Gene L. Colborn

Elevated basilic vein arteriovenous fistula

BACKGROUND Many surgeons continue to use prosthetic arteriovenous grafts for dialysis access despite the clear superiority of native arteriovenous fistulas. This study was undertaken to review our experience with elevated brachial-basilic fistulas as an alternative to prosthetic grafts in patients lacking veins suitable for more conventional arteriovenous fistulas. METHODS We retrospectively reviewed the outcomes of 67 patients receiving elevated brachial-basilic arteriovenous fistulas over a 10-year period. Operative complications and causes of failure were identified and actuarial fistula patency determined. RESULTS No patients suffered wound infections, and only 1 developed a steal syndrome in the late postoperative period. Actuarial fistula patency was 84% at 1 year, 73% at 3 and 5 years, and 52% at 10 years. CONCLUSIONS The elevated brachial-basilic arteriovenous fistula is a superb alternative to prosthetic arteriovenous grafts in patients lacking suitable cephalic veins for native arteriovenous fistulas. Operative complications are uncommon, vascular steal is rare, and long-term patency is excellent.

Hepatic Surgery and Hepatic Surgical Anatomy: Historical Partners in Progress

Abstract. Whether for hepatic trauma or transplantation, a surgeon’s knowledge of hepatic anatomy commonly determines a patient’s outcome. The first medically relevant anatomic studies of the liver emerged with the endeavors of Herophilus and Erasistratus between 310 and 280 bc . Yet it was not until after the development of anesthesia and antisepsis that the first formal resections were performed during the late 1800s. After vascular occlusion principles had been developed as a means of successful hemorrhage control, several deliberate attempts were made to repair the liver surgically. Such efforts culminated in the work of Wendel in 1910 when he followed avascular planes during hepatectomy. The functional anatomy of surgery and surgical technique had suddenly joined in an effort to advance the practice, and eventually the efficacy of hepatic surgeons in facilitating the modern era of segmental anatomy extended hepatectomies and transplantation surgery.

The dimensions and vascular anatomy of the cricothyroid membrane: Relevance to emergent surgical airway access

Following traumatic injury, rapid surgical access to the airway may be required, with surgical cricothyroidostomy the procedure of choice. Immediate complications of cricothyroidostomy include unsuccessful or incorrect site of tube placement and hemorrhage. Subglottic stenosis is the most common late complication. This project was undertaken to better define the dimensions and vasculature of the cricothyroid region. In 15 cadaveric specimens, cervical dissection revealed the average width of the cricothyroid membrane visible between cricothyroid muscles to be 8.2 mm, and the average height 10.4 mm. Latex injection of the carotid artery demonstrated a transverse cricothyroid artery arising from the superior thyroid artery in 93% of cases. The cricothyroid artery crossed the upper one‐half of the cricothyroid membrane in all but one specimen. Branches of the cricothyroid artery penetrated the membrane and ascended along the undersurface of the thyroid cartilage. Unilateral superior thyroid artery injection demonstrated anastomoses between right and left cricothyroid arteries. In 54% of specimens, the superior thyroid artery coursed anterior to the sternothyroid muscle and then the lateral edge of the cricothyroid membrane. The membrane was also crossed by venous tributaries to the superior and inferior thyroid veins. To lessen the possibility of complications following cricothyroidostomy, a knowledge of the dimensions, relations, and vasculature of the cricothyroid membrane is of inestimable value.

OBTURATOR HERNIA: Embryology, Anatomy, and Surgical Applications

Obturator hernia is a rare clinical entity. In most cases, it produces small bowel obstruction with high morbidity and mortality. The embryology, anatomy, clinical picture, diagnosis, and surgery are presented in detail.

The Surgical Anatomy of the Spleen

The surgical embryology and anatomy of the spleen are reported with emphasis given to ligaments, blood supply, and segmentation. The anatomic entities involved with splenic surgery are presented. Surgical applications are emphasized. Knowledge of splenic anatomy and technique, with efforts to save the organ if possible, is paramount for good results.

Tribute to a Triad: History of Splenic Anatomy, Physiology, and Surgery—Part 2

By the early 1900s it was widely accepted that the efforts of Wells, Bryant, Kaznelson, and Micheli necessitated a surgical appreciation of the pathophysiologic activities of the spleen. The respect bestowed on the diseased spleen, however, did not cohere to its healthy prototype. What else could explain Du Bois-Reymond’s telling statement of the late 1800s: “Now we come to the spleen, of it we know nothing. So much for the spleen” [1]. The essential question remained: “Este igitur splenatam necessarius?” The answer continued to be “no” well into the twentieth century. Despite Du Bois-Reymond’s sentiments, this resounding “no” did not indicate a lack of physiologic knowledge. Sir William Osler once commented, “Of the physiology of the spleen we know really very little.” To this, he quickly added, “That it is concerned with the process of blood scavenging; that it acts as a sort of warehouse for blood pigments; and that its structure in parts indicates hematopoiesis—these are about the only functions which are recognized” [2]. In 1928 William Mayo added his opinions on the topic while imparting an immunologic role to the spleen as well. He wrote:

The surgical anatomy of the deep femoral artery

Lower extremity ischemia is a common disorder that in the majority of cases is associated with occlusion of the superficial femoral artery. The deep femoral artery is recognized as an important collateral pathway to the genicular arterial system, thus accounting for the appearance of symptoms only after its involvement in the disease process. Surgical exposure of the deep femoral artery is often necessary in vascular reconstructive procedures. Furthermore, because it supplies the bulk of the thigh musculature, plastic surgeons have shown great interest in the muscular branches of the deep femoral artery when designing procedures that incorporate myocutaneous flaps. This article gives a detailed account of the embryology, anatomical relations, important variations, and branches of the deep femoral artery. Recommendations for the surgical exposure of this artery at different levels are also presented.

Embryologic And Anatomic Basis Of Inguinal Herniorrhaphy

The embryology and surgical anatomy of the inguinal area is presented with emphasis on embryologic and anatomic entities related to surgery. We have presented the factors, such as patent processus vaginalis and defective posterior wall of the inguinal canal, that may be responsible for the genesis of congenital inguinofemoral herniation. These, together with impaired collagen synthesis and trauma, are responsible for the formation of the acquired inguinofemoral hernia. Still, we do not have all the answers for an ideal repair. Despite the latest successes in repair, we, to paraphrase Ritsos, are awaiting the triumphant return of Theseus.

Multiple variations of the hepatobiliary vasculature including double cystic arteries, accessory left hepatic artery and hepatosplenic trunk: a case report.

Anatomical variations in the origins and branching patterns of the hepatobiliary arterial system may be encountered during both conventional surgical and laparoscopic cholecystectomy. We report a rare case of double cystic arteries arising from both the right hepatic artery and the proximal part of the posterior superior pancreaticoduodenal artery. Additional variations consisting of an accessory left hepatic artery arising from a left gastric which in turn arose from the descending aorta superior to the origin of the celiac trunk and a small left hepatic artery arising from the hepatic proper artery were also noted. The celiac trunk bifurcated into the splenic artery and the common hepatic artery forming a hepatosplenic or lienohepatic trunk. The possible clinical implications are discussed.

Laparoscopic inguinal anatomy

SummaryIrrespective of the merits of laparoscopic herniorrhaphy, the anatomy of this surgical approach is poorly understood by most surgeons. To describe and document the normal analtomy and its variations, the inguinal region was dissected from peritoneum outward by the open method in 70 cadaveric sides and by the closed laparoscopic method in 28 cadaveric sides. In our results we describe the various layers, fossae, spaces and their contents. The data presented include variations of nerves in the inguinal area and measurements of bony landmarks from important neurovascular elements. In 74%, the distance from anterior superior iliac spine (ASIS) to pubic tubercle (PT) was 11 cm (10.0–14.0); in 56% ASIS to external iliac vessels was 6 cm (4.5–7.5 cm); ASIS to femoral nerve in 64% was 5 cm (3.0–7.5). The lateral femoral cutaneous nerve was found 1–4.5 cm medial to ASIS in 15%, increasing the possibility of nerve injury. In 25.5% the ilioinguinal nerve ran through the iliac fossa, in some cases passing through the iliopubic tract. In 18% the lateral femoral cutaneous and ilioinguinal nerves were combined, and in 7.7% the ilioinguinal and genitofemoral nerves were combined. It is critical for laparoscopic surgeons to be aware of the normal inguinal anatomy and its variants to avoid unnecessary injury and pain. It is important to remember that in approximately 30% of cases, the laparoscopic anatomy of one side will not be a mirror image of the other side.