K. S. Satyapal

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.

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.

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.

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.

Bilateral styloid chain ossification: case report.

The styloid chain is defined as the styloid process of the temporal bone, the stylohyoid ligament and the lesser cornua of the hyoid bone. Unusually long, incidental bilateral styloid chain ossification is described. This paper is presented for its unusual incidence, unusual length, the presence of ossification rather than calcification and its embryological correlation. Brief mention is made on the embryology and clinical significance of this condition.

Duplicate gallbladder: an unusual case report.

Duplication of the gallbladder, a rare congenital anomaly, is important in clinical practice as it may cause some clinical, surgical and diagnostic problems. In this report we present a case of duplicated gallbladder diagnosed serendipitously in a 63-year-old male patient who had previously undergone successful laparoscopic cholecystectomy (confirmed histologically) approximately a year before for gallstones. The patient was re-admitted with obstructive jaundice. An abdominal computed tomography scan and magnetic resonance cholangiogram both revealed the presence of a gallbladder, which was thereafter removed at surgery undertaken to palliate the jaundice.

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.

Congenital absence of the gall bladder

Congenital absence of the gall bladder is an extremely rare embryological aberration with a reported incidence ranging between 0.013 and 0.075%. This report, the first from South Africa, discusses 2 cases of gall bladder agenesis, bringing to 413 the number of cases reported in the literature. In confirming the diagnosis of an agenesis of the gall bladder, it is necessary to exclude the abnormal locations which are intrahepatic, retrohepatic, on the left side, or within the lesser omentum or falciform ligament and retroperitoneal. Patients with gall bladder agenesis are classified into 3 categories: i) Multiple foetal anomaly (12.9%), ii) Asymptomatic (31.6%) and iii) Symptomatic (55.6%). Notwithstanding current diagnostic modalities, this rare condition may still present a dilemma to the abdominal surgeon. Agenesis of the gall bladder is a well-recognised but uncommon congenital abnormality. With the advent of minimal access surgery laparotomy may be avoided as the condition, when suspected, may be confirmed by ERCP and CT scan.

Morphometry of the internal thoracic arteries

The surgical significance of the internal thoracic arteries (ITA’s) in procedures such as coronary artery bypass grafting, transverse rectus abdominis myocutaneous flaps and minimal incision direct coronary artery bypass surgery is well recognised. However, the detailed morphometry of these vessels is not well documented. This study aimed to detail the morphometry of the ITA’s. Morphometric analysis of these vessels from post mortem en-bloc specimens, consisting of aortic arch, great vessels and ITA’s with anterior chest wall was conducted on 62 adults. The mean lengths and diameters of the ITA’s at the origin, costal cartilage levels and termination were: length of the right ITA, 18.05 ± 0.6 cm and the left, 18.085 ± 0.6 cm. The average diameters recorded at the origin, first costal cartilage, fourth costal cartilage and termination were: right : 3.24 ± 0.5 mm; 2.85 ± 0.4 mm; 2.33 ± 0.6 mm; 1.98 ± 0.2 mm and left: 3.05 ± 0.4mm, 2.67 ± 0.3 mm; 2.22 ± 0.3 mm; 1.92 ± 0.2mm respectively. Morphometry of the ITA’s are detailed. There was no significant difference in length between right and left ITA’s although differences between the race groups were demonstrated. Significant differences in diameters in sides and race exist.