Shinichi Kawata

History and future of human cadaver preservation for surgical training: from formalin to saturated salt solution method

Traditionally, surgical training meant on-the-job training with live patients in an operating room. However, due to advancing surgical techniques, such as minimally invasive surgery, and increasing safety demands during procedures, human cadavers have been used for surgical training. When considering the use of human cadavers for surgical training, one of the most important factors is their preservation. In this review, we summarize four preservation methods: fresh-frozen cadaver, formalin, Thiel’s, and saturated salt solution methods. Fresh-frozen cadaver is currently the model that is closest to reality, but it also presents myriad problems, including the requirement of freezers for storage, limited work time because of rapid putrefaction, and risk of infection. Formalin is still used ubiquitously due to its low cost and wide availability, but it is not ideal because formaldehyde has an adverse health effect and formalin-embalmed cadavers do not exhibit many of the qualities of living organs. Thiel’s method results in soft and flexible cadavers with almost natural colors, and Thiel-embalmed cadavers have been appraised widely in various medical disciplines. However, Thiel’s method is relatively expensive and technically complicated. In addition, Thiel-embalmed cadavers have a limited dissection time. The saturated salt solution method is simple, carries a low risk of infection, and is relatively low cost. Although more research is needed, this method seems to be sufficiently useful for surgical training and has noteworthy features that expand the capability of clinical training. The saturated salt solution method will contribute to a wider use of cadavers for surgical training.

Histopathology of the tubuli recti at the start of experimental autoimmune orchitis in mice.

We previously established an experimental model of autoimmune orchitis (EAO) by means of immunization with testicular germ cells (TGC) alone in mice and confirmed that the disease can be transferred to mice that had received CD4+ but not CD8+ or B lymphocytes obtained from TGC-immunized donor mice. The tubuli recti (TR) are special in that lymphocytes first accumulate around them before spreading to the peripheral seminiferous tubules in EAO. However, the minute changes in the TR remain unknown. Therefore, we investigated the histopathology of the TR before the induction of spermatogenic disturbance. The results revealed that the first infiltrating lymphocytes around the TR were not only of T-cell but also of B-cell lineage. Moreover, it was also shown that some of these infiltrating lymphocytes migrated into the TR, with resultant degeneration of the TR epithelium before damage to the seminiferous epithelium. These findings indicate that TR epithelial cells are the first targets of autoreactive T and B lymphocytes in EAO.

Saturated Salt Solution Method: A Useful Cadaver Embalming for Surgical Skills Training

AbstractThis article evaluates the suitability of cadavers embalmed by the saturated salt solution (SSS) method for surgical skills training (SST).SST courses using cadavers have been performed to advance a surgeons techniques without any risk to patients. One important factor for improving SST is the suitability of specimens, which depends on the embalming method. In addition, the infectious risk and cost involved in using cadavers are problems that need to be solved.Six cadavers were embalmed by 3 methods: formalin solution, Thiel solution (TS), and SSS methods. Bacterial and fungal culture tests and measurement of ranges of motion were conducted for each cadaver. Fourteen surgeons evaluated the 3 embalming methods and 9 SST instructors (7 trauma surgeons and 2 orthopedists) operated the cadavers by 21 procedures. In addition, ultrasonography, central venous catheterization, and incision with cauterization followed by autosuture stapling were performed in some cadavers.The SSS method had a sufficient antibiotic effect and produced cadavers with flexible joints and a high tissue quality suitable for SST. The surgeons evaluated the cadavers embalmed by the SSS method to be highly equal to those embalmed by the TS method. Ultrasound images were clear in the cadavers embalmed by both the methods. Central venous catheterization could be performed in a cadaver embalmed by the SSS method and then be affirmed by x-ray. Lungs and intestines could be incised with cauterization and autosuture stapling in the cadavers embalmed by TS and SSS methods.Cadavers embalmed by the SSS method are sufficiently useful for SST. This method is simple, carries a low infectious risk, and is relatively of low cost, enabling a wider use of cadavers for SST.

Anatomical etiology of “pseudo-sciatica” from superior cluneal nerve entrapment: a laboratory investigation

Objective The superior cluneal nerve (SCN) may become entrapped where it pierces the thoracolumbar fascia over the iliac crest; this can cause low back pain (LBP) and referred pain radiating into the posterior thigh, calf, and occasionally the foot, producing the condition known as “pseudo-sciatica.” Because the SCN was thought to be a cutaneous branch of the lumbar dorsal rami, originating from the dorsal roots of L1–L3, previous anatomical studies failed to explain why SCN causes “pseudo-sciatica”. The purpose of the present anatomical study was to better elucidate the anatomy and improve the understanding of “pseudo-sciatica” from SCN entrapment. Materials and methods SCN branches were dissected from their origin to termination in subcutaneous tissue in 16 cadavers (5 male and 11 female) with a mean death age of 88 years (range 81–101 years). Special attention was paid to identify SCNs from their emergence from nerve roots and passage through the fascial attachment to the iliac crest. Results Eighty-one SCN branches were identified originating from T12 to L5 nerve roots with 13 branches passing through the osteofibrous tunnel. These 13 branches originated from L3 (two sides), L4 (six sides), and L5 (five sides). Ten of the 13 branches showed macroscopic entrapment in the tunnel. Conclusion The majority of SCNs at risk of nerve entrapment originated from the lower lumbar nerve. These anatomical results may explain why patients with SCN entrapment often evince leg pain or tingling that mimics sciatica.

A novel classification of musculocutaneous nerve variations: The relationship between the communicating branch and transposed innervation of the brachial flexors to the median nerve

The musculocutaneous nerve innervates the brachial flexors; i.e., the coracobrachialis, biceps brachii, and brachialis. The musculocutaneous and median nerve sometimes share a communicating branch and also muscular branches to brachial flexors are sometimes transposed to median nerve. Because these variations constitute a potentially important clinical and surgical issue, we evaluated 130 upper limbs of 65 cadavers and 184 cases of musculocutaneous and median nerve variations in the literature and devised a novel system of classification that covers each pattern of variation. Our proposed classification was applicable in all of our cases and those previously reported. In addition, transposed innervation of the brachial flexors from the musculocutaneous nerve to the communicating branches was observed in one limb in our case series. In this case and all previously reported cases of transposed innervation of the brachial flexors, communicating branches between the musculocutaneous and median nerve were found and no brachial flexor branch arose from the musculocutaneous nerve distal to the communicating branches. Consequently, we established that, as per our novel classification, all patterns of communicating branches could be classified into five types and the patterns of transposed innervation of the brachial flexors into three types.

Anatomical structure of the subcutaneous tissue on the anterior surface of human thigh

The anterior thighs of 16 limbs from eight donated cadavers were observed using ultrasonic imaging and gross dissection with a specific focus on the subcutaneous tissue, which is considered an auxiliary element of locomotion. On ultrasonic imaging, the subcutaneous tissue was found to comprise multiple layers. The number of layers gradually decreased on progressing distally in the thigh. On gross dissection, a lot of fatty tissue and loose multiple laminar structures were observed in the medial and proximal areas. However, on progressing distally, these layers thinned out and became less fatty. Cutaneous nerves were apparent among the layers below the dermis. In addition, there were many associated fiber bundles between the dermis and muscle fascia, some of which appeared to be so-called skin ligaments that run through the subcutaneous tissue perpendicularly from the fascia to dermis, accompanying cutaneous nerve fibers and blood vessels. While identifying the peripheral cutaneous nerve fibers, several anastomosing rami and neural networks were recognized. These observations suggest that skin ligaments could be elements regulating motor restriction during muscular movement.

Nine renal arteries in a Japanese female cadaver

A rare case of multiple renal arteries was found in a 78-year-old female cadaver undergoing routine dissection. The characteristic findings in the cadaver included the presence of four right and four left renal arteries with one common trunk (a total of nine renal arteries). This variation may represent an immature form of complicated development of the renal arteries.

Pathological effect of arterial ischaemia and venous congestion on rat testes

Many studies on various organs have concluded that venous congestion (VC) causes severe organ dysfunction with elevation of oxidative stress relative to that of arterial ischaemia (AI). However, a comparison of the pathological effects of AI and VC on the testes has not been conducted. In this study, models of AI and VC and their reperfusion in rat testes, respectively, were developed and analysed. Testicular arteries or veins were interrupted for 6 h, re-perfused and kept for 4 weeks; the effects on the testes were then evaluated. Severe spermatogenic disturbances were observed at 4 weeks after reperfusion in AI but not in VC. At 6 h after blood flow interruption, oxidative stress was significantly increased and germ cells were severely damaged in AI compared with those in VC. RT-PCR analyses revealed that haem oxygenase-1, which exhibits anti-oxidative effects, and vascular endothelial growth factor-A, which exhibits vasculogenic effects, were significantly increased in VC but not in AI. Surprisingly, the results of our experiment in rat testes differed from those of experiments in previous studies performed in other organs. Oxidative stress in testes was more easily elevated by AI than it was by VC, explainable by the different experimental conditions.

Development of heterotopic transplantation of the testis with the epididymis to evaluate an aspect of testicular immunology in rats

Transplantation of testicular cells and tissues has been studied for the investigation of immunology of the testis, which is an immunologically privileged organ. However, reports of transplant of the testis at organ level have been extremely limited because of technical difficulties of the orthotopic testis transplantation (OTT) in experimental animals. In the present study, we developed a new and simple model of the heterotopic testis transplantation (HTT), which is donor testis transplantation into the cervical region of recipients, in a syngeneic model in rats [donor Lewis (LEW) graft to LEW recipient]. The duration of HTT was significantly shorter and success rate higher than that of OTT. To histologically evaluate HTT, the local immune responses were compared among the syngeneic model, an acute rejection allogeneic model [donor Augustus Copenhagen Irish (ACI) graft to LEW recipient] and a chronic rejection allogeneic model (donor F344 graft to LEW recipient) at postoperative day 3. We found that allogeneic ACI grafts resulted in mild and not severe orchitic lesions, whereas immune responses of allogeneic F344 grafts seemed intact and were not significantly different from those of syngeneic LEW grafts. These results suggest that our new operative procedure will be useful in future for the investigation of the testicular immunology.

Anatomical study of middle cluneal nerve entrapment

Object Entrapment of the middle cluneal nerve (MCN) under the long posterior sacroiliac ligament (LPSL) is a possible, and underdiagnosed, cause of low-back and/or leg symptoms. To date, detailed anatomical studies of MCN entrapment are few. The purpose of this study was to ascertain, using cadavers, the relationship between the MCN and LPSL and to investigate MCN entrapment. Methods A total of 30 hemipelves from 20 cadaveric donors (15 female, 5 male) designated for education or research, were studied by gross anatomical dissection. The age range of the donors at death was 71–101 years with a mean of 88 years. Branches of the MCN were identified under or over the gluteus maximus fascia caudal to the posterior superior iliac spine (PSIS) and traced laterally as far as their finest ramification. Special attention was paid to the relationship between the MCN and LPSL. The distance from the branch of the MCN to the PSIS and to the midline and the diameter of the MCN were measured. Results A total of 64 MCN branches were identified in the 30 hemipelves. Of 64 branches, 10 (16%) penetrated the LPSL. The average cephalocaudal distance from the PSIS to where the MCN penetrated the LPSL was 28.5±11.2 mm (9.1–53.7 mm). The distance from the midline was 36.0±6.4 mm (23.5–45.2 mm). The diameter of the MCN branch traversing the LPSL averaged 1.6±0.5 mm (0.5–3.1 mm). Four of the 10 branches penetrating the LPSL had obvious constriction under the ligament. Conclusion This is the first anatomical study illustrating MCN entrapment. It is likely that MCN entrapment is not a rare clinical entity.