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Anatomical segmentectomy is a technically difficult procedure owing to the complexity of the segmental anatomy of the liver. In the conventional Glissonean approach from the liver hilum, the tertiary portal pedicles may be difficult to dissect because of their anatomical variations and deep location. We present a technique of purely laparoscopic anatomical segmentectomy of the liver using the transfissural Glissonean approach. We performed purely laparoscopic anatomical segmentectomy using the transfissural Glissonean approach. This approach involved initially opening the liver parenchyma along the fissure line (main portal, right portal, and umbilical fissures). Thereafter, the target tertiary portal pedicles were approached and ligated within the liver parenchyma above the liver hilum. Between August 2014 and September 2019, we performed 17 cases of laparoscopic anatomical segmentectomy using the transfissural Glissonean approach. The median operative time was 200 min (range 120–310 min), and the intraoperative blood loss was 80 mL (range 30–280 mL). The median postoperative hospital stay was 6 days (range 3–9 days). There was no major morbidity or mortality. The transfissural Glissonean approach in laparoscopic anatomical segmentectomy is technically feasible because opening the fissure allows direct access to the tertiary portal pedicles.

We report a lateral approach using the grasping technique for uniportal major lung resection. Grasping dissected tissue with grasping forceps enables the dissected surface to be three-dimensionally dissected from important organs, such as blood vessels, which, therefore, makes the procedure safe. Furthermore, there is an incision wound on the middle axillary line at the 6th intercostal space, and therefore, either the anterior or posterior side of the hilum can be easily observed, and a stapler can pass through all structures of the hilum easily.

Introduction: Pelvi-calyceal system consists of renal pelvis along with major and minor calyces.The minor calyces unite with their neighbors two or three chambers to form the major calyces. The major calyces drain into the infundibula. The renal pelvis is formed from the junction of the infundibula. The common pattern of arrangement of structures at the renal hilum, antero-poteriorly is renal vein, renal artery and pelvis. Objectives: To compare the study of pelvi-calyceal system and relationship of structures at hilum of kidney between Nepalese and North Americans. Methodology: The gross and prosected kidney specimens were studied for pelvi-calyceal system and relationship of structures at hilum of kidney in Anatomy department. In Nepal, the study was undertaken in Gandaki Medical College, Kaski and in USA, it was done in Well-cornel University, New York. Result: Tricalyceal major calyx were found in 63.8% in Nepalese and Bicalyceal were found in 65.6% North Americans which is statistically significant variations. The number of minor calyces and pyramids varying 6 in Nepalese and 9 in North Americans were also statistically significant (p

Laparoscopic nephrectomy is a commonly performed procedure. As with any surgical procedure, this too has a significant learning curve. The management of renal hilum is the most critical part of this surgery. It requires a meticulous intra-hilar dissection to identify the renal artery and vein. The kidneys are extremely vascular structures and any injury to these vessels during dissection can result in life-threatening bleeding. Hence, it is obvious that beginners most often face difficulty and apprehension at this step of the laparoscopic nephrectomy. We describe a simple technique of laparoscopic nephrectomy which includes the creation of two windows, one at the lower pole and the second at the upper pole, isolation of the hilum, and en bloc stapling of the renal hilar vessels. This method safeguards against collateral damage to the surrounding structures. It also avoids the need for intra-hilar dissection, hence decreasing the chances of vascular injuries.

Background Thoracic surgeons rarely encounter stab wounds with injury to the intrathoracic organs. However, such sudden and urgent situations could arise; therefore, experiences in managing such cases are invaluable. Case presentation An 84-year-old woman with depression who had a stab injury in the neck caused by a broad-bladed kitchen knife was brought to our facility by ambulance. She was stable in the emergency room; however, a computed tomography scan revealed that the blade had penetrated the right thoracic cavity. A right hemopneumothorax was seen. Considering the possibility of injury to the major vessels, a median sternotomy was performed. During the dissection around the blade, the patient started bleeding profusely, which required repair of an injury to the right internal jugular vein. The blade tip had penetrated the dorsal right upper lung lobe; however, it did not reach the hilum, and the knife was carefully removed. The damaged area of the lung was removed by wedge resection. Conclusion Patients with deep stab wounds from knives are often hemodynamically stable because the blade acts as tamponade and prevents hemorrhage. Therefore, a surgical approach that allows for good visualization should be considered for the extraction of the blade.

Background Although several distribution patterns of periprostatic neurovascular bundles have been proposed, variant dissection technique based on these patterns still confused surgeons. The aim of this study was to describe the periprostatic neurovascular bundles and their relationship with the fascicles around prostate and provide the accurate morphologic knowledge of periprostatic tissue for prostate operation. Methods The pelvic viscera were obtained from 26 adult male cadavers. They were embedded in celloidin and cut into successive slices. The slices were explored with anatomic microscopy. 3-Dimensional reconstruction was achieved with celloidin sections and series software. Results The prostatic capsule which surrounded the dorsal, bilateral aspect of the prostate was attached ventrally to anterior fibrous muscular stroma (AFMS). The lower part of the striated sphincter completely embraced the urethral; the upper part of this muscle covered the lower ventral surface of prostate. The upper ventral surface of prostate is covered by the circular muscle of detrusor. The levator fascia and the capsule adhered on the most convex region of the lateral prostate, but separated on the other region. The pelvic neurovascular bundles (PNVB) divided into the anterior and posterior divisions. The anterior division continued as dorsal vascular complex (DVC). The distal part of DVC entered into penile hilum. The posterior division continued as neurovascular bundles, and then as the cavernous supply (CS). The distal part of CS joined into pudendal neurovascular bundles. Conclusions The capsule and AFMS formed a pocket like complex. There were anterior and posterior neurovascular approaches from PNVB to penile hilum.

This chapter covers tips and tricks for approaching the renal hilum and for minimizing the impact of warm ischemia during robotic partial nephrectomy. Surgeons performing robotic partial nephrectomy should have experience with laparoscopic vascular dissection, management of vascular complications, actively guiding a bedside assistant, and open partial nephrectomy. Novice robotic surgeons should begin with anterior or lower pole exophytic tumors and then gradually progress to more complex tumors. Routine hilar dissection and clamping are recommended earlier in the learning curve even for tumors that appear superficial. Adequate mobilization of the bowel to provide an unobstructed view of the hilum and lateral aspect of the ipsilateral great vessel and retracting the lower pole of the kidney to stretch the hilar vessels during dissection are key initial maneuvers. Only minimal renal artery and vein dissection is needed to allow placement and full engagement of the body of the bulldog clamp across the vessels. Additional steps taken in case there is bleeding despite clamping and bleeding after unclamping, use of hemostatic agents and sealers (and their differences), use of Doppler and near-infrared imaging, and various practical strategies to reduce ischemia time are discussed.

The biliary tree extends from the intrahepatic biliary radicals to the main biliary branches draining the left and right livers and their confluence in the liver hilum to form the common hepatic duct. The cystic duct, draining the gallbladder, joins the common hepatic duct to form the common bile duct, which courses through the porta hepatis and the head of the pancreas, joining with the pancreatic duct to empty into the duodenum at the ampulla. Cholangiocarcinoma can develop in different parts of this system, with radically different consequences in terms of surgical treatment. Moreover, variations on standard biliary anatomy can pose particular surgical challenges. This chapter will examine biliary anatomy, in particular its common variants and anomalies, with special attention to its relationship with cholangiocarcinoma and its treatment.

To understand the hilar region, we must first of all understand that although the extrahepatic portal triad consisting of the hepatic artery, the portal vein and the bile duct is enclosed by connective tissues and peritoneum up to the hepatic hilum, the term Glisson’s sheath is reserved for the Glisson’s capsule which extends into the intrahepatic portion of the liver beyond the hilum. Also, because the hepatic hilar plate system is formed by the fusion of Glisson’s capsule with the connective tissue sheaths surrounding the biliary and vascular elements at the inferior aspect of the liver, branches of the biliary and vascular elements can ramify in the hepatic hilar plate system before they go into the Glisson’s sheath of a particular sector or segment of the liver. Alternatively, the elements can go straight into a particular Glisson’s sheath after branching. Sometimes, for a particular liver sector or segment, branches of the artery, and bile duct can act differently from branches of the portal vein before they go into the Glisson’s sheath.

Robotic hepatectomies have been demonstrated to be feasible since the introduction of the robotic platform. The robot allows a fine dissection of the liver hilum, enhanced means of intraoperative biliary anatomy assessment, a safe selective suturing during the hepatocaval dissection, and a seamless biliary anastomosis creation. Three clear phases of the surgery are identified for the hepatectomy: hilum dissection, hepatocaval dissection, and parenchymal transection. There are important technical considerations along the surgery that are described with useful tips and tricks by an expert robotic surgeon.

The Perihilar area is a complex region where bile ducts, portal veins, hepatic arteries, lymphatics, and nerves intertwine often in an unpredictable way. Anatomical variation is common and the spatial relationships between the vessels are difficult to predict. Imaging techniques greatly assist the surgeon in visualizing the individual anatomy, improving operative precision, patient safety, and shortening duration of surgery. This chapter outlines the characteristic anatomical variation and spatial relationships between the portal veins, hepatic arteries, and bile duct. It categorizes: perihilar diseases and discusses their impact on the hilum, atrophy, and hypertrophy of the liver lobes. We discuss the nature of invasive disease and concomitant difficulties during surgery. We also outline the treatment of disease, and the value of imaging technologies, modeling hepatic lobe segmentation and related vasculature to enable simulated surgery, and for precise preoperative and intraoperative guidance. The chapter closes with a description of the 3D imaging software systems, from image acquisition, and data migration to 3D modelling of the perihilar region and the liver.

The study of the features of the topographic anatomy and individual anatomical variability of the renal calix-pelvis system (RCPS) during the fetal period of a human being intrauterine development (IUD) is important for elucidation and understanding of the complex transformations of their structure, syntopy and skeletotopy, in particular, to explain the causes and time of appearance of the structural variants, possible origin of the congenital malformations of the organ. Purpose of the work: to find out the dynamics of topographic and anatomical changes and anatomical variability of the renal calyx-pelvis system in the fetal period of human ontogenesis. Material and methods. 102 biomannequin of a human being fetuses of 160.0-480.0 mm parietal-coccygeal length (PCL) (4-10 months of IUD) were studied. A complex of methods of morphological research was applied, which included anthropometry, morphometry, injections of blood vessels with X-ray contrast mixtures, X-ray techniques, dissection, microscopy, three-dimensional reconstruction and statistical analysis. Results. It has been found that a lobar structure of the kidneys of human fetuses is observed on all specimens. Two main variants of their external structure were revealed – bean-shaped and oval-shaped. At the beginning of the fetal period of human ontogenesis, the oval shape of the kidney is most often observed, but from the 6th month of the IUD, the bean-shaped form begins to prevail, and from the 8th month of the IUD it is determined almost twice as often. Two variants of the structure of the renal hilum were observed – their open and compact forms. Until the 6th month of IUD, the open form of the renal hilum prevails, and from the end of the 7th month and at the beginning of the 8th months of IUD, a compact form of the organ hilus was revealed on most preparations. In 10-month-old human fetuses, the compact form occurs almost three times more often than the open one. Simultaneously with changes in the shape of the renal hilum, changes in their holotopy occur: in 4-7-month-old fetuses, the hilus is directed forward and medially, and from the 8th month of IUD they are reoriented and placed already on the medial surface of the kidney. Among the variants of the structure of the RCPS, we observed ampullar and branched types. During the study of the renal pelvis skeletotopy, it has been found that at the beginning of the fetal period (4-5-months-old fetuses), the right and left renal pelvis are located almost at the same level in relation to the spine – approximately at the level of the interval between the II and III lumbar vertebrae, but starting from the 6th month, they "rise" on the left to the level of the middle third of the II lumbar vertebra, and on the right, on the contrary, "descend" to the middle third of the III lumbar vertebra. Syntopy of the renal pelvis and pyelo-ureteral segment with renal vessels on the right and on the left is almost the same, and in the dynamics of the fetal period of IUD does not change significantly. Conclusions. 1. The topography of the renal calyx-pelvic system is largely determined by the peculiarities of the spatial structure of the kidney – its external shape, size, skeletotopy, individual features of the hilum of the organ, their syntopy with the renal vessels. 2. Close syntopy of the renal pelvis and pyelo-ureteral segment with renal vessels with a compact form of the renal hilum may be an anatomical prerequisite for impaired urodynamics, provided there are variants of renal vessels branching or the existence of an abnormal vessel in the renal hilum region. 3. Variants of the structure of the kidneys and their structures are clearly observed from the beginning of the fetal period of human intrauterine development, significantly affect the topography of the calyces and pelvis, and in some cases can cause impairment of urodynamics.

Thoracoscopic segmentectomy for the posterior basal segment (S10) and its variant (e.g., S9+10 and S10b+c combined subsegmentectomy) is one of the most challenging anatomical segmentectomies. Stapler-based segmentectomy is attractive to simplify the operation and to prevent post-operative air leakage. However, this approach makes thoracoscopic S10 segmentectomy even more tricky. The challenges are caused mostly from the following three reasons: first, similar to other basal segments, "three-dimensional" stapling is needed to fold a cuboidal segment; second, the belonging pulmonary artery is not directly facing the interlobar fissure or the hilum, making identification of target artery difficult; third, the anatomy of S10 and adjacent segments such as superior (S6) and medial basal (S7) is variable. To overcome these challenges, this article summarizes the "bidirectional approach" that allows for solid confirmation of anatomy while avoiding separation of S6 and the basal segment. To assist this approach under limited thoracoscopic view, we also show stapling techniques to fold the cuboidal segment with the aid of "standing stiches". Attention should also be paid to the anatomy of adjacent segments particularly that of S7, which tends to be congested after stapling. The use of virtual-assisted lung mapping (VAL-MAP) is also recommended to demark resection lines because it flexibly allows for complex procedures such as combined subsegmentectomy such as S10b+c, extended segmentectomy such as S10+S9b, and non-anatomically extended segmentectomy.

Objectives/purpose To determine the diagnostic value of morphological features on computed tomography (CT) in the differentiation of pulmonary arteriovenous malformation (pAVM) and its mimics. Materials and methods We retrospectively examined 59 consecutive patients (109 lesions) with initially suspected or occult pAVM who underwent contrast-enhanced chest CT from January 2006 to June 2016. All lesions were divided into two groups based on their diagnosis: AVM (n = 93) and non-AVM (n = 16). The non-AVM group comprised patients with an anomalous unilateral single pulmonary vein and congenital pulmonary venous atresia. Two board-certified radiologists reviewed the CT images and achieved consensus. Paired abnormal vessels were assessed with respect to their configuration, direction and continuity with the hilum, location, angle between them, and dilation ratio. Results All pAVM lesions had parallel, straight-running, paired abnormal vessels; most of the vessels ran through the identical segment. Conversely, in the non-AVM group, paired abnormal vessels did not run in parallel but detoured to the hilum through different segments from each other (i.e., the configuration, direction and continuity with the hilum and the location of the vessels were all significantly different between the two groups). The angle between the paired abnormal vessels was significantly narrower in the AVM group. The dilation ratio was not significantly different between the two groups. Conclusion Morphological features can be useful in the differentiation of pAVM and its mimics without contrast-enhanced CT to directly visualize the connection between the abnormal and normal pulmonary vessels. Pulmonary AVMs characteristically had a narrow angle between the two vessels, appearing like a pair of pine-needle leaves.

Since 1995, video-assisted thoracoscopic oesophagectomy (VATS), according the same surgical principles as the Japanese open surgery, has been completed in 700 patients with oesophageal cancer. Our indication for VATS is (I) no extensive pleural adhesion; (II) no contiguous tumor spread; (III) pulmonary function capable of sustaining single-lung ventilation, and (IV) non radiated patients. We use 4 ports around a 5 cm mini-thoracotomy on 5th intercostal space. We laid emphasis on utilizing magnifying effect of video (5 to 20 magnifications), obtained by positioning the camera at close vicinity to the dissection. Magnified view facilitates recognizing the fine layer structure of the mediastinum. The dissection should be performed following this layer structure just like open the page of a book. Tearing the layer makes the dissection irrational and cause unnecessary bleeding and invasiveness. The microanatomies we recognize during upper mediastinal dissection are (I) the most outer layer below the mediastinal pleura are branches from the vagus nerve and thoracic sympathetic trunk; (II) there is no vessel flow in the nerves or out, in the field of dissection; (III) the ideal layer of dissection along the nerve is exposing the epineurium; (IV) the strongest fixing structures in the mediastinum are the vagal nerves and nerves form thoracic sympathetic trunk; (V) the stump of thoracic duct shows particular appearance because of the intramural smooth muscle; (VI) the lymphonodes in the mediastinum are fixed strongly with nerves and gently with vessels; (VII) the aorta is covered with fine fibrous membrane consisting of branches form thoracic sympathetic trunk, etc. Magnified view shows the microstructure of the lymph node such as the afferent lymphatics penetrating the capsule and the hilum structure consisting the efferent lymphatics, artery, vein and nerve. The direction of the hilum of nodes is defined in each region. Therefore, understanding the hilum direction facilitates rational dissection. The hospital mortality was four patients (0.6%). The rate of regional control was 95%. The 5-year survival rates of the patients with pStage 0, 1, 2, 3, 4 were 92%, 88%, 69%, 52% and 24%, respectively, which were favorably compared with open surgery.

The anatomy of pulmonary vessels varies. The right upper pulmonary vein usually drains in front of the pulmonary artery to the left atrium. We herein describe a case of the right upper lobe pulmonary vein draining posterior to the pulmonary artery and absent right upper lobe pulmonary vein in the ventral hilum. A 64-year-old woman suspected to have lung cancer and scheduled for surgery underwent pre-operative three-dimensional computed tomography (3D-CT), which revealed that pulmonary vessels V1 + 3 and V2 drain posteriorly to the pulmonary artery. Video-assisted right upper lobectomy was performed because the patient was diagnosed with lung adenocarcinoma through intraoperative pathologic analysis, and all the pulmonary vessels were identified correctly during the operation. Despite the limited surgical field of video-assisted lobectomy, the operation was performed safely because the pre-operative 3D-CT assessment revealed the anatomy of the anomalous pulmonary vessels, helping us avoid missing any anomaly and vessel injury.

Begin by reviewing the systematic approach to the left lateral chest radiograph in Fig. 11.1.

The right lung is the larger of the two lungs and is divided in three lobes: the upper, middle and lower lobes. The major fissure separates the upper and middle lobes from the lower lobe and the minor fissure separates the upper lobe from the middle one; the latest is usually less evident. The right lung is fixed centrally by the hilum that is composed by the right main bronchus, the pulmonary artery and the superior and inferior pulmonary veins, and distally by the inferior pulmonary ligament. From the hilum the right main bronchus, the pulmonary artery and the superior and inferior pulmonary veins divide into lobar, segmental and subsegmental branches. The lymphatic drainage pathway from subpleural lymphatic vessels runs with the arteries and bronchi and subsequently into the segmental, lobar, interlobar, hilar and mediastinal nodes.

Pancreaticoduodenectomy (PD), first reported by Codivilla and Kausch [1], is a complex and delicate surgical operation for treating the periampullary and pancreatic head tumors. This technique was finally polished and popularized by Whipple et al. [2]. To date, several versions of the Whipple’s technique have been modified; however, PD is usually detected, dissociated, and removed by standard approach in most cases. It can be performed within these situations: no distant organ metastasis of tumor, no tumor invasion and fixation in transverse mesocolon root, no tumor invasion of important peripancreatic vessels, and no large number of abnormal collateral vessels in the hilum of the liver can be removed by abdominal exploration.

The pleura are a composition of two serous membranes: the visceral pleura lining the lungs and the parietal pleura lining the inner chest wall, diaphragm, and mediastinum. The pulmonary hilum is composed of blood vessels, airways, nerves, and lymph nodes and denotes the meeting point between the mediastinum and the pleural cavities. This review covers disorders of the pleura, mediastinum, and hilum. Figures show a schematic diagram of normal filtration/resorption of fluid in the pleural space; comparison of a simultaneously obtained chest x-ray (CXR) and a chest computed tomographic (CT) scan of the same patient; an algorithm for evaluation of patients with pleural effusion (PE); a three-compartment model of mediastinal anatomy; photographs of a resected, well-encapsulated thymoma and a benign, multiloculated thymic cyst that were completely removed by sternotomy, a resected esophageal duplication cyst, and an esophageal leiomyoma being removed by means of a right thoracotomy; CT scans demonstrating the characteristic appearance of an invasive thymoma, an extragonadal germ cell tumor, a primary mediastinal B cell lymphoma, a goiter with extension behind the trachea, right paratracheal adenopathy in the middle mediastinal compartment, a middle mediastinal cystic mass, a large subcarinal bronchogenic cyst, a tracheal chondrosarcoma, gas in the mediastinum due to esophageal perforation, and mediastinal fibrosis; coronal imaging showing a large, smooth muscle tumor associated with the distal esophagus; a barium swallow showing a large esophageal perforation that resulted in soilage of the middle mediastinum; and posteroanterior and lateral CXRs of a posterior mediastinal neurogenic tumor accompanied by a CT scan showing the posterior mediastinal neurogenic tumor visualized in the posteroanterior radiograph. This review contains 19 figures, 51 tables, and 83 references. Keywords: Mediastinum, mediastinitis, pleural effusion, empyema, congestive heart failure, adenopathy, thymoma, esophageal perforation

Background To describe the hepatic arterial anatomy in detail, tracing the individual hepatic arteries from their origin, extrahepatic course, branching to their segmental territorial supply as applicable to the vascular mapping for hepatic endovascular procedures. Methods The study was conducted on 100 formalin fixed adult cadaveric livers. The hepatic arterial anatomy was dissected from the origin of hepatic arteries up to their segmental branching. Results The origin of hepatic arteries was standard in 72% and aberrant in 28% livers. In livers with standard origin, extrahepatic branching of the main hepatic artery was close to the hepatic hilum in 48% and was in the lower part of the hepatoduodenal ligament in 24% livers. The pattern of extrahepatic branching in each type was three and five respectively. Aberrant arterial anatomy was broadly categorized into three groups. The mapping of segmental arterial vascularization of individual hepatic arteries in each type was also done. Conclusions In the present study, an attempt was made to systematically describe the complex hepatic arterial anatomy in a clinically applicable fashion. High variability was seen in the hepatic arterial anatomy at each level, a lot of which could not be included in the current classification systems. The information provided is an important prerequisite for performing accurate intra-arterial hepatic interventions.

Background Laparoscopic surgery has been gradually promoted by people because of its advantages of small trauma and quick recovery. Methods However, the operation is difficult, the first hepatic portal should be completely fastened during the operation. In this paper, through the study of the existing structure of the blocker, a kind of blood flow blocker for the first hepatic hilum blocking under laparoscope is designed. All kinds of parameters were calibrated through equation calculation, and the pressure guiding the blood flow blocking of hepatic portal during operation was calculated. Results The dynamic analysis was carried out with ANSYS software, and it was found that the fluid movement state was most uniform when the airflow velocity reached 8 m/s. The experimental apparatus was set up to simulate the process of hepatic portal vein being blocked in vitro, then the feasibility of blocking effect was evaluated. Conclusions Finally, it is concluded that the designed blood flow blocking device can have good blocking effect on blood vessels.

Arterial supply of the kidney is by the Renal artery. These renal arteries are the Antero lateral branches of the abdominal Aorta at the L1 to L2 Inter vertebral disc level. During the dissection of Cadavers in the department of anatomy we observed more than one arterial supply to the kidney and a number of renal arteries showing early ramification before entering into the hilum of kidney. As per our study 70% of the kidneys are irrigated by single renal artery and 20 % irrigated by the extra renal arteries and 10% specimens showing early ramification. Variations in renal arterial pattern is more common. So it is useful to have awareness to prevent the surgical hazards because of anatomical consideration.

Introduction: The spleen is hypothesized to play a role in the autonomic nervous system (ANS)-mediated control of host defence, but the neuroanatomical evidence for this assumption rests on a sparse number of studies, which mutually disagree with respect to the existence of cholinergic or vagal innervation.Methods: We conducted an immuno- and enzyme-histochemical study of the innervation of the human spleen using a complete hilum-embedding approach to ensure that only nerves that entered or left the spleen were studied, and that all splenic nerves were included in the sampled area. Furthermore, a complete embedded spleen was serially sectioned to prepare a 3D reconstruction of the hilar nerve plexus.Results: All detected nerves entering the spleen arise from the nerve plexus that surrounds branches of the splenic artery and are catecholaminergic. Inside the spleen these nerves continue within the adventitia of the white pulpal central arteries and red pulpal arterioles. Staining for either choline acetyltransferase or acetylcholinesterase did not reveal any evidence for cholinergic innervation of the human spleen, irrespective of the type of fixation (regularly fixed, fresh-frozen post-fixed or fresh-frozen cryoslides). Furthermore, no positive VIP staining was observed (VIP is often co-expressed in postganglionic parasympathetic nerves).Conclusion: Our comprehensive approach did not produce any evidence for a direct cholinergic (or VIP-ergic) innervation of the spleen. This finding does not rule out (indirect) vagal innervation via postganglionic non-cholinergic periarterial fibres.

Introduction: The knowledge of the accessory renal arteries has grown importance with the increasing number of renal transplants and other uroradiological procedures and for surgeons in view of nephrectomy and segmental renal resections. Renal artery variations include their origin, number and course. The most common is the presence of additional vessels. There may be several renal arteries or veins on each side or the renal artery may divide close to its origin into several branches. Aim and Objective: To study morphological variations and anomalies in the renal vasculature of Kidney. Material and Method: In order to facilitate the clinical approaches, we studied renal vascular pattern in 50 embalmed cadavers during the period of two years to establish the incidence of additional renal vessels in human cadavers and to understand the abnormalities of anatomical and embryological variations. Results: In our study we found, renal artery passing anterior to renal vein. Study also showed that accessory renal arteries arising from aorta are passing few to the upper pole, few to the lower pole unilaterally and few showed the same variation bilaterally. Early segmental branches of renal artery before entering the kidneys were also found in our study. Renal vein passing behind the abdominal aorta in one case and two or more renal veins at the hilum of kidney were also found in our study. Conclusion: Total renovascular variations were found in 42.42% cadavers. Detailed review of the literature shows that variations of renal arteries are more common than the renal veins, but in present study we found variations of renal veins (27.27%) more than the renal arteries(12.12%). A detailed knowledge of variations of renal vessels is obligatory for the safe performance of endovascular, laparoscopic, uroradiological procedures, renal transplants, clamping of vessels during partial nephrectomy and abate the complications in various procedures.

Lobectomy of the lung is performed for primary lung cancer with individual ligation of the pulmonary vasculature and bronchus along with division of the fissures. Recent estimates claim nearly 30% of lobectomy cases are performed in a minimally invasive fashion, the robotic approach of the nonrobotic minimally invasive option may have some advantages that includes a potentially more oncologic resection, less instrument movement at the chest wall that may result in less trauma to nerves and, thus, potentially less postoperative discomfort, and a simpler technique to learn and teach, more closely approximating the moves of surgery by thoracotomy. The operative setup and surgical details for each of the five lobes is described and illustrated, outlining the technique to divide the hilar structures first and then to divide the fissures. Over the 15 years of performing the technique, particular learning points are described.

OBJECTIVES To minimize air leak after anatomical lung resections, many video-assisted thoracic surgery (VATS) surgeons use a 'fissureless' technique, using staplers to divide the hilar bronchovascular structures first and the main part of the fissure last. We describe a cohort of 198 consecutive patients operated with an alternative fissureless technique, opening the fissure completely with staplers at an early stage of the VATS anatomical lung resection. METHODS To open the incomplete fissure first and with staplers, a tunnel dissection is started anterior between the triangle of pulmonary veins and the parenchyma. After identification of the pulmonary artery, the anvil of a first stapler is placed on top of the artery and the anterior part of the fissure is divided. Dissection between artery and parenchyma is continued until the fissure is completely stapled. From a prospectively managed single institution database, we retrieved 405 patients scheduled for VATS anatomical resection between October 2009 and December 2014. The patients were categorized in four consecutive periods: a learning curve with the first 50 cases of VATS lobectomy technique (LC), a period of consecutive 'hilum first, fissure last' (HF), a transition group (TG) during which both techniques were used and a period of consecutive 'fissure first, hilum last' (FF). RESULTS No significant differences in operating time, frequency of prolonged air leak or hospital stay were observed between HF (n = 45) and FF (n = 198). Chest tubes were removed earlier in the FF period (6.9 vs 5.2 days, P = 0.025). Excluding the learning curve, we found 2 patients (2.8%) operated 'hilum first' with an intraoperative complication that potentially could have been avoided by a 'fissure first' technique. CONCLUSIONS By making a tunnel between the bronchovascular structures and parenchyma from anteriorly to posteriorly, one can open the fissure completely with staplers at an early stage of an anatomical lung resection. This combines the advantages of both the 'fissureless' hilum first technique and classic (open) fissure first dissection, i.e. minimal air leak and optimal anatomical overview before bronchovascular structures are divided, potentially avoiding inadvertent transections. A cohort of 198 consecutive patients operated with this alternative fissureless technique demonstrates the feasibility and non-inferiority regarding hospital stay, chest tube duration, operation time and complications in comparison with the hilum first technique.

We present the case of a 64-year-old man who was referred to our service after sustaining a self-inflicted nail-gun injury to his chest. He received three nails penetrated into his chest. Computer tomography revealed no massive haemorrhage or damage to major vessels. He underwent an emergency sternotomy, two nails caused pericardial perforation and myocardial injury were noted easily and removed easily via sternotomy. Myocardial injury showed a trajectory near the junction of the left anterior descending artery and the diagonal artery with no significant bleeding appreciated. The third nail was deep in the lung parenchyma at the hilum. A pacemaker magnet was used to locate the third nail, which was subsequently removed. Our case demonstrates the use of magnets in emergency surgery, to locate and remove metallic foreign bodies.

Hepatic trisectionectomy is a challenge for surgeons. We describe a technique by combination of the Glisson pedicle method and anterior approach to perform hepatic trisectionectomy. In this technique, the Glisson pedicles are isolated above the hilar plate without hilar dissection. After dividing these pedicles, the hepatic hilum can be lowered more easily. With the hepatic hilum brought down, the following step of hepatic parenchyma transection using the anterior approach can be performed safely, avoiding accidental injury to the vessels and hepatic duct in the hilar plate. This technique provides a safe, easy way to perform hepatic trisectionectomy without warm ischemia injury to the remnant liver.

Our results were obtained on 24 cases, 12 plastic molds and 12 dissections, examining the relations between the branches of origin of the pulmonary veins, and of their roots and trunks with the corresponding bronchuses and arteries. We assessed the situation of the superior and inferior right pulmonary veins, of the superior, middle and inferior lobes pedicles, together with the general assessment of the right pulmonary pedicles. Same is on the left. We cannot speak of a general sample that applies to the broncho-pulmonary vascular pedicles or to the relations between the pulmonary veins and their branches with broncho-arterial elements, as they are quite varied; they are characteristic of each lung lobe and even segment, being unable to assess standard relations only in the hilum. When variation in number occurs, even into the hilum we may have altered relations. Also is quite common that vascular branches may pass from one lobe to another, as long as the pulmonary fissures are rarely complete.

Advances in the development of staplers for pulmonary vessels have contributed to safe and convenient procedures in thoracic surgery. However, adverse events (AEs) can occur during vascular stapling and cause fatal hemorrhage. We aimed to assess the risk level of using the vessel stapling procedure to reduce such AEs.First, an animal experiment using pig cardiopulmonary blocks was conducted. Pulmonary arteries were closed with staplers under stressful conditions such as lifting or twisting; vessel stump endurance was analyzed through different methods. Second, AEs associated with clinical stapler use for pulmonary vessels were retrospectively reviewed by studying clinical videos of 263 patients.In the animal experiment, the pressure resistance was significantly lower in the twisted group than in the no strain group (no strainThe pulmonary vessel stapling causes stress due to twisting and lifting that decreased stump durability. Avoiding such stress when using stapler for vessels leads to a safer thoracic surgery.

Among the variations of the renal system, abnormalities of structure and position of kidney along with the variations of renal vessels are reported most frequently. However, reports on rotational abnormalities and abnormal positions of renal hilum are scanty. During routine dissection of the posterior abdominal wall, laterally rotated kidneys with laterally facing hila were observed in about 60-year-old male cadaver. On right side, the hilum was more on the anterior surface of the organ and right renal vein was emerging almost from the middle of the anterior surface at the lateral edge of the hilum. However, the hilum of the left kidney was observed along the lateral border of the organ and left renal artery was crossing transversely anterior to the kidney forming a loop to reach the hilum. It was also observed that because of the lateral position of the hilum, the renal vessels and pelvis where passing over the anterior surface of the kidney. Rotational variations and abnormal locations of renal hilum are of importance in surgical procedures like percutaneous nephrectomy. Further clinical and surgical importance of the case is discussed in the paper.DOI: http://dx.doi.org/10.3126/ajms.v6i5.12414 Asian Journal of Medical Sciences Vol.6(5) 2015 82-84

Although the rabbit is routinely used as the animal model of choice to investigate cardiac electrophysiology, the neuroanatomy of the rabbit heart is not well documented. The aim of this study was to examine the topography of the intrinsic nerve plexus located on the rabbit heart surface and interatrial septum stained histochemically for acetylcholinesterase using pressure-distended whole hearts and whole-mount preparations from 33 Californian rabbits. Mediastinal cardiac nerves entered the venous part of the heart along the root of the right cranial vein (superior caval vein) and at the bifurcation of the pulmonary trunk. The accessing nerves of the venous part of the heart passed into the nerve plexus of heart hilum at the heart base. Nerves approaching the heart extended epicardially and innervated the atria, interatrial septum and ventricles by five nerve subplexuses, i.e. left and middle dorsal, dorsal right atrial, ventral right and left atrial subplexuses. Numerous nerves accessed the arterial part of the arterial part of the heart hilum between the aorta and pulmonary trunk, and distributed onto ventricles by the left and right coronary subplexuses. Clusters of intrinsic cardiac neurons were concentrated at the heart base at the roots of pulmonary veins with some positioned on the infundibulum. The mean number of intrinsic neurons in the rabbit heart is not significantly affected by aging: 2200 ± 262 (range 1517–2788; aged) vs. 2118 ± 108 (range 1513–2822; juvenile). In conclusion, despite anatomic differences in the distribution of intrinsic cardiac neurons and the presence of well-developed nerve plexus within the heart hilum, the topography of all seven subplexuses of the intrinsic nerve plexus in rabbit heart corresponds rather well to other mammalian species, including humans.

Endoscopic ultrasound (EUS) can demonstrate the detailed anatomy of the liver from the transgastric and transduodenal routes. Most of the liver segments can be imaged with EUS, except the right posterior segments. The intrahepatic vascular landmarks include the major hepatic veins, portal vein radicals, hepatic arterial branches, and the inferior vena cava, and the venosum and teres ligaments are other important intrahepatic landmarks. The liver hilum and gallbladder serve as useful surface landmarks. Deciphering liver segmentation and anatomy by EUS requires orienting the scan planes with these landmarkstructures, and is different from the static cross-sectional radiological images. Orientation during EUS requires appreciation of the numerous scan planes possible in real-time, and the direction of scanning from the stomach and duodenal bulb. We describe EUS imaging of the liver with a curved linear probe in a step-by-step approach, with the relevant anatomical details, potential applications, and pitfalls of this novel EUS application.

Context: There is a variation in the arrangement of structures at hilum which may create problem for the surgeon during dissection of hilum of kidney. Moreover, developmental anomalies like, constriction at pelviureteric region, double renal pelvis, accessory renal arteries etc are not uncommon. So, adequate anatomical knowledge of kidney specially at hilum is required for successful surgery of this reason. Objective: To study the variation in the arrangement of renal vessels and renal pelvis at hilum. Study design: Descriptive type. Place and period: Department of Anatomy, Mymensingh Medical College, Mymensingh, Bangladesh from January 2004 to June 2005. Materials and methods: A total of 100 fresh human kidneys of both sexes and sides were collected from the morgue of Mymensingh Medical College at postmortem. The selected cases were between 5 to 60 years of age. The samples were preserved to observe the variations in the arrangement of main structures at hilum of kidneys regardless of age groups. Results: When hilum of the kidneys viewed before backwards, anteriorly and at the middle, there was 1% variation in the arrangement of renal vessels but posteriorly renal pelvis was found in variably and it was double in 2% of kidneys. Posterior division of renal artery was present behind the renal pelvis in 12% of kidneys. Conclusion: Variation in the arrangement of structures at hilum was observed in 1% of kidneys. DOI: http://dx.doi.org/10.3329/bja.v10i2.17322 Bangladesh Journal of Anatomy, July 2012, Vol. 10 No. 2 pp 76-79

Introduction Proper knowledge of variations of the vessels of the kidney is essential to radiologist and surgeons. Methods One such variation was observed during dissection of a 68-year-old male cadaver at Medical College, Kolkata. The cadaver was preserved and dissected by following proper steps. Observation On right side in addition to normal renal artery, an additional renal artery originated from the abdominal aorta and entered into the kidney through the lower part of its hilum. The additional renal vein emerged from the lowermost point of the hilum, passed medially to end in the posterior part of inferior vena cava below the opening of normal right renal vein. Conclusion The comprehensive knowledge of different vascular patterns is the key issue in determining the technical feasibility of different surgical interventions.

The congenital anomalies of kidney are important as they may cause renal failure in middle age group. The horseshoe kidney is the most common congenital fusion anomaly in which both kidneys were fused at their lower poles by an isthmus in front of the inferior vena cava and the abdominal aorta. We present a case report of horseshoe kidney with long hilum opened anteriorly and extrarenal calyces in the left kidney along with an accessory renal artery arising from the aorta, supplied to lower pole of the left kidney and there was a separate renal vein opening into the inferior vena cava. The knowledge of horseshoe kidney with accessory renal vessels and extrarenal calyceal