Petros Mirilas

Microsurgical subinguinal varicocelectomy in children, adolescents, and adults: surgical anatomy and anatomically justified technique.

Microsurgical varicocelectomy has become the gold standard in adults because of low recurrence and postoperative hydrocele rates; it is increasingly applied in children and adolescents. This review aims to provide the surgeon with the necessary surgical anatomy of the spermatic cord and with a step-by-step, anatomically justified description of technique, toward clearer comprehension and improved application. The anatomic compartments of the spermatic cord are delineated by the external and internal spermatic fasciae. Venous drainage of testis-epididymis is accomplished by the internal spermatic, deferential, and external spermatic (cremasteric) veins. All 3 anastomose at the caudal pole of testis, and then via gubernacular veins with the posterior scrotal veins. Another anastomosis exists between a cremasteric branch and anterior scrotal veins, which gives the external pudendal vein. Subinguinal approach offers access to varicose spermatic veins and collaterals. Use of surgical microscope offers identification of small veins, preservation of arteries, lymphatics, and nerves, and appreciation of spermatic cord fasciae, which permits the development of two surgical planes. In the surgical plane of internal spermatic vessels, internal spermatic veins are ligated, whereas the testicular artery and innervation, as well as lymphatics, are preserved. In the plane of cremasteric vessels and vas, cremasteric veins are ligated, whereas the cremasteric artery, vas deferens and its vasculature, lymphatics, and the genital branch of genitofemoral nerve are preserved. Delivery of the testis to ligate gubernacular veins is at the discretion of the surgeon. Finally, venous return is effected by deferential and scrotal veins, or, when gubernacular veins are ligated, by deferential veins only.

“To Afford the Wounded Speedy Assistance”: Dominique Jean Larrey and Napoleon

Dominique Jean Larrey (1766–1842) has been described as the father of modern military surgery and is considered even today as the model military surgeon. He developed a plan of rapid evacuation of wounded soldiers from the battlefield during combat, using flexible medical units which he named ambulances volantes (“flying ambulances”). He won the admiration of Napoleon Bonaparte (1769–1821), who was amazed by the results of Larrey’s sanitary system. Larrey spent almost 18 years with Napoleon, accompanying him in 25 campaigns, 60 battles, and more than 400 engagements. Napoleon’s enormous military success was due not only to his strategy and skill but also to the medical services provided by Larrey. The surgeon became a master of wound management and limb amputation. In his vivid battlefield journals, Larrey documented the course of tetanus, the pathophysiology of cold injury, the effective control of hemorrhage, the drainage of empyema and hemothorax, the aspiration of pericardial effusion or hemopericardium, and the packing of sucking chest wounds. Larrey established a categorical rule for the triage of war casualties, treating the wounded according to the observed gravity of their injuries and the urgency for medical care, regardless of their rank or nationality.

Secondary Internal Inguinal Ring and Associated Surgical Planes: Surgical Anatomy, Embryology, Applications

m third inguinal ring—referred to in this paper as the secndary internal inguinal ring—is found internal to the nternal inguinal ring. In the few articles devoted to it, the econdary internal inguinal ring bears various names: in ddition to “secondary internal inguinal ring,” it is reerred to as “deeper internal ring,” “preperitoneal fascial ing,” “preperitoneal ring,” and “internal ring” (the ring lassically named “internal” was called “middle” in this ase). An “intermediate inguinal ring” has been described xternal to the inguinal ring. This multiplicity of terms eflects the confusion about the concept of the surgical lane in which this ring is located. After a critical review of he relevant literature, we will present the surgical anatomy nd embryology of the secondary internal inguinal ring nd the associated fasciae. Important everyday applicaions, such as the repair of inguinal hernia (pediatric or dult, open, or laparoscopic), orcheolysis/orchiopexy, and he search for impalpable testis, are testimony to the need or a thorough understanding of the ring, which is signifiant not only to academia but also, mainly, to the field of attle, ie, the operating room.

Long-term outcomes following 282 consecutive cases of infrapopliteal PTA and association of risk factors with primary patency and limb salvage.

We aimed to determine the long-term results after infrapopliteal PTA (primary patency, limb salvage, survival) and examine for association with risk factors (e.g. diabetes, infection, etc). We studied 268 patients with 282 critically ischemic limbs treated with PTA of at least one crural artery during a six-year period. Data included TASC II morphological classification of lesions and risk factors. Technical success rate was 97.2%, and overall mortality 0.7%. Patients with milder TASC lesions preserved primary patency longer than patients with more severe lesions. Similar results were obtained for limb salvage and survival. Fontaine stage, TASC class and postoperative infection of operated limb increased the risk for loss of primary patency and major amputation. Concomitant carotid stenosis was associated with loss of primary patency. Diabetes mellitus, preoperative ulcer or gangrene were associated with need of major amputation. PTA was a safe and effective treatment for CLI due to lesions of infrapopliteal vessels.

Testis Rigidity Tester: A prototype device for intraoperative detection of changes in testicular pressure and/or elasticity. First experimental experiences *

OBJECTIVEnIn order to quantitatively evaluate testicular consistency, we designed a device for measurement of testis rigidity, which reflects the resistance caused by testicular pressure and elasticity. The device was tested in experimental models of cryptorchidism and torsion.nnnMATERIALS AND METHODSnThe Testis Rigidity Tester (TRT) prototype consists of a system of weights and levers. It measures the force needed for a known deformation of the testis, defined as rigidity. We inhibited testis descent in 10 18-day-old Lewis rats; another 10 age-matched rats underwent sham operation. At the age of 40 days we measured testicular rigidity using the TRT. Additionally, left testes of eight adult Lewis rats underwent 720 degrees torsion; rigidity was measured by the TRT before and 1h after torsion. To investigate repeatability of TRT measurements, the rigidity of five twisted testes was measured 10 times by three researchers.nnnRESULTSnThe TRT revealed a significant decrease of rigidity in undescended testes and an increase in twisted testes. Measurements were repeatable, independent of the observer.nnnCONCLUSIONnThe TRT is a safe, reliable and objective device that successfully measured the altered rigidity in experimental models of testicular disease.

DO NOT GET LOST IN THE SPACES OF THE SPERMATIC CORD DURING SUBINGUINAL MICROSURGICAL VARICOCELECTOMY

4 9 6 B J U I N T E R N A T I O N A L

Grades of Zuckerkandl's tubercle in normal thyroids.

I read with great interest the article by Yalçın et al., an anatomical study of Zuckerkandl’s tubercle (ZT) in nondiseased thyroids that utilizes the size grading system for diseased thyroid invented by Pelizzo et al. in 1998. Previously, only Musajo et al. reported ZT with mean dimensions 6 × 9 × 8 mm in specimens without thyroid disease, evidently ignoring Pelizzo’s system. Originally, Zuckerkandl (1902) described a 15-mm long tubercle. We herein examine how Pelizzo’s system applies to normal thyroids. We applied chi-square tests to Table 2 of Yalçın et al. The overall reported presence of ZT (86.2%) was signifi cantly higher than in Pelizzo et al. (77%, P = 0.032), and Gauger et al. (63%, P < 0.001) (Hisham and Aina merged grades 0 and 1; comparison was impossible). This outcome is puzzling: ZT, a “constant” anatomical characteristic of normal thyroids, was found less frequently in diseased thyroids. One can defend that nodules of diseased thyroids can shadow ZT. Nevertheless, ZT, composed of thyroid tissue, is expected to be involved in hyperplastic or neoplastic disease. For medullary carcinoma in particular, ZT is embryologically designated as the primary site. Therefore, more frequent and bigger ZTs would be expected in this disease. However, the incidence of ZTs grade 2 and grade 3 did not differ from Pelizzo’s study. This brings further confusion, since in the more diseased thyroid ZT of grade 3 is more frequent: Gauger et al. found them in 19 out of 22 total thyroidectomies, 10 out of 14 subtotal, and 28 out of 52 unilateral. Zuckerkandl’s tubercle was bilateral in 15%; it would be interesting to know if Yalçın et al. encountered any. The comparison of grade 3 ZT with the studies of Hisham and Aina, and Gauger et al. is troublesome, since they already reported signifi cantly higher results than Pelizzo et al.: 55.2% and 45%, respectively, instead of 14.4%. They attributed this discrepancy to population-related factors. Others, who commented on Pellizo’s publication, reported grade 3 (>1 cm) ZT in 14% and 17% of resected lobes. Another disadvantage of Pelizzo’s system is the unclear discrimination between grade 1 (a thickening) and grade 2 (<1 cm). As seen in Table 2, Hisham and Aina merged grade 0 (unrecognizable) and grade 1, and Gauger et al. grades 1 and 2. In conclusion, Pelizzo’s system seems problematic. Further refi nements for both diseased and normal thyroids may therefore be needed, not necessarily using the same grading for hyperplasia/neoplasia and normal variations of the thyroid.

A diagnostic model for histologic damage in undescended testes based on testis rigidity measurement: an experimental study with a novel device.

BACKGROUNDnWe aimed to test whether testis rigidity (hardness) measured using a newly-designed device we previously introduced would offer more reliable assessment of histologic damage in undescended testes than conventional methods (consistency feel at palpation, volume measurement).nnnMATERIALS AND METHODSnForty-five 18-d-old Lewis rats underwent surgical inhibition of descent of left testes and were followed to 40 (nxa0=xa016), 63 (nxa0=xa014), or 90xa0days (nxa0=xa015). Another 45 18-d-old Lewis rats were sham operated (left side) and followed likewise (nxa0=xa014, nxa0=xa015, and nxa0=xa016). At the designated time points, testes were exposed bilaterally, rigidity was measured, and consistency at palpation was scored; testes were removed and subjected to length, width, weight measurements, volume calculation, and histomorphometry (mean Johnsen score [MJS], mean tubular diameter [MTD], and mean capsule width [MCW]). Testes of experimental group were compared with ipsilateral testes of sham-operated rats.nnnRESULTSnAt all time points, undescended testes had decreased rigidity, MJS, and MTD, increased MCW, decreased volume and weight; contralateral testes remained unaffected. Rigidity was associated only with MJS and MTD, and most strongly with MJS (multiple stepwise linear regression, Fxa0=xa0694.44, Pxa0<xa00.0005). MJS could be precisely predicted from rigidity: MJSxa0=xa00.699 × testis rigidity (Fxa0=xa01358.82, Pxa0<xa00.0005). This model showed good fit between predicted and actual MJS values (R(2)xa0=xa00.94), low error, nonsignificant bias, sensitivity 75% and specificity 90%. Model validation showed low prediction error and nonsignificant bias, indicating generalizability. Testis volume and palpation proved imprecise MJS predictors.nnnCONCLUSIONSnTestis rigidity is an effective predictor of histologic damage in rat undescended testes, with diagnostic value superior to testis palpation scoring and volume measurement.

The unidirectional testis tunneller: concerns about a new device and objections to suturing the testis or cauda epididymis.

To create a tunnel from the inguinal opening to the scrotum we, as many others, use a curved Kelly forceps (or mosquito forceps in infants), holding a rolled piece of gauze of size similar to the testis. The gauze is pushed against the scrotal walls; the skin and dartos are cut until the gauze is seen. Then a baby-mosquito forceps enters from outside the scrotal opening and grasps the gauze, is pulled cephalad by the Kelly, and exits from the inguinal wound. The mosquito grasps the mobilized gubernaculum and pulls the testis into the scrotum. This technique has the ergonomic virtues of UTT and is, in our opinion, atraumatic. We agree that finger-tunnelling is not as ergonomic, and it is unsafe to cut with the non-dominant hand. Using the traditional techniques, the width of the dartos’ hole can be shaped to the size of the testis. Instead, a standard 10-mm-wide hole is obtained by the UTT head. The ‘button-hole’ effect attributed to the narrow shaft of UTT depends instead on the width of the hole and on the dartos’ ability to return back to ‘native shape’. The maximum width of the baby-mosquito at its base is 10 mm, i.e., equal to the width of UTT head. However, for testes narrower than 10 mm, the baby-mosquito can support a smaller hole, i.e., a better ‘button-hole’ effect. The same applies for finger-tunnelling and baby-mosquito. More importantly, the UTT head, although designed for ages 1–4 years, was used by Evans et al. to accommodate testes of children up to 16 years old (age range is 6 months–16 years and 1 month), resulting in an evident discrepancy between size of the UTT head and the size of the operated testes. And in the photos of the authors, this head seems larger than the mean 0.3 cm or the maximum 0.5 cm testis volume for this age [range is 0.09–0.52 cm (±2SD)] [2]. Finally, we object to late orchiopexy (mean age for the patients of Evans et al. was 5 years and 3 months). The current view is that orchiopexy should be performed at about 1 year of age or earlier, from 6 months on, because there is evidence of early histological damage of the testis [3].

Subinguinal Varicocelectomy With Loupes Only, Sans Surgical Microscope

Dear Editor, n nI would like to comment Abdelrahman and Eassa on their important paper on the assessment of loupe-assisted subinguinal varicocelectomy in infertile men (1). n nMethodology was complete, including a group of patients and another of controls, of adequate sample size, defined with valid inclusion and exclusion criteria, and followed-up at 3 and 6 months with measures of seminal count/morphology and relevant hormones. n nAs for surgical anatomy and technique, the authors correctly approached internal spermatic veins after opening the internal spermatic fascia. They correctly mention a ‘compartment of the vas’ internal to the internal spermatic fascia. Many experts, however, erroneously state that the vas sits outside the internal spermatic fascia (2). The vas indeed lies internal to the internal spermatic fascia (i.e. in the spermatic cord’s internal compartment) but is further ensheathed by a membranous layer continuing from the respective layer of the abdominopelvic extraperitoneal tissue. The internal spermatic vessels, nerves and lymphatics all within the internal compartment are similarly packed by another membranous sheath (3). n nThe authors preserved the veins of the vas, “except when abnormally engorged veins were evident”. My preference is not to ligate these, but instead cremasteric veins plus their anastomoses with the external pudendal vein. The cremasteric veins are found between the internal and external spermatic fasciae, i.e. in the cord’s external compartment. Intact veins of the vas serve for venous flow after ligation of the internal spermatic and cremasteric veins. Gubernacular veins were not ligated; consequently the testis was not delivered. I concur: if sacrificed, testicular venous return relies only on the small deferential veins (3). n nWith loupes only (sans surgical microscope), 0% recurrence and 0% hydrocele were achieved; admirable rates, totally comparable with those of subinguinal varicocelectomy under microscope -better than rates of others using loupes [2.9% hydrocele, 2.9% reccurence (4)]. Complication rates of subinguinal varicocelectomy without loupes— 15% hydrocele, 10% recurrence seem higher than others’ 7.3% hydrocele, 2.63% recurrence (5), which, however, merge inguinal and subinguinal procedures. n nIn statistical analysis, the authors unfortunately disregarded their paired and time-series design, and performed multiple, pair-wise comparisons, increasing probability of type I error. Instead, analysis should start with testing for normal distribution; if so, a 2-way-ANOVA for repeated measurements would reveal an overall difference; then post-hoc analysis should follow to detect differences between duos of data. In case of non-normal distribution, Friedman test should be applied for the time-series triplets of each group, and Mann-Whitney U-tests for duos of data at each time point (6). n nIn conclusion, the paper strongly supports loupe-assisted subinguinal varicocelectomy in infertile adults. It can be ameliorated in surgical anatomy regarding compartments of the spermatic cord, and has pitfalls in statistical analysis. Nevertheless, the paper has great virtues: excellent surgical results and justified semen and hormonal findings. What I liked most was the honest declaration ‘so it [this technique] should be used, especially in developing countries where the microsurgery equipment is not available every where”. I hope the authors obtain this equipment. I look forward to reading their next paper on microsurgical subinguinal varicocelectomy.