porcine abdominal walls were removed immediately after death and divided into 2 groups: A and B (N = 19 each). Two suturing methods using double-loop polydioxanone were tested in 14-cm midline incisions: group A consisted of large stitches (1 cm) with a large suture distance (1 cm), and group B consisted of small stitches (.5 cm) with a small suture distance (.5 cm). Results: The geometric mean tensile force in group B was significantly higher than in group A (787 N vs 534 N; P = .006). Conclusions: Small stitches with small suture distances achieve higher tensile forces than large stitches with large suture distances. Therefore, small stitches may be useful to prevent the development of a burst abdomen or an incisional hernia after midline incisions.

Level of arterial ligation in total mesorectal excision (TME): An anatomical study (Article)

2009-07-17T00:00:00Z

Introduction: High-tie ligation is a common practice in rectal cancer surgery. However, it compromises perfusion of the proximal limb of the anastomosis. This anatomical study was designed to assess the value of low-tie ligation in order to obtain a tension-free anastomosis. Materials and methods: Consecutive high- and low-tie resections were performed on 15 formalin-fixed specimens, with or without splenic flexure mobilization. If the proximal colon limb could reach the superior aspect of the symphysis pubis with more than 3 cm, the limb would be long enough for a tension-free colorectal anastomosis. Results: In 80% of cases, it was not necessary to perform high-tie ligation as sufficient length was gained with low-tie ligation. The descending branch of the left colic artery was the limiting factor in the other 20% of cases. Resecting half the sigmoid resulted in four times as many tension-free anastomoses after low-tie resection. Conclusion: In the majority of cases, it was not necessary to perform high-tie ligation in order to create a tension-free anastomosis. Low-tie ligation was applicable in 80% of cases and might prevent anastomotic leakage due to insufficient blood supply of the proximal colon limb.

MR-plastination-arthrography: A new technique used to study the distal tibiofibular syndesmosis (Article)

2009-07-01T00:00:00Z

Purpose: The purpose of this study was to describe a new technique called MR plastination arthrography to study both intra- and extra-articular anatomy. Materials and methods: In six human cadaveric lower legs MR arthrography was performed in either a one-step or two-step procedure. In the former a mixture of diluted Gadolinium and dyed polymer was injected. In the latter the dyed polymer was injected after arthrography wih diluted Gadolinium. Three-millimeter slices of these legs, obtained in a plane identical to that of the MR images, were plastinated according to the E12 technique of von Hagens. The plastination slices were subsequently compared with the MR images. Results: The one-step procedure resulted in an inhomogeneous arthrogram. The two-step procedure resulted in a good correlation between the high-resolution MR images and plastination slices, as expressed by a good comparison of anatomic detail of the small syndesmotic recess. Conclusions: Images of the distal tibiofibular syndesmosis obtained with plastination arthrography correlated well with images acquired by MR arthrography when performed in a two-step procedure.

Colorectal Anastomotic Leakage: A New Experimental Model (Article)

2009-07-01T00:00:00Z

Background: Anastomotic leakage is the major complication after colorectal surgery. To date, animal experiments concerning colorectal anastomosis focus on anastomotic healing instead of anastomotic leakage. This study aims to develop a new experimental model for colorectal anastomotic leakage. Methods: A control group, receiving an anastomosis with 12 interrupted sutures, was compared to a group receiving an anastomosis with 6 interrupted sutures. When the leakage rate was observed to be too low, the number of sutures was decreased stepwise, to 5 or less. Each group contained 9 "C57Bl6-mice". After 7 d the Anastomotic Bursting Pressure (ABP) was determined. Results: In the first experiment, one mouse (11.1%) in the case group and none in the control group developed leakage. Average ABP was 152,2 mmHg in the control group and 138,8 mmHg in the case group (P = 0,111). In the second experiment, case group receiving an anastomosis with 5 sutures, 4 mice (44.4%) in the case group developed leakage. This experiment was repeated twice resulting in leakage rates of 33.3% and 44.4%. The average overall ABP in the case group was 142,7 mmHg vs. 179,9 mmHg (P = 0,022) in the control group. The mice without leakage showed a stabilization of average weight loss around day 2 and 3 and a decrease afterwards. The mice with leakage showed a decrease only after day 5. The difference in wellness-scores between the groups with- and without leakage was 2 points, increasing during follow-up. Conclusions: The model of anastomotic leakage caused by creating an anastomosis with 5 interrupted sutures is feasible. Weight loss and wellness-scores are good predictors of leakage.

Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method (Article)

2009-05-01T00:00:00Z

Background: Neck surgery is one of the newest fields of application of minimally invasive surgery. The technique of minimally invasive video-assisted thyroidectomy (MIVAT) developed by Miccoli [1] is the method that has so far become most widespread. Limiting factors of this method include the bothersome 20-mm cervical incision and consequently the specimen size to remove. Several papers describing an access outside the front neck region have been published. Such approaches are via the chest, axillary, a combined axillary bilateral breast, or a bilateral axillary breast approach [2-5]. The development of cervical scarless thyroid surgery is a great step toward better cosmetic outcomes. However, these techniques just moved the scars from the front neck region to the axilla or the chest where they are still visible. And the mentioned minimally invasive accesses as well as the conventional approaches to the thyroid gland do not respect the anatomically given surgical planes. This may result in complaints by the patients, e.g., scar development and swallowing disorders. Furthermore, the extracervical approaches do not comply with the use of the term "minimally invasive," because they are associated with an extensive dissection of the chest and neck region, thus being rather maximally invasive for the patients. The main goal of this project was the introduction of a technique of thyroid resection that fulfills the following criteria: (i.{open box}Respecting surgical planes and minimizing surgical trauma in thyroidectomy, ii. The access itself should be close to the thyroid gland to achieve a minimally invasive procedure, iii. Achieving an optimal cosmetic result may only be obtained by performing a scarless operation, iv.{open box}This optimal cosmetic result with scarless surgery should be achieved with minimal trauma, v. The minimally invasive character of this approach and the optimal cosmetic result may not be reached at the expense of patient's safety.). The technique that meets all of these criteria is the transoral access because the distance between the sublingual place and the thyroid gland is short, thus avoiding extensive dissection maneuvers. Furthermore, the mouth mucosa can be sutured without difficulties and repairs itself without leaving any visible scars. Feasibility of the transoral access has been recently demonstrated by a member of our group in a porcine model by using a modified axilloscope [6]. However, the described technique is a hybrid one because an additional medial access (3.5-mm incision) 15-mm below the larynx was necessary for the insertion of a fixation forceps through a trocar. The main goal of our{open box}project was the investigation and introduction of a technique of totally endoscopic thyroid resection that is minimally invasive and safe for the patient and at the same time cosmetically optimal (scarless). Methods: For this purpose, a total of five human cadavers were used. In three cadavers, safety and reproducibility to reach and resect the thyroid gland was assessed according to a defined road map. At the end of the procedure, the cadavers were dissected to evaluate all defined anatomical key structures regarding possible injuries and also allow an evaluation of the surgery performed. The TOVAT itself was performed on two more human cadavers with the help of one 5-mm and two 3-mm trocars that were introduced through the mouth floor and the vestibulum of the mouth subplatysmal. A working space was created by insufflating CO2 at a pressure of 4-6 mmHg ("air dissection"). Surgical dissection of the further working space was realized with 3-mm bipolar scissors. The procedure consists of the following steps: (i. Patient in supine position and nasotracheal intubation, ii. 5-mm small incision between the carunculae sublinguales, iii. Penetration through the mouth floor along the superficial fascia colli with a blunt instrument, iv. Insertion of a 5-mm trocar, v. Blunt dissection subplatysmal by CO2 insufflation ("air dissection"), vi. CO2 insufflation (4-6 mmHg) and creation of a working space, vii. Insertion of two 3-mm trocars in the vestibulum oris on the right and left side, viii. Separation of the platysma from the strap muscles approximately at level of the larynx, extending up to the suprasternal notch. Laterally, this dissection can be continued up to the medial border of the sternocleidomastoid muscles, ix. Division of the linea alba coli and exposure of the strap muscles, x. Separation of the strap muscles from the thyroid gland, xi. Isthmus transection and blunt dissection of the thyroid gland from the trachea, xii. Dissection and division of the upper pole arteries and medial thyroid vein closely to the gland, xiii. Division of branches of the inferior thyroid artery closely to the gland, xiv. If necessary, preparation of the retro-thyroidal area, including visualization of the recurrent laryngeal nerve, xv. Thyroid resection from cranial to caudal and transoral removal of the specimen through the 5-mm midline incision. If the gland is too large, the midline incision can be extended longitudinally, xvi. All three incisions are closed with absorbable sutures.) Results: Description of landmarks of surgical steps and dissection of defined anatomic structures could be achieved. The subplatysmal space could be reached without any major problems within a short time. Anatomical dissection showed intact muscles and vascular structures. One-side subtotal thyroid resection could be successfully performed without any additional skin incision in 60 minutes. Conclusions: The minimally invasive aspect and the scarless character of TOVAT form the rationale for the preclinical investigation of this method in human cadavers. We could succeed in defining objective parameters, which describe the procedure in details and also allow an evaluation of the surgery performed. Access and feasibility of TOVAT could be demonstrated. The next step will be its application in living pigs before it may be applied in humans. To our knowledge of the literature, this is the first report on NOS application in thyroid surgery and also the first totally and scarless performed video-assisted thyroidectomy.

After-hours colorectal surgery: A risk factor for anastomotic leakage (Article)

2009-04-08T00:00:00Z

Purpose: This study aims to increase knowledge of colorectal anastomotic leakage by performing an incidence study and risk factor analysis with new potential risk factors in a Dutch tertiary referral center. Methods: All patients whom received a primary colorectal anastomosis between 1997 and 2007 were selected by means of operation codes. Patient records were studied for population description and risk factor analysis. Results: In total 739 patients were included. Anastomotic leakage (AL) occurred in 64 (8.7%) patients of whom nine (14.1%) died. Median interval between operation and diagnosis was 8 days. The risk for AL was higher as the anastomoses were constructed more distally (p = 0.019). Univariate analysis showed duration of surgery (p = 0.038), BMI (p = 0.001), time of surgery (p = 0.029), prophylactic drainage (p = 0.006) and time under anesthesia (p = 0.012) to be associated to AL. Multivariate analysis showed BMI greater than 30 kg/m2(p = 0.006; OR 2.6 CI 1.3-5.2) and "after hours" construction of an anastomosis (p = 0.030; OR 2.2 CI 1.1-4.5) to be independent risk factors. Conclusion: BMI greater than 30 kg/m2and "after hours" construction of an anastomosis were independent risk factors for colorectal anastomotic leakage.

Reply to: doi:10.1007/s00464-009-0677-y: Re: Natural orifice surgery on thyroid gland-totally transoral video-assisted thyroidectomy (TOVAT)-report of first experimental results of a new surgical method (2009 (23):1119-1120) (Article)

2009-01-01T00:00:00Z

Relapse and Stability of Surgically Assisted Rapid Maxillary Expansion: An Anatomic Biomechanical Study (Article)

2009-01-01T00:00:00Z

Purpose: This anatomic biomechanical study was undertaken to gain insight into the underlining mechanism of tipping of the maxillary segments during transverse expansion using tooth-borne and bone-borne distraction devices. Materials and Methods: An anatomic biomechanical study was performed on 10 dentate human cadaver heads using tooth-borne and bone-borne distraction devices. Results: The amount of tipping of the maxillary halves was greater in the tooth-borne group, but the difference was not significant. Four of the specimens demonstrated an asymmetrical widening of the maxilla. Conclusions: Segmental tipping was seen in both study groups. In this anatomic model, tooth-borne distraction led to greater segmental tipping compared with bone-borne distraction. Keep in mind, however, that this anatomic model by no means depicts a patient situation, and any extrapolation from it must be done with great care. The fact that the tooth-borne group demonstrated greater tipping might reflect the general opinion that bone-borne distraction causes less segmental angulation than tooth-borne distraction. Some tipping was seen in the bone-borne group, suggesting that overcorrection to counteract relapse will be necessary with this treatment modality.

Non-invasive measurement of intra-abdominal pressure: A preliminary study (Article)

2008-08-01T00:00:00Z

The importance of measuring intra-abdominal pressure (IAP) has increased since the negative effects of sustained increased IAP, also known as intra-abdominal hypertension (IAH), have become known. The relation between IAP and abdominal wall tension has been included in several reports. We have developed a device to measure abdominal wall tension by measuring force and distance. This device enables us to investigate the correlation between the abdominal wall tension and IAP. The abdomens of two corpses (one female, one male) were insufflated with air. IAP was increased and measured at intervals by means of a laparoscopic set-up. Abdominal tension was measured at seven points on the abdominal wall at each interval. Pearson's correlation coefficients were used to determine the relationship between IAP and tension for each point measured. ANOVA was used to assess relations between measured tensions versus applied pressure, locations and subjects. In both corpses, all points showed significant (p < 0.001) correlations between IAP and abdominal wall tension. The points along the mid transverse plane appear to be more similar compared to more cranial and caudal points. We have assessed the feasibility of a device that non-invasively can track changes in IAP. Measurements performed with the device are preliminary results, and further investigation is needed.

The anatomical limits of the posterior vaginal vault toward its use as route for intra-abdominal procedures (Article)

2008-08-01T00:00:00Z

Background: The use of natural openings for abdominal surgery started at the beginning of the 21th century. A trans-Douglas endoscopic device has been designed to perform most of the intra-abdominal operations in women through the pouch of Douglas. The posterior vaginal vault is limited in size and could be damaged by an oversized instrument. This study investigates the optimal dimensions of the instrument by measuring the limiting factor in the passage. Methods: In ten female embalmed bodies the transversal and sagittal diameter of the fornix posterior vaginalis was measured by two observers. The pouch of Douglas was filled to its maximal capacity with mouldable latex through an open abdomen. By internal vaginal examination the connective tissue borders of the fornix posterior were palpated and the impression in the cast was measured. The mean value of these two diameters was evaluated in this study. The level of agreement between the observers was calculated. Results: The mean fornix posterior diameter was 2.6 cm (standard deviation, SD 0.5 cm) with a range of 2.0-3.4 cm. The mean difference between the two observers of all measurements was 0.08 cm (not significant). Both observers had an acceptable intraobserver variation. The interobserver agreement was excellent. Conclusion: Instruments with dimensions within the measured limits can be used safely for intra-abdominal operations via the natural orifice of the vagina.

Oefentherapie bij volwassenen met een acuut lateraal enkeltrauma (Article)

2008-06-01T00:00:00Z

Enkeldistorsies zijn een van de meest voorkomende blessures aan het bewegingsapparaat. Men schat dat in Nederland jaarlijks ongeveer 600.000 mensen een enkeldistorsie oplopen. In de Nederlandse huisartsenpraktijk ligt de incidentie op 12,8 enkelblessures per 1000 patiënten per jaar.1 Experimentele onderzoeken naar ligamentherstel laten zien dat progressieve oefeningen en oefeningen met functionele belasting het herstel stimuleren en de ligamenten versterken.2-4 Hoewel letsel aan de ligamenten tot een afname van de mechanische stabiliteit van de enkel leidt, is het aannemelijk dat er ook neuromusculaire gebreken ontstaan aan het musculotendineuze weefsel.5-7 Dit kan resulteren in een onstabiele enkel en eventueel leiden tot een recidief en een gevoel van instabiliteit. Diverse auteurs stellen dat balanstraining als onderdeel van de revalidatie na een enkeldistorsie de functionele instabiliteit kan beperken en de controle over de houding kan verbeteren.8-10 Verschillende systematische reviews wijzen erop dat de standaardzorg moet bestaan uit vroegtijdige mobilisatie, met mobilisatie- instructies en vroegtijdige belasting gecombineerd met of zonder externe ondersteuning.11-16 Van Os et al. concluderen in een recente systematische review dat er beperkt bewijs is dat de standaardzorg gecombineerd met oefentherapie bij acuut letsel aan het laterale ligamentencomplex beter is dan alleen standaardzorg. 17 Het is dus niet duidelijk of de standaardbehandeling moet worden aangevuld met oefentherapie om op de lange termijn het gevoel van instabiliteit en, belangrijker nog, het aantal recidieven te verminderen. Verschillende systematische reviews adviseren om in dit kader een gerandomiseerde, gecontroleerde trial op te zetten.12,15,17 In dit prospectieve gerandomiseerde onderzoek vergelijken wij de korte- en langetermijneffecten van de standaardbehandeling van een acuut lateraal enkeltrauma bij volwassen patiënten met die van de standaardbehandeling gecombineerd met oefentherapie onder begeleiding van een fysiotherapeut.

Indications for incisional hernia repair: An international questionnaire among hernia surgeons (Article)

2008-06-01T00:00:00Z

Background: Incisional hernia repair can be a significant challenge for both surgeon and patient. Despite the growing amount of literature describing various methods of surgical techniques, little has been published regarding the natural course of incisional hernia and the opinions about indications for incisional hernia repair. Methods: A questionnaire was sent to a group of surgeons internationally renowned in incisional hernia surgery and research. Results: Pain and limitations of daily activities were considered the most important indications for repair. Cosmetic complaints were seen as least important. About 23% of patients were asymptomatic. More than 20% did not receive surgical treatment. Conclusions: A large proportion of patients with incisional hernia is not operated. Despite this large group of patients, valid data describing the natural course are absent. A prospective trial monitoring incisional untreated hernias as well as comparing conservative treatment with repair should be performed.

Vascular anatomy of the stomach related to gastric tube construction (Article)

2008-05-01T00:00:00Z

In view of constructing a gastric tube after esophagus resection, the vascular anatomy of the greater curvature of the stomach, especially the connection between the left and right gastro-epiploic arteries, was investigated. The vascular anatomy was studied in 20 embalmed human specimens. After dissection a gastric tube of 4 cm wide was constructed, using the greater gastric curvature. Various lengths of the arterial arcades were measured. In 70% an anastomosis between the right and left gastro-epiploic arteries was present. With the construction of an isoperistaltic gastric tube, in which the left gastro-epiploic artery is left in situ (ligating it at the splenic hilus), there is an 18.7% increase of length of arterial arcade along the gastric tube. Leaving the left gastro-epiploic artery in situ increases the feeding arterial arcaded-length along the gastric tube with 5.0 cm (19%). © 2007 The Authors Journal compilation

Anastomotic leakage, the search for a reliable biomarker. A review of the literature (Article)

2008-02-01T00:00:00Z

Background: Colorectal anastomotic leakage (AL) is a severe complication leading to severe infection, sepsis and sometimes death. At present the diagnosis is made clinically, usually at 6-8days after surgery. An objective biomarker reflecting the intra-abdominal milieu surrounding the anastomosis would be a useful additional diagnostic tool to make the diagnosis of AL before its clinical presentation. This review aims to assess the current status of the search for such a biomarker in peritoneal fluid. Method: A literature search was carried out, using MEDLINE, PubMed and the Cochrane library, for all publications concerning human peritoneal fluid in relation to postoperative complications in general, and, more specific, anastomotic leakage after colorectal surgery. Results: Analysis of several immune parameters, tissue repair parameters, parameters for ischaemia and microbiological composition of peritoneal fluid show that these can be determined reliably in the fluid, albeit with a large variance. Furthermore the data show that changes in concentration of these parameters precede AL and other postoperative complications by several days. Conclusion: The results ofthe review demonstrate that it is possible to distinguish between patients with and without AL by measuring biomarkers in fluid from the peritoneal drain. Prospective studies with larger numbers of patients should, however, be performed and additional biomarkers should be studied to explore the full diagnostic potential of this approach. © 2008 The Authors. Journal Compilation

Supervised exercises for adults with acute lateral ankle sprain: a randomised controlled trial (Article)

2007-10-01T00:00:00Z

BACKGROUND: During the recovery period after acute ankle sprain, it is unclear whether conventional treatment should be supported by supervised exercise. AIM: To evaluate the short- and long-term effectiveness of conventional treatment combined with supervised exercises compared with conventional treatment alone in patients with an acute ankle sprain. DESIGN: Randomised controlled clinical trial. SETTING: A total of 32 Dutch general practices and the hospital emergency department. METHOD: Adults with an acute lateral ankle sprain consulting general practices or the hospital emergency department were allocated to either conventional treatment combined with supervised exercises or conventional treatment alone. Primary outcomes were subjective recovery (0-10 point scale) and the occurrence of a resprain. Measurements were carried out at intake, 4 weeks, 8 weeks, 3 months, and 1 year after injury. Data were analysed using intention-to-treat analyses. RESULTS: A total of 102 patients were enrolled and randomised to either conventional treatment alone or conventional treatment combined with supervised exercise. There was no significant difference between treatment groups concerning subjective recovery or occurrence of resprains after 3 months and 1-year of follow-up. CONCLUSION: Conventional treatment combined with supervised exercises compared to conventional treatment alone during the first year after an acute lateral ankle sprain does not lead to differences in the occurrence of resprains or in subjective recovery.

Authors' reply: Nerve management during open hernia repair (Br J Surg 2007; 94: 17-22) [12] (Article)

2007-07-01T00:00:00Z

Authors' reply: Optimizing the critical view of safety in laparoscopic cholecystectomy by clipping and transecting the cystic artery before the cystic (Br J Surg 2007; 94: 473-474) [10] (Article)

2007-07-01T00:00:00Z

Hartmann's gallbladder pouch revisited 60 years later (Article)

2007-07-01T00:00:00Z

Background: Hartmann's gallbladder pouch was the subject of an article in The Lancet 60 years ago. It has regained new interest in view of laparoscopic cholecystectomy. However, different opinions exist with regard to its incidence and nature. To elucidate these discrepancies, a descriptive study was performed with regard to the incidence and morphology of Hartmann's pouch. Methods: Gallbladders were obtained after elective laparoscopic cholecystectomy. In addition, gallbladders were obtained during routine postmortem examination. The gallbladders were divided in two groups: those with Hartmann's pouch and those without Hartmann's pouch. All the gallbladders were examined macroscopically and microscopically. Fisher's Exact Probability Test (p < 0.05, two-tailed) was used to analyze the data. Results: A total of 98 gallbladders were examined: 49 obtained after laparoscopic or open cholecystectomy and 49 obtained after postmortem examination. Among the gallbladders with Hartmann's pouch (n = 51), 65% contained stones and 35% had no stones. Among the gallbladders without Hartmann's pouch, 43% contained stones and 57% had no stones. Macroscopically, in all the gallbladders with Hartmann's pouch, the pouch was observed to result from adhesions between the cystic duct and the neck of the gallbladder. After cleavage of these adhesions, the phenomenon of Hartmann's pouch was abolished in all cases. Conclusions: Hartmann's gallbladder pouch is a frequent but inconstant feature of normal and pathologic human gallbladders. There is a significant association between the presence of Hartmann's pouch and stones (p < 0.05). Adhesions between the cystic duct and the neck of the gallbladder are responsible for Hartmann's pouch. Consequently, Hartmann's gallbladder pouch is a morphologic rather than an anatomic entity.

Riolan's arch: confusing, misnomer, and obsolete. A literature survey of the connection(s) between the superior and inferior mesenteric arteries (Article)

2007-06-01T00:00:00Z

Background: There are 2 interpretations of Riolan's arch: (1) Riolan's arch is identical to a central part of the marginal artery (MA), connecting the superior (SMA) and the inferior mesenteric (IMA) arteries; and (2) Riolan's arch represents a rare artery, connecting the SMA and the IMA. The current review aims to emphasize the clinical importance of the colon's vasculature and to show the feasibility of abolishing the terms "Riolan's arch" and "meandering mesenteric artery.". Methods: A literature survey was performed. Results: It appears that no distinct identity can be ascribed to Riolan's arch and that the "meandering mesenteric artery" represents an angiographically hypertrophied MA and/or the ascending branch of the left colic artery. However, a rare, centrally located, communicating artery has been described. Generally, the MA is sufficient for left colic circulation after ligation of the IMA, but at the splenic flexure, patency of the ascending branch of the left colic artery can be primordial. Conclusion: As connections between the SMA and the IMA can be adequately described using structures mentioned in Terminologica Anatomica, the terms "Riolan's arch" and "meandering mesenteric artery" should be abolished.

Optimizing the critical view of safety in laparoscopic cholecystectomy by clipping and transecting the cystic artery before the cystic duct (Article)

2007-04-01T00:00:00Z

Surgical techniques preventing chronic pain after Lichtenstein hernia repair: State-of-the-art vs daily practice in the Netherlands (Article)

2007-04-01T00:00:00Z

Background: Morbidity associated with open inguinal hernia repair (IH repair) mainly consists of chronic pain. The aim of this study was to identify possible disparities between state-of-the-art Lichtenstein repair, and its application in general practice. Methods: A questionnaire was mailed to all surgeons and surgical residents (n = 1,374) in the Netherlands in February 2005. The objective was to determine the state of general practice with respect to technical steps during the Lichtenstein repair that are suggested to be involved in the development of chronic pain, as recently updated by Lichtenstein's successor, Amid. Results: More than half of the respondents do not act according to the Lichtenstein guidelines with respect to surgical steps that are suggested to be involved with the origin of chronic pain of somatic origin. Compliance with Amid's guidelines with respect to the handling of the nerves is variable. Surgeons conducting high numbers of IH repair are more likely to operate according to the key principles of the state-of-the-art Lichtenstein repair. Conclusion: There is a substantial disparity between the state-of-the-art Lichtenstein repair and its application in general practice with respect to steps that are suggested to play a role in the origin of chronic groin pain.

Nerve-identifying inguinal hernia repair: A surgical anatomical study (Article)

2007-02-01T00:00:00Z

Background: Pain syndromes of somatic and neuropathic origin are considered to be the main causes of chronic pain after open inguinal hernia repair. Nerve-identification during open hernia repair is suggested to be associated with less postoperative chronic pain. The aim of this study was to define clinically relevant surgical anatomical zones facilitating efficient identification of the three inguinal nerves during open herniorrhaphy. Method: Through dissection of 18 inguinal areas of embalmed and unembalmed human cadavers, identification zones were developed for the inguinal nerves (in particular for the genital branch of the genitofemoral nerve). Results: The iliohypogastric nerve was identifiable running approximately horizontally and ventrally to the internal oblique muscle perforating the external oblique aponeurosis at a mean of 3.8 cm (range 2.5-5.5 cm) cranially from the external ring. When present, the ilioinguinal nerve was identifiable running ventrally and parallel to the spermatic cord, dorsally from the aponeurosis of the external oblique muscle. Identification of the genital branch of the genitofemoral nerve was more comprehensive. The course of the genital branch is laterocaudal at the level of the internal inguinal ring. Conclusion: Based on the newly defined identification zones, peroperative identification of all inguinal nerves is possible. Further research is warranted to assess clinical feasibility of these zones and to evaluate the influence of (facultative) division, preservation or omittance of the identification of inguinal nerves on the incidence of chronic pain.

Nerve management during open hernia repair (Article)

2007-01-01T00:00:00Z

Background: Peroperative identification and subsequent division or preservation of the inguinal nerves during open hernia repair may influence the incidence of chronic postoperative pain. Methods: A systematic literature review was performed to identify studies investigating the influence of different types of nerve management. Results: Based on three randomized studies the pooled mean percentage of patients with chronic pain after identification and division of the ilioinguinal nerve was similar to that after identification and preservation of the ilioinguinal nerve. Two cohort studies suggested that the incidence of chronic pain was significantly lower after identification of all inguinal nerves compared with no identification of any nerve. Another cohort study reported a significant difference in the incidence of chronic pain in favour of identification and facultative pragmatic division of the genital branch of the genitofemoral nerve compared with no identification at all. Conclusion: The nerves should probably be identified during open hernia repair. Division of and preservation of the ilioinguinal nerve show similar results. Copyright

Compensatory increase of the cervico-ocular reflex with age in healthy humans. (Article)

2003-11-15T00:00:00Z

The cervico-ocular reflex (COR) is an ocular stabilization reflex that is elicited by rotation of the neck. It works in conjunction with the vestibulo-ocular reflex (VOR) and the optokinetic reflex (OKR) in order to prevent visual slip over the retina due to self-motion. The gains of the VOR and OKR are known to decrease with age. We have investigated whether the COR, a reflexive eye movement elicited by rotation of the neck, shows a compensatory increase and whether a synergy exists between the COR and the other ocular stabilization reflexes. In the present study 35 healthy subjects of varying age (20-86 years) were rotated in the dark in a trunk-to-head manner (the head fixed in spaced with the body passively rotated under it) at peak velocities between 2.1 and 12.6 deg s-1 as a COR stimulus. Another 15 were subjected to COR, VOR and OKR stimuli at frequencies between 0.04 and 0.1 Hz. Three subjects participated in both tests. The position of the eyes was recorded with an infrared recording technique. We found that the COR-gain increases with increasing age and that there is a significant covariation between the gains of the VOR and COR, meaning that when VOR increases, COR decreases and vice versa. A nearly constant phase lag between the COR and the VOR of about 25 deg existed at all stimulus frequencies.

Quantification of first tarsometatarsal joint stiffness in hallux valgus patients (Article)

2001-10-01T00:00:00Z

OBJECTIVE: Comparison of the clinical mobility test of the first tarsometatarsal joint with Doppler Imaging of Vibrations measurement of the stiffness of this joint in hallux valgus patients. DESIGN: Clinical testing of first tarsometatarsal joint mobility was related to independent Doppler Imaging of Vibrations measurement of first tarsometatarsal joint stiffness. BACKGROUND: Hypermobility of the first tarsometatarsal joint has consequences for the surgical treatment of hallux valgus deformity. However, the clinical test is subjective. Doppler Imaging of Vibrations could be helpful in quantification of the stiffness of this joint. METHODS: Clinical examination of the mobility of 32 first tarsometatarsal joints in 20 hallux valgus patients was compared with Doppler Imaging of Vibrations stiffness measurements performed by an independent observer. RESULTS: There was a statistically significant relation between the clinical test and the stiffness measurement by Doppler Imaging of Vibrations. CONCLUSION: Doppler Imaging of Vibrations proves to be a method to quantify first tarsometatarsal joint stiffness and could contribute to a rational policy for the surgical treatment of hallux valgus deformity. RELEVANCE: The clinical test to establish hypermobility of the first tarsometatarsal joint is subjective. Doppler Imaging of Vibrations offers objective criteria and quantification of first tarsometatarsal joint stiffness. This provides additional information for the choice of the surgical procedure to correct hallux valgus deformity.

The sacroiliac part of the iliolumbar ligament (Article)

2001-01-01T00:00:00Z

The iliolumbar ligament has been described as the most important ligament for restraining movement at the lumbosacral junction. In addition, it may play an important role in restraining movement in the sacroiliac joints. To help understand its presumed restraining effect, the anatomy of the ligament and its orientation with respect to the sacroiliac joints were studied in 17 cadavers. Specific dissection showed the existence of several distinct parts of the iliolumbar ligament, among which is a sacroiliac part. This sacroiliac part originates on the sacrum and blends with the interosseous sacroiliac ligaments. Together with the ventral part of the iliolumbar ligament it inserts on the medial part of the iliac crest, separate from the interosseous sacroiliac ligaments. Its existence is verified by magnetic resonance imaging and by cryosectioning of the pelvis in the coronal and transverse plane. Fibre direction, length, width, thickness and orientation of the sacroiliac part of the iliolumbar ligament are described. It is mainly oriented in the coronal plane, perpendicular to the sacroiliac joint. The existence of this sacroiliac part of the iliolumbar ligament supports the assumption that the iliolumbar ligament has a direct restraining effect on movement in the sacroiliac joints.

Influence of posture and motion on peripheral nerve tension: Anatomical, biomechanical and clinical aspects (Doctoral Thesis)

1997-01-24T00:00:00Z

The dorsal branch of the ulnar nerve: An anatomic study with surgical application (Article)

1996-12-01T00:00:00Z