Marius Fahrer

Mobilization of the Rectum Anatomic Concepts and the Bookshelf Revisited

INTRODUCTION: Sound surgical technique is based on accurate anatomic knowledge. In surgery for cancer, the anatomy of the perirectal fascia and the retrorectal plane is the basis for correct mobilization of the rectum to ensure clear surgical margins and to minimize the risk of local recurrence. METHODS: This review of the literature on the perirectal fascia is based on a translation of the original description by Thoma Jonnesco and a later account by Wilhelm Waldeyer. The Jonnesco description, first published in 1896 in French, is compared with the German account of 1899. These were critically analyzed in the context of our own and other techniques of mobilizing the rectum. CONCLUSIONS: Mobilization of the rectum for cancer can be performed along anatomic planes with minimal blood loss, preservation of the pelvic autonomic nerves and a low prevalence of local recurrence. Different techniques including total mesorectal excision are based on the same anatomic principles, however, popular words have been used to replace accepted, established terminology. In particular, the description of total mesorectal excision has been confusing because of its emphasis on the words “total” and “mesorectum.” The use of the word “mesorectum” anatomically is inaccurate and the implication that total excision of all the perirectal fat contained within the perirectal fascia “en bloc” in all patients with rectal cancer will minimize local recurrence remains contentious.

The anatomy of the pubic region revisited: implications for the pathogenesis and clinical management of chronic groin pain in athletes.

Chronic groin pain is a common complaint for athletes participating in sports that involve repetitive sprinting, kicking or twisting movements, such as Australian Rules football, soccer and ice hockey. It is frequently a multifactorial condition that presents a considerable challenge for the treating sports medicine practitioner. To better understand the pathogenesis of chronic groin pain in athletes, a precise anatomical knowledge of the pubic symphysis and surrounding soft tissues is required. Several alternative descriptions of pubic region structures have been proposed. Traditionally, chronic groin pain in athletes has been described in terms of discrete pathology requiring specific intervention. While this clinical reasoning may apply in some cases, a review of anatomical findings indicates the possibility of multiple pathologies coexisting in athletes with chronic groin pain. An appreciation of these alternative descriptions may assist sports medicine practitioners with diagnostic and clinical decision-making processes. The purpose of this literature review is to reappraise the anatomy of the pubic region, considering findings from cadaveric dissection and histology studies, as well as those from diagnostic imaging studies in athletes.

Should there be a national core curriculum for anatomy

Are medical students taught enough anatomy? It is now abundantly clear that there are serious concerns about the level of anatomy taught to medical students. Concerns have been expressed by the students themselves, by those responsible for training procedural specialities and by the community at large. Currently, a sufficient knowledge of Anatomy is assumed by certain medical educationalists. However, Craig et al., in a unique and timely survey detailing issues in teaching anatomy to medical students in Australia and New Zealand, demonstrate convincingly that this is not always the case. Their survey is unique because it sheds light on what is actually taking place at the teaching coal face, and it is timely, given that the theme of the recent annual scientific meeting of the Australian and New Zealand Association of Clinical Anatomists (ANZACA) held at Monash University was anatomy education. The ANZACA meeting included a forum exploring the need for agreed, national core curricula in anatomy for students in professional courses. It is no accident that anatomy education galvanized the establishment of ANZACA in 2004 and that clinical anatomy is the future of anatomy. This is also of direct interest to surgeons with implications for the college and postgraduate surgical training. The findings of a mailed questionnaire sent to all 21 Australian and New Zealand medical schools by staff at the University of Wollongong, Graduate School of Medicine are not altogether surprising, although informative and remindful for they resonate with the concerns previously expressed by contributors to this journal. These were in response to the invited comments made by one of us almost a decade ago lamenting the decline of dissection-based teaching of anatomy in medical curricula. This followed the introduction of graduate medical programmes with shorter courses and a broader mix of students (including some from non-science backgrounds) as well as the adoption of problem-based learning (PBL) to ensure integration and to more adequately deal with the rapid expansion of medical knowledge. The radically changed educational approaches commencing from the mid-1990s resulted in a very significant reduction in total contact teaching time for all preclinical disciplines, especially anatomy, with the consequent loss of cadaver dissection and viva vocé examinations, once the major drivers for learning, teaching and assessing this subject. The ensuing debate as to how, when and what anatomy to teach medical students has generated considerable interest with lively correspondence, often anecdotal, and with little factual information. This is now largely redressed by the findings of the survey by Craig et al. Indeed, despite the use of prosected specimens, models, body painting, innovative computer simulation and radiology imaging, including computerized tomography and ultrasonography, it has to be said that the loss of the opportunity for cadaver dissection was a serious deficit and a concern to many, including the students themselves. The sentiment from both the Craig et al. paper and the ANZACA forum is that anatomy must be reinstated primarily (though not exclusively) as a ‘stand-alone’ subject within the framework of PBL curricula. This could include dissection and not just as an ‘option’. Furthermore, with the dissolution of the Anatomical Society of Australia and New Zealand in 1996 (until resurrected as ANZACA in 2004), the onus seemed to be on the college to set the agenda, to safeguard content and standards and even to fill the gap by providing teachers capable of teaching the subject. What is the state of play now, and what needs to be performed in the short to medium term? These are important considerations in the debate given that many medical students (who are now recent graduates) felt very insecure about their anatomical knowledge, especially those considering future surgical careers; the critical loss of medically qualified teachers from anatomy departments who are capable of teaching clinically relevant anatomy and the alarm this continues to generate in the press. The most important finding of the survey by Craig et al. was the considerable variation in all aspects of the teaching of anatomy throughout Australasian medical schools. Currently, the average time allocated to anatomy according to the survey is 171 h (standard deviation (SD) ~117), mainly delivered in the early years of the course, typically using a combined regional/systemic approach. It seems to us that given a mean contact time of about 170 h throughout the course, if 130 h of that was ‘stand-alone’ anatomy (see Table 1), this would enable time within practical classes to include targeted dissection (and even incorporate the anatomical basis of clinical procedures that can be required of a first port of call doctor). The 40 h not designated as ‘stand alone’ anatomy ideally should be integrated (including within PBL tutorials) and also permeate later years of the course.

Undiagnosed fracture in a common foot variant: the biphalangeal little toe.

The biphalangeal little toe is an anatomical anomaly that has been previously well described in the early anatomical literature. But, as is the case with many anomalies, there is a lack of awareness of it amongst current clinicians. We report the case of a fracture through the distal phalanx of the little toe, with a delay in the diagnosis due to confusion over the X-ray findings. X-rays revealed a biphalangeal toe with a fracture through the distal phalanx, which mimicked the usual triphalangeal toe. This is the first reported case of clinical confusion over this anatomical variation. A review of 102 human skeletal feet at the Department of Anatomy, University of Melbourne, was performed to evaluate the frequency of the biphalangeal little toe variant, revealing an incidence of 26%.

Bartholomeo Eustachio − the third man: Eustachius published by Albinus

In 1744, Albinus from Leyden, the most illustrious anatomist of his time, published, with ample comments, the long lost anatomical Tables of Eustachius. Engraved on copper plates in 1552, these tables illustrated the results of the dissections of Eustachius. Albinus considered this work to be vastly superior to that of Vesalius, first published in 1543. The rivalry between the famous and flamboyant Vesalius and the almost unknown Eustachius marked the official acceptance of dissection of the human body as a legitimate research and teaching method. The tale unfolds against a backdrop of Renaissance and Reformation effervescence, with Popes, Kings and an Emperor playing a direct or indirect part in the development of anatomy as a science.

Art macabre: Is anatomy necessary: Reply

The late Sir Sydney Sunderland, Professor of Anatomy at Melbourne University, would be writhing in his grave and threatening resurrection by some mystical force if he knew that ‘postmodernism’ had invaded the teaching of anatomy in his former precincts. Sunderland was a charismatic genius who delivered spellbinding lectures of great eloquence using only his voice, coloured chalks and a blackboard. He was also a fervent advocate of a two year stint of cadaver dissection for all medical students and regarded this as essential for surgeons. Sunderland looked many a student in the eye and said, ‘ The surgeon must know his way around ’. Over the ages acquisition of cadavers has always been a contentious practice. Yet even the most macabre efforts to obtain bodies pale into insignificance in comparison to the everyday atrocities of the modern world. In addition, the good enabled by the use of cadavers far outweighs the distasteful aspects. It was crucial to the work of the Hunter brothers and thus contributed to the establishment of modern British surgery. At a recent hand surgery meeting the audience was treated to a high-tech demonstration of the anatomy of the wrist joint. The computer-based presentation utilized simulation, models, graphic design and a professional narrator. It was superb and won a prize. As a vision of carpal anatomy and dynamics is was true and a win for postmodernism. But for a practising surgeon dissecting a palmar ganglion stalk tentacling its way towards dorsolateral ligaments it was not a true picture of the real anatomy of the wrist ligaments. These ligaments are notoriously difficult to delineate. This writer would not demean the rightful place of simulation in teaching, especially in situations in which simulation approximates ‘real’ situations. Flight simulators can accurately mimic the physical sensations caused, for example by unexpected descent due to engine failure. The situation is similar for cardiopulmonary resuscitation. Deep-seated neurosurgical dissection, cardiac surgery and many other cases are amenable to simulation because of the mediating significance of display and endoscopic instrumentation. Other examples, such as microsurgery, seem to require both traditional anatomical knowledge and laboratory simulation of neurovascular anastomosis. However, many surgical techniques are more vagarious due to the almost infinite variations in human anatomy. Dissection of a pancreatic or other deep tumour is a more difficult proposition and could not be adequately simulated. Would a surgeon of the calibre of Norman C. Tanner, feeling by tactile gnosis around the lesser sac, or, for that matter, D.G. Bradman, have learned the precisions of their skills without decades of practise with the ‘real thing’.

CHEMISTRY OF ANTOINE BAUMÉ (1774)

The book (Fig. 1) Chymie Expérimentale et Raisonnée 1 is the result of many years of solid, honest and meticulous work. Antoine Baumé (1728–1804) aimed at debunking alchemy and making chemistry into ‘a science based on experience: its object is the analysis or decomposition of all bodies in nature and the recombination of all these bodies or of their principles, to form new compounds’. Born in 1729, in Senlis, Antoine Baumé moved to Paris where he became a Master Apothecary in 1752. His scientific work, inter alia the description of an alembic to make brandy and the invention of the areometer, an instrument for measuring the density of fluids (still used today to measure the alcohol content in liquor or the acid in car batteries) led to his election to the Royal Academy of Sciences. Ruined by the French revolution, he was elected in 1796 Member of the Institute of France and died, honoured by his peers, in 1804. 2