B. Singh

Additional renal arteries : incidence and morphometry

Advances in surgical and uro-radiological techniques dictate a re-appraisal and definition of renal arterial variations. This retrospective study aimed at establishing the incidence of additional renal arteries. Two subsets were analysed viz. a) Clinical series-130 renal angiograms performed on renal transplant donors, 32 cadaver kidneys used in renal transplantation b) Cadaveric series - 74 en-bloc morphologically normal kidney pairs. The sex and race distribution was males 140, females 96 African 84, Indian 91, White 43 and “Coloured” 18, respectively. Incidence of first and second additional arteries were respectively, 23.2% (R 18.6% L 27.6%) and 4.5% (R 4.7% L 4.4%). Additional arteries occurred more frequently on the left (L 32.0% R 23.3%). The incidence bilaterally was 10.2% (first additional arteries, only). The sex and race incidence (first and second additional) was males, 28.0%, 5.1% females, 16.4%, 3.8% and African 31.1%, 5.4% Indian 13.5%, 4.5% White 30.9%, 4.4% and “Coloured” 18.5%, 0% respectively. Significant differences in the incidence of first additional arteries were noted between sex and race. The morphometry of additional renal arteries were lengths (cm) of first and second additional renal arteries 4.5 and 3.8 (right), 4.9 and 3.7 (left) diameters 0.4 and 0.3 (right), 0.3 and 0.3 (left). Detailed morphometry of sex and race were also recorded. No statistically significant differences were noted. Our results of the incidence of additional renal arteries of 27.7% compared favourably to that reported in the literature (weighted mean 28.1%). The study is unique in recording detailed morphometry of these vessels. Careful techniques in the identification of this anatomical variation is important since it impacts on renal transplantation surgery, vascular operations for renal artery stenosis, reno-vascular hypertension, Takayasu’s disease, renal trauma and uro-radiological procedures.

Left renal vein variations

The highly complex embryological development of the left renal vein compared to its right counterpart results in greater variations which are clinically significant. The study aimed to identify these variations and to document its incidence. Cadaveric study: 153 kidney pairs were harvested en bloc, dissected, 100 resin casts prepared and 53 plastinated; renal venography performed on further 58 adults and 20 foetal cadavers. Clinical study: (retrospective analysis): a) radiological study, 104 renal venograms; b) live related renal transplantation, 148 donor left kidneys; c) abdominal aortic aneurysm surgery, 525 patients. Total sample size: 1008. Renal collars observed in 0.3%; retro-aortic vein 0.5%; additional veins 0.4%; posterior primary tributary 23.2%, (16.7% Type IB; 6.5% Type IIB, cadaveric series, only). Our results differ significantly in incidence to that reported in the literature: renal collar 0.2-30%; retro-aortic vein 0.8-7.1%; additional renal vein 0.8-6%. Variations are clinically silent and remain unnoticed until discovered during venography, operation or autopsy. To a transplant surgeon, morphology acquires special significance, since variations influence technical feasibility of operation. Prior knowledge of circum-aortic vein is important when blood samples from suprarenal or renal veins are collected. Collar may provide developed collateral pathway immediately after surgery if renal interruption planned without awareness of its presence. Variations restrict availability of vein for mobilisation procedures. In aortic aneurysm repair, retro-aortic vein is important. During retroperitoneal surgery, the surgeon may visualise a pre-aortic vein but be unaware of an additional retroaortic component or a posterior primary tributary, and may avulse it while mobilising the kidney or clamping the aorta.

Left renal vein variations@@@Variations de la veine rénale gauche

SummaryThe highly complex embryological development of the left renal vein compared to its right counterpart results in greater variations which are clinically significant. The study aimed to identify these variations and to document its incidence. Cadaveric study: 153 kidney pairs were harvested en bloc, dissected, 100 resin casts prepared and 53 plastinated; renal venography performed on further 58 adults and 20 foetal cadavers. Clinical study: (retrospective analysis): a) radiological study, 104 renal venograms; b) live related renal transplantation, 148 donor left kidneys; c) abdominal aortic aneurysm surgery, 525 patients. Total sample size: 1008. Renal collars observed in 0.3%; retro-aortic vein 0.5%; additional veins 0.4%; posterior primary tributary 23.2%, (16.7% Type IB; 6.5% Type IIB, cadaveric series, only). Our results differ significantly in incidence to that reported in the literature: renal collar 0.2–30%; retro-aortic vein 0.8–7.1%; additional renal vein 0.8–6%. Variations are clinically silent and remain unnoticed until discovered during venography, operation or autopsy. To a transplant surgeon, morphology acquires special significance, since variations influence technical feasibility of operation. Prior knowledge of circum-aortic vein is important when blood samples from suprarenal or renal veins are collected. Collar may provide developed collateral pathway immediately after surgery if renal interruption planned without awareness of its presence. Variations restrict availability of vein for mobilisation procedures. In aortic aneurysm repair, retro-aortic vein is important. During retroperitoneal surgery, the surgeon may visualise a pre-aortic vein but be unaware of an additional retroaortic component or a posterior primary tributary, and may avulse it while mobilising the kidney or clamping the aorta.RésuméDu développement embryologique très complexe de la veine rénale gauche, comparé à son homologue droit, il résulte dimportantes variations, significatives du point de vue clinique. Le but de cette étude est didentifier ces variations et de préciser leur fréquence. 1-Recherches cadavériques : (153 paires de reins ont été prélevées en bloc, disséquées) 100 moulages par résines et 53 plastinations. En outre, des phlébographies rénales post-mortem ont été réalisées, 58 chez des adultes, 20 chez des fœtus. 2-Etudes cliniques (analyse rétrospective) : a) radiologiques : 104 veinogrammes rénaux, b) lors de transplantations rénales : 148 reins gauches de donneurs, c) au cours de la chirurgie de lanévrysme de laorte thoracique : 525 patients. Soit, au total, 1008 reins. Le collier rénal a été observé dans 0,3 % de la série ; la v. rétro-aortique, 0,5 %, des vv. rénales supplémentaires : 0,4 % ; enfin, un collecteur rénal postérieur existait dans 23,2 % des séries cadavériques (16,7 % du type IB de notre classification et 6,5 % du type II B). Nos résultats diffèrent de façon significative par leur faible fréquence de celle relatée dans la littérature : collier rénal (0,2–30 %), veine rétro-aortique (0,8–7,1 %), veine rénale supplémentaire (0.8–6%). Les variations sont silencieuses cliniquement et demeurent méconnues jusquà leur découverte par phlébographie, opération ou autopsie. Pour le chirurgien transplanteur, la morphologie a une signification particulière puisque les variations déterminent la faisabilité technique ou non de lopération. La connaissance préalable de la veine circum-aortique est importante lors du prélèvement déchantillons sanguins des veines surrénaliennes ou rénales. Le collier rénal peut favoriser la formation dun réseau collatéral dense immédiatement après lopération, si linterruption de la veine rénale est pratiquée sans connaissance de ce dispositif. Les variations restreignent lutilisation de la veine dans les techniques de mobilisation. Lors de la cure dun anévrysme aortique, lexistence dune veine rétro-aortique est importante à connaitre. Lors dune intervention rétro-péritonéale, le chirurgien repère la veine pré-aortique, mais il méconnait une branche rétro-aortique supplémentaire, ou un tronc primaire postérieur quil peut léser en mobilisant le rein ou en clampant laorte.

Thoracic origin of a sympathetic supply to the upper limb: the ‘nerve of Kuntz’ revisited

An understanding of the origin of the sympathetic innervation of the upper limb is important in surgical sympathectomy procedures. An inconstant intrathoracic ramus which joined the 2nd intercostal nerve to the ventral ramus of the 1st thoracic nerve, proximal to the point where the latter gave a large branch to the brachial plexus, has become known as the ‘nerve of Kuntz’ (Kuntz, 1927). Subsequently a variety of sympathetic interneuronal connections down to the 5th intercostal space were reported and also described as the nerve of Kuntz. The aim of this study was to determine: (1) the incidence, location and course of the nerve of Kuntz; (2) the relationship of the nerve of Kuntz to the 2nd thoracic ganglion; (3) the variations of the nerve of Kuntz in the absence of a stellate ganglion; (4) to compare the original intrathoracic ramus with sympathetic variations at other intercostal levels; and (5) to devise an appropriate anatomical classification of the nerves of Kuntz.

Conservative management of thoracobiliary fistula

BACKGROUNDnThoracobiliary fistulas are rare manifestations of biliary disruption. Given their rarity it is not surprising that there is little consensus on the optimal management of thoracobiliary fistulas.nnnMETHODSnPatients presenting with thoracobiliary fistulas over a 5-year period (1996 to 2001) were evaluated. Initial management was conservative with tube thoracostomy or drainage of sepsis when appropriate, or both; antibiotics and somatostatin were routinely administered. Endoscopic retrograde cholangiography was performed when symptoms persisted to delineate the thoracobiliary communication and undertake sphincteroplasty.nnnRESULTSnEight patients with a mean age of 31.9 years (range 15 to 42) were evaluated. Biliary effusion occurred in 3 patients after hepatic injury (n = 2) and percutaneous transhepatic cholangiography (n = 1). Bilioptysis occurred in 5 patients after hepatic abscess (n = 4) and hepatic injury (n = 1) The biliary effusion (n = 3) was successfully managed by endoscopic sphincterotomy in 2 patients; the third patient underwent urgent surgical biliary drainage. Bilioptysis (n = 5) was successfully managed in 3 patients; persistence of symptoms in 2 patients prompted surgical intervention.nnnCONCLUSIONSnThoracobiliary fistulas may be successfully managed using a conservative approach. Surgery should be reserved for persistence of symptoms after exhaustion of this approach.

Thoracic splanchnic nerves: implications for splanchnic denervation

Splanchnic neurectomy is of value in the management of chronic abdominal pain. It is postulated that the inconsistent results of splanchnicectomies may be due to anatomical variations in the pattern of splanchnic nerves. The advent of minimally invasive and video‐assisted surgery has rekindled interest in the frequency of variations of the splanchnic nerves. The aims of this study were to investigate the incidence, origin and pattern of the splanchnic nerves in order to establish a predictable pattern of splanchnic neural anatomy that may be of surgical relevance. Six adult and 14 fetal cadavers were dissected (n = 38). The origin of the splanchnic nerve was bilaterally asymmetrical in all cases. The greater splanchnic nerve (GSN) was always present, whereas the lesser splanchnic nerve (LSN) and least splanchnic nerve (lSN) were inconsistent (LSN, 35 of 38 sides (92%); LSN, 21 of 38 sides (55%). The splanchnic nerves were observed most frequently over the following ranges: GSN, T6–9: 28 of 38 sides (73%); LSN, when present, T10–11: (10 of 35 sides (29%); and lSN, T11–12: 3 of 21 sides (14%). The number of ganglionic roots of the GSN varied between 3 and 10 (widest T4–11; narrowest, T5–7). Intermediate splanchnic ganglia, when present, were observed only on the GSN main trunk with an incidence of 6 of 10 sides (60%) in the adult and 11 of 28 sides (39%) in the fetus. The higher incidence of the origin of GSN above T5 has clinical implications, given the widely discussed technique of undertaking splanchnicectomy from the T5 ganglion distally. This approach overlooks important nerve contributions and thereby may compromise clinical outcome. In the light of these variations, a reappraisal of current surgical techniques used in thoracoscopic splanchnicectomy is warranted.

Thoracoscopic splanchnicectomy: pilot evaluation of a simple alternative for chronic pancreatic pain control.

Abstract. Achieving adequate pain control in patients with chronic pancreatitis remains a surgical challenge. The quest for a procedure that retains all of the residual pancreatic tissue in the absence of ductal dilatation remains elusive. This study sought to evaluate the feasibility and efficacy of thoracoscopic splanchnicectomy and attempted to outline the surgical anatomy appropriate to an adequate denervation. Of 17 patients considered suitable for the procedure, 16 had a sucessful outcome, which was statistically significant (p < 0.001). The longest follow-up of 30 months suggests that the procedure may be more enduring than percutaneous procedures. However, the surgical anatomy is not predictable owing to the racemose arrangement of the splanchnic fibers, and a long pleurotomy with transection of all medial fibers is necessary to effect denervation. Thoracoscopic splanchnicectomy may effect immediate pain relief with negligible morbidity and absent mortality. Although the follow-up period is short, the patient with the longest follow-up remains pain-free at 30 months. This procedure warrants scrutiny for its role in long-term pancreatic pain control.

The sympathetic contributions to the cardiac plexus

Cardiac sympathetic denervation for intractable angina pectoris in patients unsuitable for conventional revascularization is currently gaining popularity since this procedure may be performed via minimally invasive surgery. A thorough understanding of cardiac innervation and its variations is crucial to successfully effect cardiac denervation. This study aimed to demonstrate the cervical and thoracic sympathetic contributions to the cardiac plexus. The cervical and thoracic sympathetic trunks in 21 fetuses and eight adults were micro-dissected bilaterally and documented (n=58 sides). The superior cervical cardiac ramus originated from the superior cervical ganglion (present in all specimens) in 53% of cases. The middle cervical ganglion (incidence 81%) gave rise to the middle cervical cardiac ramus in 88% of cases. The cervico-thoracic ganglion (incidence 85%) gave the cervico-thoracic cardiac ramus in 84%. In the thoracic region, four cardiac rami arose from the T2–T6 segment of the thoracic sympathetic trunk. All cervical and thoracic cardiac rami were traced consistently to the deep cardiac plexus. Khogali et al.s (1999) success of limited T2–T4 sympathectomy in relieving pain at rest of patients with intractable angina pectoris appears to indicate that a significant afferent pain pathway from the heart is selectively interrupted. The variability in pattern of the cervical ganglia, cardiac rami and cervical contributions to the cardiac plexus does not appear to affect the outcome of limited sympathectomy. The complexity of cardiac pain pathways is not fully understood. The study is continuing and attempts to contribute to defining these cardiac neuronal pathways.RésuméLa dénervation sympathique cardiaque pour angine de poitrine réfractaire chez les patients ne pouvant bénéficier dune revascularisation conventionnelle est en train de connaître un regain de popularité depuis que cette technique peut être réalisée en chirurgie minimalement invasive. Une compréhension approfondie de linnervation cardiaque et de ses variations est cruciale pour réaliser une dénervation cardiaque réussie. Cette étude avait pour but de démontrer les contributions sympathiques cervicale et thoracique au plexus cardiaque. Une microdissection bilatérale des troncs sympathiques cervico-thoraciques de 21 fœtus et de 8 adultes a été réalisée sous microscope et documentée (n=58 côtés). Le rameau cardiaque cervical supérieur naissait du ganglion cervical supérieur (présent dans tous les cas) dans 53% des cas. Le ganglion cervical moyen (présent dans 81%) donnait naissance au rameau cardiaque cervical moyen dans 88% des cas. Le ganglion cervico-thoracique (fréquence 85%) donnait naissance au rameau cardiaque cervico-thoracique dans 84% des cas. Dans la région thoracique, 4 rameaux cardiaques naissaient du segment T2–T6 du tronc sympathique cervical. Tous les rameaux cardiaques cervicaux et thoraciques étaient suivis jusquau plexus cardiaque profond. Les succès enregistrés par Khogali et al. avec une sympathectomie limitée à T2–T4 pour la sédation de la douleur au repos des patients présentant une angine de poitrine réfractaire, semblent indiquer quune importante voie afférente de la douleur du cœur est interrompue de façon sélective. La variabilité dans lorganisation des ganglions cervicaux, des rameaux cardiaques et des contributions du plexus cervical au plexus cardiaque ne semble pas avoir dimpact sur le résultat de la sympathectomie limitée. La complexité des voies de la douleur cardiaque nest pas complètement comprise. Létude est à poursuivre et vise à contribuer à définir les voies nerveuses du cœur.

Pitfalls in thoracoscopic sympathectomy: mechanisms for failure.

The technical ease of thoracoscopic sympathectomy has established this as the procedure of choice for upper-limb sympathectomy. Notwithstanding the invariable success of this procedure, those rare instances of unsuccessful sympathectomy are disconcerting to the surgeon. Unsuccessful sympathectomy manifests as persistent or recurrent sympathetic activity after a seemingly successful procedure. The causes of this phenomenon include misinterpretation of the sympathetic chain at thoracoscopy, regeneration of the sympathetic chain, and alternate neural pathways via the nerve of Kuntz. With the large numbers of sympathectomies being undertaken, the few instances of unsuccessful sympathectomy have prompted a review of this subject. Although alternate neural pathways may have little significance when a T2 ganglionectomy is undertaken, anatomic misinterpretation of the sympathetic chain is an important yet under-recognized cause of an unsuccessful sympathectomy. Sympathetic nerve regeneration remains extremely uncommon. Persistent and recurrent sympathetic activity may be successfully managed by resympathectomy performed thoracoscopically.

Anatomical variations of the second thoracic ganglion

In recent years the second thoracic ganglion has gained anatomical significance as an important conduit for sympathetic innervation of the upper extremity. Thoracoscopic excision of the second thoracic ganglion is now widely recognized as affording the most effective treatment option for palmar hyperhidrosis. This study recorded the incidence, location and associated additional neural connections of the second thoracic ganglion. Bilateral dissection of 20 adult cadavers was undertaken, and all neural connections of the second thoracic ganglion were recorded. Nineteen cadavers (95%) demonstrated additional neural connections between the first thoracic ventral ramus and second intercostal nerve. These were classified as either type A (47.5%) or type B (45%) using the intrathoracic ramus (nerve of Kuntz) between the second intercostal nerve and the ventral ramus of the first thoracic nerve as a basis on both right and left sides. The second thoracic ganglion was commonly located (92.5%) in the second intercostal space at the level of the intervertebral disc between the second and third thoracic vertebrae. Fused ganglia between the second thoracic and first thoracic (5%) and stellate (5%) ganglia were noted. These findings should assist the operating surgeon with a clear knowledge of the anatomy of the second thoracic ganglion during thoracoscopic sympathectomy with a view to improving the success rate for upper limb sympathectomy.