Lee J. Skandalakis Surgical Anatomy and Technique

Sharen Selvadurai

Lee J. Skandalakis Surgical Anatomy and Technique

Sharen Selvadurai

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Abstract
AI

The paper discusses the surgical anatomy and techniques associated with various procedures, with particular emphasis on the anatomy of the scalp, including its vascular, lymphatic, and nerve supplies. It presents detailed insights into the blood supply of the scalp, highlighting the important arterial branches and their anastomoses, as well as the implications for surgical procedures. Additionally, the paper outlines techniques for surgical interventions, positioning, and considerations necessary for effective outcomes.

Figures (683)

Figure 1.3. Arterial blood supply shown on right. Nerve distribution shown on left. Veins are not shown, but follow the arteries.

VY Consider the medicolegal aspects of the case. If the case involves a large facial lesion, obtain the advice of a plastic surgeon.

Figure 2.1. The subdivision of the anterior triangle of the neck. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Am Surg 45(9):590-596, 1979.)

Figure 2.2. The roof of the submandibular triangle (the first surgical plane). The platysma lies over the mandibular and cervical branches of the facial nerve. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Am Surg 45(9):590-596, 1979.)

Figure 2.4. The contents of the submandibular triangle (the second surgical plane). Exposure of the superficial portion of the submandibular gland. (By per- mission of JE Skandalakis, SW Gray, and JR Rowe. Am Surg 45(9): 590-596, 1979.)

Figure 2.6. The basement of the submandibular triangle (the fourth surgical plane). Exposure of the deep portion of the submandibular gland, the lingual nerve, and the hypoglossal (XII) nerve. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Am Surg 45(9):590-596, 1979.)

Figure 2.7. The posterior triangle of the neck. The triangle may be divided into two smaller triangles by the omohyoid muscle. (By permission of JE Skandala- kis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.

Figure 2.8. The superficial fascia of the neck lies between the skin and the investing layer of the deep cervical fascia. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 2.9. Diagrammatic cross section through the neck below the hyoid bone showing the layers of the deep cervical fascia and the structures that they envelop. (By permission of JE Skandalakis, SW Gray, and LJ Skandalakis. In: CG Jamieson (ed), Surgery of the Esophagus, Edinburgh: Churchill Livingstone, 19-35, 1988.

Figure 2.11. The lymph nodes of the neck. SH = superior horizontal chain; IH = inferior horizontal chain; PV = posterior vertical chain; IV = intermediate verti- cal chain; AV = anterior vertical chain. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 2.12. The thoracic duct and main left lymphatic trunks. Trunks are vari- able and may enter the veins with the thoracic duct or separately. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 2.13. The right lymphatic duct is formed by the junction of several lym- phatic trunks. If they enter the veins separately, there may be no right lymphatic duct. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 2.14. Normal vestiges of thyroid gland development. None are of clini- cal significance, but their presence may be of concern to the surgeon. (By per- mission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 2.15. The arterial supply to the thyroid gland. The thyroid ima artery is only occasionally present. (By permission of S Tzinas, C Droulias, N Harlaftis, et al. Am Surg 42(9):639-644, 1976.)

Figure 2.16. Relations at the crossing of the recurrent laryngeal nerve and the inferior thyroid artery. (A-C) Common variations. Their frequencies are given in Table 2.2. (D) A nonrecurrent nerve is not related to the inferior thyroid artery. (E) The nerve loops beneath the artery. (By permission S Tzinas, C Droulias, N Harlaftis, et al. Am Surg 42(9):639-644, 1976.)

Figure 2.17. The venous drainage of the thyroid gland. The inferior thyroid veins are quite variable. (By permission S Tzinas, C Droulias, N Harlaftis, et al. Am Surg 42(9):639-644, 1976.)

Anatomy of the Thyroid Gland Figure 2.18. The course of the recurrent laryngeal nerve at the level of the thyroid gland in 102 cadavers. In about one-half of the cases, the nerve lay in the groove between the trachea and the esophagus. (Top) Lateral view. (Bottom) Cross-sectional view. (By permission of JE Skandalakis, C Droulias, N Harlaftis, et al. Am Surg 42(9):629-634, 1976.)

Figure 2.21. Relations of the parotid gland to the facial nerve and its branches. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Compili- cations in General Surgery. New York: McGraw-Hill, 1983.)

Figure 2.23. Relations of the parotid gland to tributaries of the external and internal jugular veins. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 2.22. Relations of the parotid gland to branches of the external carotid artery. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Branchial Cleft Sinuses and Cysts Figure 2.24. Lateral view of the structures in the left carotid sheath at the base of the skull. The posterior belly of the digastric is shown in dotted outline. The hy- poglossal nerve (not shown) hooks around the vagus and appears between the artery and the vein below the lower border of the digastric. (By permission of Rd Last. Anatomy: Regional and Applied. Baltimore: Williams & Wilkins, 1972.)

Figure 2.25. Congenital cervicoaural fistula or cyst. This is a persistent remnant of the ventral portion of the 1st branchial cleft. The tract may or may not open into the external auditory canal. (Modified by permission of AH Bill and JL Vadheim. Ann Surg 142:904, 1955.)

Figure 2.26. Track of a 2nd-pouch and -cleft fistula passing from the ton- sillar fossa of the palatine (faucial) tonsils to the neck. (A) Complete fistula. (B) External (cervical) and internal (pharyngeal) sinuses. (C) Cyst of branchial cleft origin lying in the carotid notch. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 2.27. Incomplete closure of the 2nd branchial cleft or pouch may leave cysts. Type I, superficial, at the border of the sternocleidomastoid muscle Type Il, between the muscle and the jugular vein. Type Ill, in the bifurcatior of the carotid artery. Type IV, in the pharyngeal wall. Types |, Il, and III are o 2nd-cleft origin; Type IV is from the second pouch. M = sternocleidomastoic muscle; V = jugular vein; A = carotid artery. (By permission of JE Skandalakis SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Make a deep incision into the superficial cervical fascia (anteriorly: fat and platysma; posteriorly: fat only).

Thyroidectomy and Parathyroidectomy c. Place small pillow at the area of the upper thoracic spine, beneath the shoulders.

Figure 2.53. Various locations of thyroglossal duct cysts. (A) In front of the foramen cecum. (B) At the foramen cecum. (C) Above the hyoid bone. (D) Below the hyoid bone. (E) In the region of the thyroid gland. (F) At the suprasternal notch. About 50 percent of the cysts are located at (D), below the hyoid bone. (By permission of GE Ward, JW Hendrick, and RG Chambers. Surg Obstet Gynecol 89:728, 1949.)

Step 5. Excise the minute pharyngeal wall if pathology exists.

Excision of Branchial Cleft Cyst or Fistula

Figure 2.62. The completed radical dissection of the neck. Remaining struc- tures may be removed if they are involved in malignant growth. (Modified by per- mission of OH Beahrs, Surg Clin NA 57:477-493, 1977.)

Figure 3.1. Diagram of the walls of the axilla. (Modified by permission of JV Basmajian and CE Slonecker. Grant's Method of Anatomy, 11th ed. Baltimore: Williams & Wilkins, 1989.)

Figure 3.2. Topography of the axilla. Anterior view. (By permission of JE Skan- dalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 3.3. Diagrammatic sagittal section through the nonlactating female breast and anterior thoracic wall. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw- Hill, 1983.) Vascular System of the Breast 9S

Figure 3.5. Lymph nodes of the breast and axilla. Classification of Haagensen and coworkers. (Modified by permission of CD Haagensen. Lymphatics of the Breast. In: Haagensen CD, Feind CR, Herter FP, Slanetz CA Jr, Weinberg JA. The Lymphatics in Cancer. Philadelphia: Saunders, 1972, pp. 342-347.)

Figure 3.6. The triangular bed of a modified radical mastectomy. The pecto- ralis muscles are retracted, rather than removed. (Modified by permission of LJ Skandalakis, MD Vohman, and JE Skandalakis, et al. Am Surg 45(9):552—555, 1979.)

Figure 4.1. Transverse sections through the anterior abdominal wall, traditional view: (A) Immediately above the umbilicus. (B) Below the arcuate line. (C—E) Schematic transverse sections through the ventral abdominal wall showing bilaminar aponeuroses, external oblique, internal oblique, transversus abdominis, and sites of linear decussation that compacted from linea alba. (By permission of PL Williams, R Warwick, and M Dyson, et al. (eds.), Gray’s Anatomy, 37th ed. Edinburgh: Churchill Livingstone, 1989.)

Figure 4.3. Variations in the disposition of the umbilical ligaments as seen from the posterior (peritoneal) surface of the body wall. Arrows indicate: (A) Usual relations (74 percent) of the umbilical ring (UR), the round ligament (RL), the ura- chus (U), and the medial umbilical ligaments (MUL). The round ligament crosses the umbilical ring to insert on its inferior margin. (B) Less common configuration (24 percent). The round ligament splits and is attached to the superior margin of the umbilical ring. (C) Rare configuration (less than 1 percent). The round liga- ment branches before reaching the umbilical ring. Each branch continues with the medial umbilical ligament without attaching to the umbilical ring. (Modified by permission of R Orda and H Nathan. Int Surg 58(7):454—464. 1973.)

Anatomical Entities of the Groin 11S Figure 4.6. Diagram of the relations of the superficial fasciae of the inguinal area showing the formation of the superficial perineal pouch. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.7. (By permission of SW Gray, JE Skandalakis, and DA McClusky. Atlas of Surgical Anatomy for General Surgeons. Baltimore: Williams & Wilkins, 1985.)

Figure 4.8. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Ana- tomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 4.9. The “conjoined area.” (By permission of JE Skandalakis, GL Col- born, SW Gray, et al. Contemp Surg 38(1):20-34, 1991.)

Figure 4.10. (By permission of SW Gray, JE Skandalakis, and DA McClusky. Atlas of Surgical Anatomy for General Surgeons. Baltimore: Williams & Wilkins, 1985.) Anatomical Entities of the Groin 12¢

124 4. Abdominal Wall and Hernias Figure 4.11. Highly diagrammatic representation of the layers and spaces ot the inguinal area and the space of Bogros. 1 = innominate fascia; 2 = exter- nal oblique aponeurosis; 3 = internal oblique muscle; 4 = transversus abdominis muscle and its aponeurosis; 5 = transversalis fascia anterior; 6 = external sper- matic fascia; 7 = Cooper ligament; 8 = pubic bone; 9 = pectineus muscle; 10 = transversalis fascia; 11 = transversalis fascia posterior lamina; 12 = vessels; 13 = peritoneum; 14 = home (space) of the prosthesis, space of Bogros; 15 = pre- peritoneal fat; 16 = transversus abdominis aponeurosis and anterior lamina of transversalis fascia; 17 = femoral artery; 18 = femoral vein. (Drawn by RC Read. From Skandalakis JE, Colborn GL, Androulakis JA, Skandalakis LJ, and Pem- berton LB. Embryologic and anatomic basis of inguinal herniorrhaphy. Surg Clin North Am 73(4):799-836, 1993, with permission.)

Anatomical Entities of the Groin 125 =igure 4.12. Diagram of the normal relations of the transversalis fascia in he lateral and lower parts of the abdominal wall. (By permission of EW Lampe. Transversalis fascia. In: Nyhus LM, and Condon RL. Hernia, 3rd ed. Philadelphia: _ippincott, 1989.)

Figure 4.13. (By permission of LM Nyhus. The preperitoneal approach and iliopubic tract repair of inguinal hernia. In: Nyhus LM, and Condon RL. Hernia, 3rd ed. Philadelphia: Lippincott, 1989.)

Figure 4.15. Diagrammatic cross section of a “weak” posterior inguinal canal wall. Compare with Figure 4.14. (By permission of EW Lampe. Transversalis fascia. In: Nyhus LM, and Condon RL. Hernia, 3rd ed. Philadelphia: Lippincott, 1989.)

Anatomical Entities of the Groin 12¢ Figure 4.16. Anterior view of Fruchaud’s myopectineal orifice. (Modified by per- mission of GE Wantz. Atlas of Hernia Surgery. New York: Raven Press, 1991, p. 4.)

130 4. Abdominal Wall and Hernias Figure 4.17. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.18. The skin of the lower abdominal wall has been removed to show the superficial branches of the femoral artery. (By permission of SW Gray, JE Skandalakis, and DA McClusky. Atlas of Surgical Anatomy for General Surgeons. Baltimore: Williams & Wilkins, 1985.)

Figure 4.19. The course of the anterior ramus of segmental nerves in the ante- rior body wall. (A) 7th to 12th thoracic nerves. (B) 1st lumbar nerve. (By permis- sion of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 4.20. Nerves of the inguinal region with which the surgeon should be familiar. (By permission of SW Gray, JE Skandalakis, and DA McClusky. Ailas of Surgical Anatomy for General Surgeons, Baltimore: Williams & Wilkins, 1985.)

Figure 4.21. Highly diagrammatic presentation of laparoscopic anatomy of the inguinal area demonstrating layers, fossae, and spaces. (From Colborn GL, Skandalakis JE. Laparoscopic cadaveric anatomy of the inguinal area. Prob Gen Surg 12(1):13-20, 1995, with permission.)

Figure 4.23. The bladder and anterior abdominal wall viewed posteriorly. Pos- sible pathways of external supravesical hernias are shown on the left and those of internal supravesical hernias are shown on the right. A. Supravesical fossa with mouth of supravesical hernia. B. Medial fossa. C. Lateral fossa. D. Inguinal ligament. E. Umbilicus. F. Middle umbilical ligament (obliterated urachus). G. Lat- eral umbilical ligament (obliterated umbilical artery). H. Inferior (deep) epigastric artery. (By permission of PN Skandalakis, LJ Skandalakis, SW Gray, and JE Skandalakis. Supravesical hernia. In: Nyhus LM, and Condon RE, eds. Hernia, Ath ed. Philadelphia: Lippincott, 1995, p. 401.) Figure 4.22. Laparoscopic topographic anatomy of the inguinal region. In men, the spermatic vessels join the vas deferens to form the spermatic cord. The presence of a fascial defect lateral or medial to the inferior epigastric vessels defines an indirect or a direct hernia, respectively. (Modified by permission from JH Peters, and AE Ortega. Laparoscopic inguinal hernia repair. In: Hunter JG, and Sackier JM, eds. Minimally Invasive Surgery. New York: McGraw-Hill, 1993, p. 300.)

Panorama of Laparoscopic Cadaveric Anatomy 13

Figure 4.25. The deep inguinal vasculature within the space of Bogros. (By permission of R Bendavid. The space of Bogros and the deep inguinal venous circulation. Surg Gynecol Obstet 174:355-358, 1992.)

Figure 4.26. A-D. Variations in the vasculature of the deep inguinal venous system. (By permission of R Bendavid. The space of Bogros and the deep ingui- nal venous circulation. Surg Gynecol! Obstet 174: 355-358, 1992.)

Figure 4.29. With more cleaning the arch, iliopubic tract, and ligament of Cooper can be seen. (From Colborn GL, and Skandalakis JE. Laparoscopic ca- daveric anatomy of the inguinal area. Prob Gen Surg 12(1):13-20, 1995, with permission.)

Figure 4.30. With further cleaning, more entities will be seen: the spermatic cord and the iliac vessels. (From Colborn GL, and Skandalakis JE. Laparoscopic cadaveric anatomy of the inguinal area. Prob Gen Surg 12(1):13-20, 1995, with permission.)

Figure 4.31. Panoramic laparoscopic view of the anatomical entities of the inguinal area. (From Colborn GL, and Skandalakis JE. Lap- aroscopic cadaveric anatomy of the inguinal area. Prob Gen Surg 12(1):13—20, 1995, with permission.)

142 4. Abdominal Wall and Hernias Figure 4.32. Highly diagrammatic presentation of the vessels and nerves re- lated to the iliopubic tract. (From Colborn GL, and Skandalakis JE. Laparoscopic cadaveric anatomy of the inguinal area. Prob Gen Surg 12(1):13-20, 1995, with permission.)

Figure 4.33. Another panoramic laparoscopic view of the anatomy of the inguinal area. (By permission of WG Brick, GL Colbom, TR Gadacz, et al. Crucial anatomic lessons for laparoscopic herniorrhaphy. Am Surg 61:175, 1995.)

144 4, Abdominal Wall and Hernias Figure 4.34. The triangle of doom. (From Colborn GL, and Skandalakis JE. Lap- aroscopic cadaveric anatomy of the inguinal area. Prob Gen Surg 12(1):13-20, 1995, with permission.)

Figure 4.35. The triangle of pain. (From Colborn GL, and Skandalakis JE. Lap- aroscopic cadaveric anatomy of the inguinal area. Prob Gen Surg 12(1):13-20, 1995, with permission.)

General Description of the Posterior (Lumbar) Body Wall 145 Figure 4.36. The circle of death. (From Colborn GL, and Skandalakis JE. Lap- aroscopic cadaveric anatomy of the inguinal area. Prob Gen Surg 12(1):13-20, 1995, with permission.)

Incisions of the Anterior Abdominal Wall 14°

Figure 4.41. Pfannenstiel transverse abdominal incision showing the iliohy- pogastric nerve between the internal oblique muscle and the external oblique aponeurosis just lateral to the border of the rectus muscle. (By permission of CR Grosz. Am J Surg 142:628, 1981.)

Figure 4.42. The courses of the iliohypogastric and ilioinguinal nerves. Trans- verse incisions carried too far laterally may cut the iliohypogastric nerve. Inguinal incisions may injure the ilioinguinal nerve directly or it may be inadvertently in- cluded in a suture during closure of the incision. (By permission of JE Skandala- kis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 4.44. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.43. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989)

Figure 4.45. Schematic representation of a paramedial sagittal cross Section of the trunk showing the two retroparietal cleavable spaces used for prosthetic repair of large hernias. Broken line 1 = the retrofascial preperitoneal space used at the lower part of the wall. Broken line 2 = the retrorectal space used at the su- praumbilical part of the wall. (Modified by permission of Odimba BFK, Stoppa R, Laude M, Henry X, and Verhaeghe P. J Chir (Paris) 117(11):621-627; 1980.)

158 4. Abdominal Wall and Hernias Figure 4.46. Schematic representation of a horizontal cross Section of the wall at its upper level, with a mesh prosthesis (broken line) in the retrorectal cleavable space. (Courtesy Dr. Rene F. Stoppa.)

Figure 4.47. Schematic representation of a horizontal cross Section of the wall at its lower level, with a mesh prosthesis (broken line) in the retrofascial preperi- toneal cleavable space. (Courtesy Dr. Rene F. Stoppa.)

Figure 4.48. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.50. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.) Step 4. Close subcutaneous tissue and skin.

Figure 4.52. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989)

Figure 4.51. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.53. A-G. (By permission of RP Hormel. Umbilical hernia. In: Nyhus LM, and Condon RL. Hernia, 3rd ed. Philadelphia: Lippincott, 1989.)

Figure 4.55. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.57. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.58. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.59. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.) 170 4. Abdominal Wall and Hernias

Figure 4.60. (From Rutledge, RH. The Cooper’s Ligament Repair. In: Fitzgibbons, RJ Jr., and Greenburg, AG, eds. Nyhus and Condon’s Hernia, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2002, p. 143, with permission.)

Figure 4.61. (From Rutledge, RH. The Cooper’s Ligament Repair. In: Fitz- gibbons, RJ Jr., and Greenburg, AG, eds. Nyhus and Condon’s Hernia, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2002, p. 144, with permission.)

Figure 4.62. (From Rutledge, RH. The Cooper’s Ligament Repair. In: Fitzgibbons, RJ Jr., and Greenburg, AG, eds. Nyhus and Condon’s Hernia, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2002, p. 144, with permission.)

Figure 4.64. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Sliding Indirect Inguinal Hernia 173 Figure 4.63. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

174 4. Abdominal Wall and Hernias Figure 4.65. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.66. (By permission of RE Condon. Anterior iliopubic tract repair. In: Nyhus LM, and Condon RL. Hernia, 3rd ed. Philadelphia: Lippincott, 1989.)

Figure 4.67. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.69. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.68. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

178 4. Abdominal Wall and Hernias Figure 4.70. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

180 4. Abdominal Wall and Hernias Figure 4.72. Femoral hernia. Typical and atypical pathways taken by the femoral hernial sac. Note the possible relations to the femoral artery (A) and femoral vein (V). (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.73. Femoral hernia. The left half of the drawing shows an aberrant obturator artery (40 percent) passing medial to the hernial sac, making it dangerous to incise the lacunar ligament. The right half of the drawing shows an aberrant obturator artery passing lateral to the hernial sac, making it safe to incise the lacunar ligament. (By permission of JE Skandalakis, SW Gray, and JT Akin. Surg Clin North Am 54(6):1227-1246; 1974.)

Figure 4.74. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.75. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.77. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.76. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.78. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.79. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.80. (By permission of LM Nyhus. The preperitoneal approach and iliopubic tract repair of inguinal hernia. In: LM Nyhus, and RL Condon. Hernia, 3rd ed. Philadelphia: Lippincott, 1989.)

Figure 4.82. (By permission of LM Nyhus, The preperitoneal approach and iliopubic tract repair of inguinal hernia. In: LM Nyhus, and RL Condon. Hernia, 3rd ed. Philadelphia: Lippincott, 1989.)

Figure 4.81. (By permission of LM Nyhus. The preperitoneal approach and iliopubic tract repair of inguinal hernia. In: LM Nyhus, and RL Condon. Hernia, 3rd ed. Philadelphia: Lippincott, 1989.)

Figure 4.83. (By permission of LM Nyhus. The preperitoneal approach and iliopubic tract repair of inguinal hernia. In: LM Nyhus, and RL Condon. Hernia, 3rd ed. Philadelphia: Lippincott, 1989.)

Figure 4.85. Preperitoneal view of the left groin and pelvis. a. inferior epigastric vessels; b. internal ring; c. direct space; d. symphysis pubis; e. femoral canal; f. iliac artery; g. iliac vein; h. vas. (Used with permission of Surgical Sense, Inc.)

Figure 4.84. External view showing anatomical landmarks used to locate point of incision. (Used with permission of Surgical Sense, Inc.)

Kugel Hernia Repair (Preperitoneal Patch) 19 Figure 4.86. Preperitoneal view showing the transversalis incision (i) just superior to the internal ring. (Used with permission of Surgical Sense, Inc.)

Figure 4.87. Preperitoneal view showing the area of dissection. (Used with permission of Surgical Sense, Inc.)

Figure 4.88. Insertion of the patch through the open wound. (Used with permission of Surgical Sense, Inc.)

Figure 4.89. Preperitoneal view of the patch in position: parallel to the inguinal ligament, medial edge over to the symphysis, lateral and superior edge beyond the incision, and the posterior edge laying back onto the iliac vessels. (Used with permission of Surgical Sense, Inc.)

Figure 4.90. (Courtesy Dr. Rene F. Stoppa.) 194 4. Abdominal Wall and Hernias

Figure 4.92. Mesh coverage of myopectineal orifice (left). (Permission cour- tesy of Origin Medsystems Inc.)

Figure 4.91. Posterior view of Fruchaud’s myopectineal orifice (left). (Permis- sion courtesy of Origin Medsystems Inc.)

Figure 4.93. Mechanical benefits of placing mesh behind defect (preperito- neal) to resist intraabdominal forces promoting herniation. 196 4. Abdominal Wall and Hernias

Figure 4.94. Preperitoneal dissecting balloon inserted into the preperitoneal space and positioned just dorsal to symphysis pubis. (Permission courtesy of Origin Medsystems Inc.)

Figure 4.95. Preperitoneal dissecting balloon inflated to dissect the preperito- neal space. (Permission courtesy of Origin Medsystems, Inc.)

Figure 4.96. Operating room set-up and cannula sites for extraperitoneal lap- aroscopic inguinal herniorrhaphy. 198 4. Abdominal Wall and Hernias

Figure 4.97. Operating within the preperitoneal space laparoscopically.

Figure 4.98. Preperitoneal inguinal anatomy demonstrating medial structures at risk of injury. (With permission, © 1999 W.L. Gore & Associates, Inc.)

Figure 4.99. Preperitoneal inguinal anatomy demonstrating lateral structures at risk of injury. (With permission, ©1999 W.L. Gore & Associates, Inc.)

Figure 4.100. (By permission of PK Amid, AG Shulman, IL Lichtenstein. Am J Surg 165:369-371; 1993.)

Gilbert Sutureless Mesh-Plug Repair 203 Figure 4.102. (Courtesy Dr. Arthur I. Gilbert and Hernia Institute of Florida.)

Figure 4.103. (Courtesy Dr. Arthur |. Gilbert and Hernia Institute of Florida.)

Figure 4.109. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.110. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

210 4. Abdominal Wall and Hernias Figure 4.111. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.112. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 4.113. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 5.1. The crura consist of both tendinous and muscular tissue; only the tendinous portion holds sutures. In 9 out of 10 persons, the medial edge of the crura is tendinous. (By permission of SW Gray, JS Rowe, and JE Skandalakis. Am Surg 45(9):575-587, 1979.)

Figure 5.2. The most common patterns of the diaphragmatic crura. (A-1) and (B-1) seen from below. (A-2, A-3) and (B-2, B-3) seen from above. E = esophagus; A = aorta. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. In: LM Nyhus, and RJ Baker. Mastery of Surgery, 2nd ed. Boston: Little, Brown, 1992, pp. 377-396.)

Figure 5.4. The apertures of the diaphragm seen from below and the struc- tures traversing them. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. In: LM Nyhus, and RJ Baker. Mastery of Surgery. 2nd ed. Boston: Little, Brown, 1992, pp. 377-396.)

Figure 5.3. The diaphragm viewed from above. The area in contact with the pericardium is indicated. The pericardial fibrous tissue is continuous with that of the diaphragm. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. In: LM Nyhus, and Ru Baker. Mastery of Surgery, 2nd ed. Boston: Little, Brown, 1992, pp. 377-396.)

Figure 5.6. The attachments of the muscles of the diaphragm seen from below. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. In: LM Nyhus, and RJ Baker. Mastery of Surgery, 2nd ed. Boston: Little, Brown, 1992, pp. 377-396.)

Figure 5.5. The diaphragmatic openings for the inferior vena cava (IVC), the esophagus, and the aorta as seen from the left. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. In: LM Nyhus, and RJ Baker. Mastery of Surgery, 2nd ed. Boston: Little, Brown, 1992, pp 377-396.)

Figure 5.7. Three methods of narrowing the esophageal hiatus. A. Vertical with posterior approximation of the crura. B. Vertical with anterior approximation of the crura. C. Horizontal with shortening of one crus. (By permission of JE Skanda- lakis, SW Gray, and JR Rowe Jr. Anatomical Complications in General Surgery. New York: McGraw Hill, 1983.)

Figure 5.8. Structures in the inferior portion of the right mediastinum. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. In: LM Nyhus, and RJ Baker. Mastery of Surgery, 2nd ed. Boston: Little, Brown, 1992, pp. 377-396.)

Figure 5.9. Structures in the inferior portion of the left mediastinum. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. In: LM Nyhus, and RJ Baker. Mastery of Surgery. 2nd ed. Boston: Little, Brown, 1992, pp. 377-396.)

Figure 5.10. Cross section through the thorax at the level of T,, showing the relation of the pleura to the distal esophagus. (By permission of SW Gray, JS Rowe, and JE Skandalakis, Am Surg 45(9):575-587, 1979.)

Figure 5.11. Arterial supply of the diaphragm from below. The inferior phrenic arteries may arise from the celiac trunk or directly from the aorta. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. In: LM Nyhus, RJ Baker. Mastery of Surgery, 2nd ed. Boston: Little, Brown, 1992, pp 377-396.)

Figure 5.12. Venous drainage of the diaphragm from below. The left inferior phrenic vein may enter the inferior vena cava (A), the left suprarenal vein (B), or both. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. In: LM Nyhus, RJ Baker. Mastery of Surgery, 2nd ed. Boston: Little, Brown, 1992, pp. 377-396.

Figure 5.14. The major branches of the phrenic nerves from below. Each phrenic nerve divides just before entering the diaphragm from above. (By per- mission of JE Skandalakis, SW Gray, JS Rowe, et al. In: LM Nyhus, RJ Baker. Mastery of Surgery, 2nd ed. Boston: Little, Brown, 1992, pp. 377-396.)

Figure 5.15. Variations in the blood supply to the distal esophagus and the esopha- geal hiatus. A. The inferior phrenic artery supplies the margin of the hiatus. An esoph- ageal branch of the left gastric artery supplies the esophagus and anastomoses with the thoracic esophageal arteries. This is the most frequent pattern. B. The esophagus is supplied by esophageal branches of the left gastric and the inferior phrenic arteries without cranial anastomoses. C. The esophagus is supplied entirely by a branch of the inferior phrenic artery, which anastomoses with the thoracic esophageal arteries. This pattern is rare. (By permission of JE Skandalakis, SW Gray, and JR Rowe Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 5.17. Esophageal hiatus in sagittal section with (A) normal anatomy and (B-E) the various abnormalities described in the text: (B) sliding hiatus her- nia, (C) paraesophageal hiatus hernia, (D) combined sliding and paraesopha- geal hiatus hernia, (E) congenital short esophagus. (By permission SW Gray, LJ Skandalakis and JE Skandalakis. In: Jamieson, GG (ed). Surgery of the Esophagus. Edinburgh: Churchill Livingstone, 1988, pp. 143-148.)

Much debate centers around the classification of the congenital short esophagus. Three conditions must be considered. (1) In the grossly normal esophagus, the lower portion of the esophagus is lined by gastric mucosa (Barrett esophagus). This may be described also as heterotopic gastric mucosa. (2) In the irreducible partially supradiaphragmatic true stomach, the stomach has herniated into the thorax through an enlarged diaphragmatic esophageal hiatus and become fixed. This is true fixed hiatus hernia. (3) Partially supradiaphragmatic true stomach

Figure 5.18. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 5.19. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 5.21. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw Hill, 1989.)

Figure 5.22. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw Hill, 1989.)

Figure 5.23. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw Hill, 1989.)

Figure 5.24. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 5.25. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 5.26. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 5.27. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 5.28. The Nissen fundoplication with 360° fundic wrap. The completed wrap should be no greater than 2 cm in length.

Figure 5.29. Operating room setup and trocar placement for laparoscopic Nissen fundoplication.

Laparoscopic Nissen Fundoplication 24 Figure 5.30. Dissection begins by opening the hepatogastric omentum over the caudate lobe of the liver and cephalad to the hepatic branch of the vagus nerve. The incision is carried across the phrenoesophageal ligament (broken line).

Figure 5.31. By dissecting at the base of the crura, the retroesophageal window can be widely opened and the posterior vagus nerve identified and protected.

igure 5.32. A Penrose drain is used to encircle and retract the esophagus.

Laparoscopic Nissen Fundoplication 24% Figure 5.33. The short gastrics are taken down beginning onethird of the way down the greater curvature of the stomach working cephalad.

Figure 5.34. The mobilization of the gastric fundus is tested by bringing it through the retroesophageal window anteriorly over the distal esophagus.

Figure 5.35. The crura are approximated using interrupted sutures tied intra or extracorporeally.

Figure 6.1. The lateral aspect of the pharyngoesophageal junction showing: (a) the upper weak area; (b) the lower weak area; (1) the oblique fibers of the inferior constrictor muscle; (2) the cricopharyngeal muscle; (3) the muscularis of the esophagus. (From J Terracol and RH Sweet. Diseases of the Esophagus. Philadelphia: Saunders, 1958.)

Figure 6.2. Top Highly diagrammatic presentation of the musculature of the pharyngoesophageal junction, demonstrating also weakness and the formation of diverticulae. AB = oblique muscle; AC = transverse muscle; AD = muscular coat; ABC = Killian’s triangle (1908) = pharyngeal diverticulum; ABD = Zenker’s (1878) = pharyngoesophageal diverticulum; ACD = esophageal weakness = esophageal diverticulum. A congenital diverticulum has a wide neck and all lay- ers. An acquired diverticulum has a narrow neck and no muscular coat. Bottom Highly diagrammatic presentation of diverticulae. Note: The anterior diverticulum is a rare congenital condition.

Figure 6.3. Highly diagrammatic view of the right mediastinum showing the disposition of its contents. (By permission of JE Skandalakis, SW Gray, and LJ Skandalakis. In: GG Jamieson. Surgery of the Esophagus. Edinburgh: Churchill Livingstone, 1988, pp. 19-35.)

Figure 6.4. Highly diagrammatic view of the left mediastinum showing the dis- position of its contents. (By permission of JE Skandalakis, SW Gray, and LJ Skandalakis. In: GG Jamieson. Surgery of the Esophagus. Edinburgh: Churchill Livingstone, 1988, pp. 19-35.)

Figure 6.5. Views of the “gastroesophageal junction” by four specialties. Each is correct. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 6.6. Diagram of a coronal section through the gastroesophageal junc- tion and the esophageal hiatus of the diaphragm. (By permission of JE Skandala- kis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 6.7. Cross section of the esophagus showing the layers of the wall. The longitudinal and circular layers of the muscularis externa contain striated muscle fibers decreasing distally. (By permission of JE Skandalakis, SW Gray, and LJ Skandalakis. In: GG Jamieson, Surgery of the Esophagus. Edinburgh: Churchill Livingstone, 1988, pp. 19-35.)

Figure 6.9. Diagram of the groups of lymph nodes draining the esophagus. There is no standard terminology. (By permission of JE Skandalakis, SW Gray, and LJ Skandalakis. Surgical Anatomy of the Esophagus. In: GG Jamieson, Surgery of the Esophagus. Edinburgh: Churchill Livingstone, 1988, pp. 19-35.)

Figure 6.16. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 6.21. Midline upper abdominal and oblique left cervical incisions. (From RI Whyte and MB Orringer. Surgery for neoplasms of the esophagus. In: Kl Bland, CP Karakousis, and EM Copeland. Atlas of Surgical Oncology. Philadel- phia: Saunders, 1995, with permission.)

Figure 6.22. Retractors in situ. (From VF Trastek. Esophagectomy: Transhiatal. In: JH Donohue, JA van Heerden, and JRT Monson. Atlas of Surgical Oncology. Cambridge, MA: Blackwell Science, 1995, with permission.)

Figure 6.23. Penrose drain around the esophagus. (From VF Trastek. Esophagectomy: Transhiatal. In: JH Donohue, JA van Heerden, and JRT Monson. Atlas of Surgical Oncology. Cambridge, MA: Blackwell Science, 1995, with permission.)

Figure 6.24. Division of the short gastric and left gastroepiploic vessels. (From VF Trastek. Esophagectomy: Transhiatal. In: JH Donohue, JA van Heerden, and JRT Monson. Atlas of Surgical Oncology. Cambridge, MA: Blackwell Science, 1995, with permission.)

Figure 6.26. Mobilization of the lower portion of the esophagus during tran- shiatal esophagectomy. A Penrose drain, encircling the esophagogastric junc- tion, is used to provide countertraction while the posterior midline dissection is performed with the volar aspects of the fingers against the esophagus. (From RI Whyte and MB Orringer. Surgery for Neoplasms of the Esophagus. In: KI Bland, CP Karakousis, and EM Copeland. Atlas of Surgical Oncology. Philadelphia: Saunders, 1995, with permission.)

Figure 6.28. A. Working from both incisions, the entire esophagus is mobilized. B. A sponge on a stick, inserted through the cervical incision into the posterior mediastinum, facilitates mobilization of the esophagus away from the prevertebral fascia. C. Mobilization of the anterior aspect of the esophagus during transhiatal esophagectomy. The palmar aspects of the fingers are placed against the esoph- agus, and pressure is exerted posteriorly to minimize cardiac displacement and resultant hypotension. (A. From RN Edie, RW Solit, JD Mannion, JJ Shannon. Esophageal Surgery. In: FE Rosato, DJ Barbot (eds). Atlas of General Surgical Technique. New York: Gower, 1992, with permission. B and C. From RI Whyte and MB Orringer. Surgery for Neoplasms of the Esophagus. In: KI Bland, CP Karakousis, and EM Copeland. Atlas of Surgical Oncology. Philadelphia: Saun- ders, 1995, with permission.)

Figure 6.29. Division of the cervical esophagus with a gastrointestinal anasto- mosis stapler (GIA). (From RI Whyte and MB Orringer. Surgery for Neoplasms of the Esophagus. In: KI Bland, CP Karakousis, and EM Copeland. Atlas of Surgical Oncology. Philadelphia: Saunders, 1995, with permission.)

Figure 6.30. After resection of the esophagus, the stomach is divided with sequential applications of the GIA stapler at least 4 to 6 cm away from palpable tumor. (From RI Whyte and MB Orringer. Surgery for Neoplasms of the Esopha- gus. In: KI Bland, CP Karakousis, and EM Copeland. Atlas of Surgical Oncology. Philadelphia: Saunders, 1995, with permission.)

Figure 6.33. A. Abdominal and right posterolateral thoracotomy. B. Thoracoab- dominal incision. (From RI Whyte and MB Orringer. Surgery for Neoplasms of the Esophagus. In: KI Bland, CP Karakousis, and EM Copeland. Atlas of Surgical Oncology. Philadelphia: Saunders, 1995, with permission.)

Figure 6.34. Right thoracotomy. (From Trastek VF. Esophagectomy: transhiatal. In: Donohue JH, van Heerden JA, and Monson JRT. Atlas of Surgical Oncology. Cambridge, MA: Blackwell Science, 1995, with permission.)

Figure 6.36. An intrathoracic esophagogastric anastomosis is placed at the apex of the right chest after the gastric fundus is suspended from the prever- tebral fascia. (From RI Whyte and MB Orringer. Surgery for Neoplasms of the Esophagus. In: KI Bland, CP Karakousis, and EM Copeland. Atlas of Surgical Oncology. Philadelphia: Saunders, 1995, with permission.)

Figure 6.37. Segments of colon can be used as esophageal substitutes. A. The right colon, with its vascular supply, which is based on the right branch of the middle colic artery, is rotated as an isoperistaltic segment. B. The left colon, with its vascular supply, which is based on the ascending branch of the left colic artery, is brought up in an isoperistaltic fashion. C. The vascular anatomy of the transverse and descending colon. Division of the transverse colon at the right of the middle colic vessels. (A and B. From RI Whyte and MB Orringer. Surgery for Neoplasms of the Esophagus. In: KI Bland, CP Karakousis, and EM Cope- land. Atlas of Surgical Oncology. Philadelphia: Saunders, 1995, with permission. C. From JA Waldhausen and WS Pierce. Johnson's Surgery of the Chest, 5th ed. Chicago: Year Book Medical, 1985, with permission.)

Figure 6.38. Colocolonic end-to-end anastomosis. Note the vascular pedicle of the colonic segment. (From JA Waldhausen and WS Pierce. Johnson's Surgery of the Chest, 5th ed. Chicago: Year Book Medical, 1985, with permission.)

Figure 7.1. The proximal gastric surgical unit. The two ends of the stomact have different lesions, and operations require different methods. (By permissior of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in Genera Surgery. New York: McGraw-Hill, 1983.)

Figure 7.2. The distal gastric surgical unit. Most gastric surgery takes place in this area. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 7.3. The arterial supply to the stomach: L.Inf Ph = left inferior phrenic artery; SG = short gastric artery; L.GE = left gastroepiploic artery; R.GE = right gastroepiploic artery; S = splenic artery; GP = great pancreatic artery; Inf P = inferior pancreatic artery; PD = pancreaticoduodenal artery; DP = dorsal pancre- atic artery; GD = gastroduodenal artery; R.G = right gastric artery; H = hepatic artery; CT = celiac trunk; L.G = left gastric artery; Post G = posterior gastric artery. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.

Figure 7.5. The terminology of vagal structures of the thorax and abdomen. In this example, two vagal trunks pass through the hiatus to enter the abdomen. 1 = hepatic division; 2 = anterior gastric division; 3 = celiac division; 4 = posterior gastric division. (By permission of JE Skandalakis, JS Rowe, and SW Gray. Surgery 75(2):233-237, 1974.)

Figure 7.4. Diagram of the lymphatic drainage of the stomach. Most of the drainage finds its way to the celiac nodes: the “vortex of the metastatic whorl.” (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complica- tions in General Surgery. New York: McGraw-Hill, 1983.)

Figure 7.6. The relation of the anterior and posterior vagal trunks to the aorta and the esophagus, showing the number of specimens with vagal trunks lying to the right or left of the midline. In most but not all of the 88 specimens, the trunks are to the right of the midline. Note that the anterior trunks are closer to the esophagus than the posterior trunks. (By permission of JE Skandalakis, JS Rowe, and SW Gray. Surgery 75(2):233-237, 1974.)

Figure 7.7. Truncal vagotomy results in vagal denervation of all abdominal or- gans. A concomitant drainage procedure is required for gastric stasis. (By per- mission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 7.8. “Typical” distribution of anterior gastric and hepatic divisions of the vagus. (Modified by permission of JE Skandalakis, SW Gray, RE Soria, et al. Am Surg 46(3):130—139, 1980.)

Step 2. Close the transverse duodenotomy in a longitudinal fashion. Apply traction on the two previously placed sutures and close in two layers using 3-0 chromic and 3-0 silk.

Figure 7.22. Some arbitrary landmarks for partial gastric resection: (line 1) 75 percent resection; (line 2) 50 percent resection. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 7.23. The antrum—body junction in the “average stomach” is found at 2/5 of the distance from the pylorus to the cardia along the lesser curvature and 1/8 of the same distance along the greater curvature. (By permission of JE Skan- dalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 7.24. Gastrostomy incisions: A. Long incision extending into pylorus. B. Closure of long incision resulting in corners (x) that may become ischemic. C. Two separate incisions. D. Closure avoids the corners of the preceding incision. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Compli- cations in General Surgery. New York: McGraw-Hill, 1983.)

Figure 7.26. Entrance to the lesser sac. A. Normal anatomy. The arrow indi- cates entrance through the greater omentum. The middle colic artery in the trans- verse mesocolon is in no danger. B. Pathological fixation of the omentum and posterior wall of the stomach with the transverse mesocolon. C. Normal anatomy, but entrance so far inferior may injure the middle colic artery. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.) tae aaa aaa” fae In the presence of pathology, such as gastric ulcer or pancreatitis, the posterior leaf of the greater omentum and the posterior wall of the stomach may have become fixed to the transverse mesocolon and pancreas, thus eliminating the cavity of the lesser sac and giving the surgeon no warning that the mesocolon has been penetrated (Fig. 7.26B).

Figure 7.34. Transsect and remove the distal stomach and a small part of the first portion of the duodenum.

Figure 7.35. The specimen is removed and the duodenum opening is closed in two layers.

Figure 7.36. Partial closure of the gastric opening at the lesser curvature side.

Figure 7.37. Elevate the transverse colon, and through an avascular area of the mesocolon, insert a proximal jejunal loop if a retrocolic anastomosis.

Figure 7.38. Suturing of the mesocolon to the posterior gastric wall close to the opening.

Figure 7.40. The four-layer anastomosis (see also Figs. 7.41 and 7.42).

Figure 7.39. The proximal loop is inserted through the opening of the meso- colon.

igure 7.42. Completion of the four-layer anastomosis.

Figure 7.43. A and B. An alternative method of anastomosis, bringing the stomach down the mesocolic opening and securing the gastric wall with inter- rupted sutures to the transverse mesocolon.

splenectomy, the splenic veins and ligaments should be ligated and cut. Continue the upward dissection of the greater omentum, with ligation of the upper short gastric vessels.

»4. With complete gastric mobilization from the gastroesophageal junction to the proximal portion of the second part of the duodenum, divide the duodenum and the abdominal esophagus (Fig. 7.49). Place 3-0 silk stay sutures on each side of the esophagus (Fig. 7.50). Remove the specimen.

Figure 7.53. Selective vagotomy preserves the celiac and hepatic divisions but will not denervate the pylorus, biliary tract, and remaining intestinal tract. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 7.54. Parietal cell (superselective) vagotomy preserves antropyloric as well as celiac and hepatic innervation. There is some risk of perforation as a result of ischemia of the lesser curvature. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 7.55. The seven areas of vagotomy. Preganglionic efferent vagus nerves reach the parietal cell mass in seven areas. Area 1 is the periesopha- geal region; area 2 is the lesser curve of the stomach; area 3 is the crow’s foot area; area 4 is represented by the broken line, as the gastropancreatic fold is no’ visible anteriorly; area 5 is the region of short gastric vessels; area 6 is the lef gastroepiploic pedicle; and area 7 is the right gastroepiploic pedicle. Areas 3, 4, 6, and 7 are divided routinely during extended highly selective vagotomy. Area 5 is preserved because the nerves at this site cannot be divided without sacrificing essential blood supply to the proximal part of the stomach. (By permission of PE Donahue, HM Richter, KJM Liu, et al. Surg Gynecol Obstet 176(1):40, 1993.)

Figure 8.1. Diagrammatic sagittal section showing the position of the duode- num in relation to the aorta and the superior mesenteric artery. The transverse mesocolon is marked by an X. (Modified by permission of SW Gray, JT Akin, JH Milsap, et al. Contemp Surg 10:33-56, 1977.)

Figure 8.3. Major arterial supply to the duodenum. (By permission of SW Gray, GL Colborn, LB Pemberton, LJ Skandalakis, and JE Skandalakis. Am Surg 15(4):257-261; 15(5):291-298; 15(7):469-473; 15(8):492-494, 1989.)

Vascular System of the Duodenum 337 Figure 8.4. Anterior view of arterial supply of the duodenum and pancreas. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. Contemp Surg 15(5):17—40 and 15(6):21-50, 1979.)

Figure 8.5. Posterior view of arterial supply of the duodenum and pancreas. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. Contemp Surg 15(5):17—40 and 15(6):21-50, 1979.)

Figure 8.6. The venous drainage of the duodenum and pancreas: anterior view. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. Contemp Surg 15(5):17—40 and 15(6):21—-50, 1979.) Within the duodenal wall are the two well known neural plexuses of the gastro- intestinal tract. Meissner’s plexus is in the submucosa, and Auerbach’s plexus is between the circular and longitudinal layers of the muscularis externa. In six of 100 specimens studied, nerves from the hepatic division of the anterior vagal trunk gave rise to one or more branches that innervated the first part of the duodenum. In most specimens, some branches could be traced upward toward the gastric incisura. The vagaries of the vagus nerve are well known. the gastric incisura. The vagaries of the vagus nerve are well known.

Figure 8.7. The venous drainage of the duodenum and pancreas, and forma- tion of the hepatic portal vein: posterior view. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. Contemp Surg 15(5):17—40 and 15(6):21—50, 1979.)

Figure 8.8. Diagrammatic presentation of duodenal lymphatica. (By permis- sion of SW Gray, LB Pemberton, LJ Skandalakis, et al. Am Surg 55, 1989.)

Figure 8.9. Mobilization of the right colon by incision of the lateral perito neum and exposure of the 3rd part of the duodenum by incision of the transverse me- socolon. Note that the superior mesenteric vein is not shown.

Figure 8.10. Arrow indicating medial retraction of the right colon. Note that the superior mesenteric vein is not shown.

Exposure and Mobilization of the Duodenum 34:

Figure 8.14. Diagrammatic sagittal section showing the duodenum be tween the superior mesenteric vessel and the aorta. (By permission of JE Skandalakis, JT Akin, JH Milsap, et al. Contemp Surg 10:33-56, 1977.)

With a little imagination the pancreas and transverse mesocolon are at the same line. Repair of Vascular Compression of Duodenum 345

Figure 8.16. A. Note the dilated proximal duodenum. B. Duodenojejunos tomy bypassing the obstruction. (By permission of SW Gray, LU Skandalakis, JS Rowe, et al. In: LM Nyhus and RJ Baker. Mastery of Surgery, 2nd ed. Boston: Little, Brown, 1992, pp. 764-772.)

Figure 8.15. Section of the ligament of Treitz will usually allow the duodenum to drop far enough to admit two fingers between the superior mesenteric artery and the aorta. (By permission of JT Akin, JH Milsap, SW Gray, et al. Contemp Surg 10:33-56, 1977.)

Figure 9.1. Anterior relationships of the pancreas. (By permission of JE Skan- dalakis, SW Gray, JS Rowe, et al. Contemp Surg 15(5):17—40, 1979.)

Figure 9.4. The five parts of the pancreas. The line between the body and the tail is arbitrary. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Ana- tomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 9.3. Posterior relationships of the pancreas. Anterior view. (By permis- sion of JE Skandalakis, SW Gray, JS Rowe, et al. Contemp Surg 15(5)17-40, 1979.)

Figure 9.5. Variations in the extent of the uncinate process of the pancreas. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. Contemp Surg 15(5):17—40, 1979.)

Figure 9.6. Variations of the pancreatic ducts. A. Both ducts open into the duodenum. B. The accessory duct ends blindly in the duodenal wall. C. The main duct is smaller than the accessory duct and they are not connected. (Modi- fied by permission of JE Skandalakis, SW Gray, JS Rowe, et al. Contemp Surg 15(5):17—40, 1979.)

Figure 9.8. The T arrangement of mucosal folds of the duodenum indicating the site of the major duodenal papilla. The papilla is sometimes covered by these folds. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. Contemp Surg 15(5):17-40, 1979.)

Figure 9.10. Distribution of lymph nodes in 18 pancreatectomy resection spec- imens. Numerator of fraction of each group indicates number of patients with me- tastasis in that lymph node group; denominator indicates number of patients in which group nodes were examined. Thirteen cases were pancreas duct cancer; five were other cancers in the head of the pancreas area. SH = superior head; SB = superior body; IH = inferior head; IB = inferior body; APD = anterior pancreati- coduodenal; PPD = posterior pancreaticoduodenal; CBD = common bile duct; Py = pyloric; LC = lesser curvature; GC = greater curvature; S = tail of pancreas and splenic; Je = jejunal; Col = midcolic. (By permission of AL Cubilla, J Fortner, and PJ Fitzgerald. Cancer 41(3):880-887, 1978.)

Figure 9.21. Exploration of the pancreas. The surgeon's index fingers are passed behind the neck of the pancreas. The neck should be separated easily from the underlying vessels. (By permission of JE Skandalakis, SW Gray, JS Rowe, et al. Contemp Surg 15(6):21-50, 1979.)

Distal Pancreatectomy (with or without Splenectomy)

Step 6. Insert a Jackson—Pratt drain and close the wound.

Figure 9.45. Cystoduodenostomy. A probe is placed in the duodenal papilla to identify and protect the pancreatic duct. The pancreatic cyst is incised through the duodenal wall and the opening is sutured. (By permission of JE Skandala- kis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

For all practical purposes, the surgical technique is the same as in distal pan- createctomy.

Figure 10.1. Section through the wall of the small intestine. The submucosa should be included in stitches forming an anastomosis. (By permission of JE Skandalakis, SW Gray, and JR Rowe Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 10.3. (By permission of JE Skandalakis, SW Gray, AR Mansberger, et al. Hernia: Surgical Anatomy and Technique. New York: McGraw-Hill, 1989.)

Figure 10.4. A. The vasa recta may divide into two short vessels to the mesen- teric side of the intestine and two long vessels supplying the rest of the intestinal wall. B. More frequently, a single, long vessel supplies one side of the intestine, alternating with a vessel supplying the other side. C. A single long and a single short vessel serving one side only. The remaining 34 percent are various com- binations of paired, single, long, and short vessels. (By permission of JE Skan- dalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 10.5. Location on the ileum and frequency of occurrence of Meckel’s diverticulum. (By permission of JE Skandalakis, SW Gray, RR Ricketts, et al. The small intestines. In: Skandalakis JE and Gray SW. Embryology for Surgeons, 2nd ed. Baltimore: Williams & Wilkins, 1994.) When present, Meckel’s diverticulum arises from the antimesenteric surface of the ileum approximately 40 cm from the ileocecal valve in infants and approxi- mately 50 cm from the valve in adults; it may be less than 15 cm or as much as 167 cm from the valve (Fig. 10.5). Not less than 2 meters of ileum should be inspected to be sure that a diverticulum has not been overlooked. The diverticu- lum may be as short as 1 cm or as long as 26 cm: in 75 percent of individuals it will be from | to 5 cm; the rest will be longer.

Figure 10.7. Diagram of the anatomy of an intestinal intussusception. Such a formation can enlarge distally until the leading edge reaches the anus. (By per- mission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery, New York: McGraw-Hill, 1983.) Anatomic Guidelines for Surgery 395

@ INTUSSUSCEPTION (ORIENTATION FIG. 10.7)

Figure 11.1. Blood supply to the appendix. A and B. Usual type with a single appendicular artery. C. Paired appendicular arteries. (By permission of JE Skan- dalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Vascular System of the Appendix 405 Figure 11.2. Lymphatic drainage of the appendix. (By permission of JE Skan- dalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Step 1. Choice of incision is up to the surgeon. We prefer McBurney (Fig. 11.3 considered. When the cecum has been identified, one of the teniae coli can be traced downward to the base of the appendix. In spite of the great mobility of the tip, the base of the appendix always arises from the cecum at the convergence of the teniae. In exposing a deeply buried retrocecal appendix, it may be necessary to incise the posterior peritoneum lateral to the cecum. Congenital absence of the appendix is too rare to be considered seriously, but its apparent absence may be the result of intussusception. In such a case, there should be an obvious dimple at the normal site of the appendix. Of course, the surgeon should inspect the abdomen for signs of previous operation. [ a eee | FF ia.) OT ROE bo OE OL SRE ES LO er, | ip nee eee EF ay 5 Se) oe hy me:

Figure 12.1. Superior and inferior ileocecal folds forming fossae. (By permis- sion of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 12.2. Degrees of attachment of the right colon to the abdominal wall. A. Normal retroperitoneal location of the colon. B. Paracolic gutter. C. Mobile colon with mesentery. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Ana- tomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 12.3. Mobile cecum, distal ileum, and proximal right colon. This configura- tion is subject to volvulus. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 12.4. “Jackson’s veil” may contain many small blood vessels from the second lumbar or renal arteries. The extent of the “veil” is variable. (By permis- sion of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 12.5. A. Average measurements of the sigmoid mesocolon. B. The relation of the base of the sigmoid mesocolon to the left ureter. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 12.8. The spaces of the anus and rectum: (1) pelvirectal space; (2) ischiorectal space; (3) intersphincteric spaces; (4) subcutaneous space; (5) cen- tral space; (6) submucous space. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw- Hill, 1983.)

Figure 12.10. Diagram of the extrinsic muscles of the surgical anal canal. (1) Coccyx; (2) pubis; (3) levator ani muscle; (4) puborectalis muscle; (5) deep external sphincter; (6) superficial external sphincter; (7) subcutaneous external sphincter; (8) anococcygeal ligament; (9) anal verge; (10) rectum. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

424 12. Colon and Anorectum Figure 12.11. The interior of the anal canal showing the rectal columns, anal valves, and anal sinuses (crypts). They form the pectinate line. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 12.12. Diagram of some of the fasciae of the pelvis seen in coronal section. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 12.14. Schema of the blood supply to the large intestine. There are many variations of this basic pattern. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 12.16. Diagram of the arterial supply to the rectum and anus. The median sacral artery supplying a few small branches to the posterior wall of the rectum is not shown in this figure. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.) A430 12. Colon and Anorectum

Figure 12.18. The lymphatics of the colon follow the arteries and drain to the principal nodes at the root of the mesentery. The path is by way of the epiploic, paracolic, and mesocolic lymph nodes. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.) 432 12. Colon and Anorectum

Figure 12.20. Lymphatic drainage of the sigmoid colon, rectum, and anus. Above the pectinate line, drainage is to the inferior mesenteric nodes. Below the line, drainage is to the inguinal nodes. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Nerve Supply of the Rectum and Anus 43) Figure 12.21. Diagram of lymph drainage of the anus and rectum. The water- shed for extramural drainage is at the pectinate line (Fig. 12.20). The watershed for intramural drainage is at the level of the middle rectal valve, about 8 cm above the anal verge. IRA = inferior rectal artery; MRA = middle rectal artery; SRA = superior rectal artery; LRV = lower rectal valve; MRV = middle rectal valve; SRV = superior rectal valve. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 12.25. Loop colostomy. The loop of colon has been brought through the incision, held in place by a glass tube with rubber tubing connecting its ends. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complica- tions in General Surgery. New York: McGraw-Hill, 1983.)

Figure 12.24. Cecostomy. The broken line surrounded by the purse-string suture indicates the incision for the insertion of the Foley catheter. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

The stoma is located at the lower descending colon or at a loop of the upper sig- moid colon. Good mobilization is essential, especially when the stoma is at the lower descending colon or at the iliac part of the sigmoid colon. The mesenteric root should be incised very carefully to avoid bleeding, which would jeopardize the vitality of the bowel. The procedures of end colostomy are the same as in left colectomy, except that the proximal end is secured to a skin opening and the distal loop is reinserted into the peritoneal cavity. Pa a | oe 8 «6 Pe ae ae et 2 ¥ _ Pi. Se

VU There are several variations to the anatomy here. Ligate the vessels twice using Mixter clamps.

Figure 12.46. (By permission of JE Skandalakis, GL Colborn, LB Pemberton, et al. Prob Gen Surg 7(1):1-17, 1990.)

at the posterolateral pelvic wall and hypogastric artery, and the nerve is medial to the ureter (Fig. 12.49).

Figure 12.51. (Copyright 1980, 1994, United States Surgical Corporation. All rights reserved. Reprinted with the permission of the United States Surgical Corporation.)

General Principles of Laparoscopic Hand-Assisted 465 m= GENERAL PRINCIPLES OF LAPAROSCOPIC HAND-ASSISTED COLECTOMY

Figure 12.64. Operating room arrangement for sigmoid resection. (From ME Franklin, Jr. Laparoscopic surgery of colon and rectum. (ME Arregui, RJ Fitzgibbons Jr., N. Katkhouda, JB McKernan, and A Reich (eds.). Principles of Laparoscopic Surgery: Basic and Advanced Techniques. New York: Springer-Verlag, 1995, with permission.)

Figure 12.65. Trocar placement for low anterior and abdominal peritoneal resection. ME Franklin, Jr. Laparoscopic surgery of colon and rectum. (From ME Arregui, RJ Fitzgibbons Jr., N. Katkhouda, JB McKernan, and A Reich (eds.). Principles of Laparoscopic Surgery: Basic and Advanced Techniques. New York: Springer-Verlag, 1995, with permission.)

Figure 12.66. Trocar placement for splenic flexure and left colon. ME Franklin, Jr. Laparoscopic surgery of colon and rectum. (From ME Arregui, RJ Fitzgibbons Jr., N. Katkhouda, JB McKernan, and A Reich (eds.). Principles of Laparoscopic Surgery: Basic and Advanced Techniques. New York: Springer-Verlag, 1995, with permission.)

Figure 12.67. Operating room arrangement for splenic flexure mobilization. ME Franklin, Jr. Laparoscopic surgery of colon and rectum. (From ME Arregui, RJ Fitzgibbons Jr., N. Katkhouda, JB McKernan, and A Reich (eds.). Principles of Laparoscopic Surgery: Basic and Advanced Techniques. New York: Springer- Verlag, 1995, with permission.)

Figure 12.71. Diagram of anorectal landmarks for sigmoidoscopic examina- tion: patient in knee/chest or knee/elbow position. (By permission of JE Skandala- kis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.) A476 12. Colon and Anorectum

»rocedures of the Surgical Anal Canal 48

Figure 12.81. (From Nesselrod JP. Anal, perianal, perineal and sacrococcy- geal sinuses. Am J Surg 1942;56:154—165; copyright Elsevier, with permission.)

Procedures of the Surgical Anal Canal 48!

Step 6. Occasionally an internal hemorrhoid has a polyp-like formation and may be excised in toto. The floor should be sutured with continuous 3-0 chromic (Fig. 12.86).

Procedures of the Surgical Anal Canal 487

Procedures of the Surgical Anal Canal 485

Procedures of the Surgical Anal Canal 49

Figure 13.2. Visceral surface of the liver. The plane between the left medial and left lateral segments is variously referred to as the umbilical fissure, the fissure of the ligamentum teres, or the fissure of the falciform ligament. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Table 13.1 Approximate Rib Levels of Liver, Lungs, and Pleura (By permission of Lockhart RD, Hamilton GF, Fyfe FW. Anatomy of the Human Body. Phila- delphia: JB Lippincott, 1959, p. 549.)

Figure 13.3. Peritoneal reflections of the liver: the lesser omentum (hepatogastric and hepatoduodenal ligaments) and its relation to the coronary ligament of the liver and diaphragm. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.4. The true lobulation and segmentation of the liver: diaphragmatic surface. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Table 13.2 Terminology and Pattern of Intrahepatic Bile Ducts Source: By permission of JE Skandalakis, SW Gray, and JR Rowe, Anatomical Complications in General Surgery, New York McGraw-Hill, 1983.

Figure 13.6. Intrahepatic segmental ducts. A. Usual pattern. B. Anomalous origin of right anterior duct. C. Anomalous origin of right posterior duct. Both ducts cross the midline to reach their destinations. (By permission of JE Skan- dalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.7. Riedel’s lobe of the liver. This anomalous lobe is found usually in middle-aged women and presents as an asymptomatic but unexplained mass. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Compli- cations in General Surgery, New York: McGraw-Hill, 1983.)

Figure 13.8. Aberrant hepatic arteries. A. Accessory type. B. Replacing type. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Compii- cations in General Surgery, New York: McGraw-Hill, 1983.)

Figure 13.10. Diagram of the intrahepatic distribution of the hepatic artery. Abbreviations as in Figure 13.5. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery, New York: McGraw-Hill, 1983.)

Figure 13.11. Relationship of the hepatic ducts, the hepatic artery, and the portal vein at the porta hepatis. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.12. Diagram of the intrahepatic distribution of the portal vein. Abbreviations as in Figure 13.5. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.13. Diagram of the intrahepatic distribution of the hepatic veins. Note that they are interlobular, rather than lobular. C = caudate; L = left; M = medial; R = right. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.14. Diagram of the superficial lymphatic drainage of the liver: frontal and sagittal views. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.15. Diagrammatic parasagittal section through the upper abdomen showing the potential right suprahepatic and subhepatic spaces. The thick black line represents the diaphragm. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.17. Relations of an abscess in the anterior portion of the right supra- hepatic space. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Ana- tomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.18. Relations of an abscess in the posterior portion of the right suprahepatic space. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.20. Relations of an abscess in the posterior portion of the left supra- hepatic space. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Ana- tomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.19. Relations of an abscess in the anterior portion of the left supra- hepatic space. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.21. Relations of an abscess in the right infrahepatic space. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complica- tions in General Surgery. New York: McGraw-Hill, 1983.) Figure 13.22. Relations of an abscess in the left infrahepatic space. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complica- tions in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.26. Types of lobar and segmental liver resections. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 13.27. Planes of transection of the liver for lobectomy and segmentec- tomy. Trisegmentectomy includes the anterior and posterior segments of the right lobe and the medial segment of the left lobe. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Step 4. If required, clamp the hepatic triad with a noncrushing clamp (Fig. 13.39).

Figure 14.3. Accessory hepatic ducts. Additional, minute hepatic ducts are no unusual. (By permission of JE Skandalakis, SW Gray, RR Ricketts, et al. The extrahepatic biliary ducts and the gallbladder. In: JE Skandalakis and SW Gray Embryology for Surgeons, 2nd ed. Baltimore: Williams & Wilkins, 1994.)

Figure 14.4. Deformities of the gallbladder. A. “Phrygian cap” deformity; B. Hartmann’s pouch. (By permission of JE Skandalakis, SW Gray, RR Ricketts, et al. The extrahepatic biliary ducts and the gallbladder. In: JE Skandalakis and SW Gray. Embryology for Surgeons, 2nd ed. Baltimore: Williams & Wilkins, 1994.)

Figure 14.5. The extrahepatic biliary tract and the four portions of the common bile duct. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 14.7. The hepatocystic triangle and the triangle of Calot. The upper boundary of the hepatocystic triangle is the margin of the liver; that of the triangle of Calot is the cystic artery; the triangle of Calot is stippled. CA = cystic artery; CD = cystic duct; CBD = common bile duct; RHA = right hepatic artery; LHA = left hepatic artery; CHD = common hepatic duct. (By permission of JE Skandalakis, SW Gray, RR Ricketts, et al. The extrahepatic biliary ducts and the gallbladder. In: JE Skandalakis and SW Gray. Embryology for Surgeons, 2nd ed. Baltimore: Williams & Wilkins, 1994.)

Figure 14.8. Some possible origins of the cystic artery. A. Usual pattern (74.7 percent) from the right normal or aberrant hepatic artery. B. Origin from the com- mon hepatic artery, its bifurcation, or from the left hepatic artery and crossing in front of the common hepatic duct (20.5 percent). C. Origin from the gastroduode- nal artery (2.5 percent). The remainder arise from a variety of sources. D,E. Very rarely the cystic artery reaches the gallbladder at the fundus or body (“recurrent” cystic artery). (By permission of JE Skandalakis, SW Gray, RR Ricketts, et al. The extrahepatic biliary ducts and the gallbladder. In: JE Skandalakis and SW Gray. Embryology for Surgeons, 2nd ed. Baltimore: Williams and Wilkins, 1994.)

Figure 14.10. Lymphatic drainage of the biliary tract. The cystic node and the node of the hiatus are relatively constant. Drainage from the gallbladder, the cys- tic duct, and the right lobe of the liver reaches the posterior pancreaticoduodenal nodes. (By permission of RB Fahim et al. Ann Surg 156(1):114-124, 1962.) 544 14. Extrahepatic Biliary Tract

‘igure 14.29. Perform the duodenotomy only if it is necessary.

Step 9. Slowly and carefully separate the gallbladder from its bed. Obtain hemostasis. Perform repeated irrigations (Fig. 14.53). Step 10. Remove the gallbladder through the umbilical port. The umbilical

Figure 14.52. (Used with permission of Ross Products Division, Abbott Labo- ratories, Columbus, OH 43216. Flexiflo Lap G. © 1992 Ross Products Division, Abbott Laboratories) 572 14. Extrahepatic Biliary Tract

Step 11. After ascertaining there is no bleeding, remove all trocars under direct vision.

Figure 15.1. Location of the spleen. (By permission of JE Skandalakis, GL Colborn, LB Pemberton, et al. Prob Gen Surg 7(1):1-17, 1990.)

Figure 15.2. Splenic borders. (Top) Anterior and posterior border. (Bottom) Relations of the tail of the pancreas to the spleen. (By permission of JE Skanda- lakis, GL Colborn, LB Pemberton, et al. Prob Gen Surg 7(1):1-17, 1990.)

Figure 15.3. Sagittal view of peritoneum covering the spleen. (By permission of JE Skandalakis, GL Colborn, LB Pemberton, et al. Prob Gen Surg 7(1):1-17, 1990.)

Figure 15.5. Chief and minor splenic ligaments. (By permission of JE Skanda- lakis, GL Colborn, LB Pemberton, et al. Prob Gen Surg 7(1):1-17, 1990.)

Figure 15.6. The splenic pedicle. A. Long pedicle with a presplenic fold. B. Short pedicle. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 15.7. Relation of the pancreatocolic, phrenicocolic, and splenocolic ligaments to the transverse mesocolon. (By permission of JE Skandalakis, GL Colborn, LB Pemberton, et al. Prob Gen Surg 7(1):1-17, 1990.)

Figure 15.8. Relation of splenic artery and splenic vein. A. Artery anterior to vein (this is the usual pattern). B. Artery both anterior and posterior to vein. C. Artery posterior to vein (this is the least common configuration). (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 15.9. Anatomy of the splenic vein. (By permission of JE Skandalakis, GL Colborn, LB Pemberton, et al. Prob Gen Surg 7(1):1-17, 1990.)

Figure 15.10. Lymphatic drainage of the spleen. (By permission of JE Skanda- lakis, GL Colborn, LB Pemberton, et al. Prob Gen Surg 7(1):1-17, 1990.)

Figure 15.13. Ligation of the splenic artery and the short gastric arteries and vein. (By permission of LB Pemberton and LJ Skandalakis. Prob Gen Surg 7(1):85-102, 1990.)

Figure 15.12. Incision for total splenectomy by the anterior approach and access to the lesser sac. 1 = Subcostal; 2 = Kehr subcostal; 3 = Bilateral subcos- tal; 4 = Midline. (By permission of LB Pemberton and LJ Skandalakis. Prob Gen Surg 7(1):85-102, 1990.)

Figure 15.14. Division of the ligaments and delivery of the spleen to the out- side of the peritoneal cavity. (By permission of LB Pemberton and LJ Skandala- kis. Prob Gen Surg 7(1):85—-102, 1990.)

Figure 15.15. Ligation of the splenic vein. (By permission of LB Pemberton and LJ Skandalakis. Prob Gen Surg 7(1):85—102, 1990.)

Figure 15.17. Compression of the splenic artery and vein. (By permission of LB Pemberton and LJ Skandalakis. Prob Gen Surg 7(1):85-102, 1990.)

Figure 15.16. Medial position of the spleen during the posterior approach to splenectomy, showing division of the splenocolic ligaments. (By permission of LB Pemberton and LJ Skandalakis. Prob Gen Surg 7(1):85—102, 1990.)

Figure 15.19. A. Splenic rupture with hematoma. B. Splenorrhaphy with omental fixation. C. Partial splenectomy with omental fixation. (By permission of LB Pemberton and LJ Skandalakis. Prob Gen Surg 7(1):85-102, 1990.)

Figure 15.20. Splenic mesh wrap. (Top) Passage of injured spleen through hole in center of mesh. (Middle) wrapping spleen in mesh. (Bottom) sewing oppo- site edges of mesh to each other to create tamponade. (By permission of DA Lange, P Zaret, GL Merlotti, et al. J Trauma 28(3):269-275, 1988.)

Figure 15.21. Autotransplantation. (By permission of LB Pemberton and LJ Skandalakis. Prob Gen Surg 7(1):85-102, 1990.) Occlusion of the Splenic Artery 591

Figure 15.23. Modified left lateral decubitus positioning with iliac crest at table break and kidney rest elevated. (From CD Smith. Laparoscopic Splenectomy. In WC Wood and JE Skandalakis, eds. Anatomic Basis of Tumor Surgery. St. Louis: Quality Medical Publishing, Inc, 1999, pp. 670-679, with permission.) Laparoscopic Splenectomy 595

Figure 15.24. Cannula sites and uses for laparoscopic splenectomy. (From CD Smith. Laparoscopic Splenectomy. In WC Wood and JE Skandalakis, eds. Ana- tomic Basis of Tumor Surgery. St. Louis: Quality Medical Publishing, Inc, 1999, pp. 670-679, with permission.)

Figure 15.25. The short gastric vessels are divided. The lesser sac is entered and the splenic artery isolated with a blunt-tipped right angle. (From CD Smith. Laparoscopic Splenectomy. In WC Wood and JE Skandalakis, eds. Anatomic Basis of Tumor Surgery. St. Louis: Quality Medical Publishing, Inc, 1999, pp. 670-679, with permission.)

Figure 15.26. The splenic hilum is the only remaining attachment of the spleen. This is easily controlled and divided with a vascular stapler. (From CD Smith. Laparoscopic Splenectomy. In WC Wood and JE Skandalakis, eds. Ana- tomic Basis of Tumor Surgery. St. Louis: Quality Medical Publishing, Inc, 1999, pp. 670-679, with permission.)

Figure 15.28. The excised spleen is placed in a specimen retrieval sac. (From CD Smith. Laparoscopic Splenectomy. In WC Wood and JE Skandalakis, eds. Anatomic Basis of Tumor Surgery. St. Louis: Quality Medical Publishing, Inc, 1999, pp. 670-679, with permission.)

Figure 16.1. The relations of the adrenal glands from the anterior approach. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Compli- cations in General Surgery. New York: McGraw-Hill, 1983.)

Figure 16.2. The arterial supply and venous drainage of the adrenal glands. As many as 60 arterial twigs may enter the adrenal gland. One or, occasionally, two veins drain the adrenal gland. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 16.3. The lymphatics of the adrenal glands. (By permission of JE Skan- dalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.) The lymphatics of the adrenal gland are usually said to consist of a profuse subcapsular plexus that drains with the arteries and a medullary plexus that drains with the adrenal veins. Drainage is to renal hilar nodes, lateral aortic nodes, and nodes of the posterior mediastinum above the diaphragm by way of the diaphragmatic orifices for the splanchnic nerves (Fig. 16.3). Lymphatics from the upper pole of the right adrenal gland may enter the liver. The major- ity of capsular lymphatic vessels pass directly to the thoracic duct without the intervention of lymph nodes.

Figure 16.4. Incisions for anterior exposure of the adrenal glands. The chevron transabdominal incision provides bilateral exposure. (By permission of JE Skan- dalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

splenic vessels, and the tail of the pancreas, which are enveloped by the sple- norenal ligament.

Figure 16.7. Approach to the left adrenal by incision of the left mesocolon near the splenic flexure. The major branches of the middle and left colic arteries must be spared, but the marginal artery may be sectioned. (By permission of JE Skan- dalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 16.6. Approach to the left adrenal through the gastrocolic omentum opening the lesser sac. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 16.8. Direction of dissection of the left adrenal gland. Note the posi- tion of the left adrenal vein. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 16.10. (By permission of JE Skandalakis, SW Gray and JR Rowe. Ana- tomical Complications in General Surgery. New York: McGraw-Hill, 1983)

Figure 16.12. Incisions for a posterior approach to the adrenal glands. (By per- mission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.)

Figure 16.18. Incision for a thoracolumbar approach to the adrenal gland. (By permission of JE Skandalakis, SW Gray, and JR Rowe. Anatomical Complica- tions in General Surgery. New York: McGraw-Hill, 1983.)

Figure 16.19. Cross section of patient in left lateral decubitus position demon- strating gravity-facilitated mobilization of spleen and distal pancreas to expose the left adrenal.

Figure 16.20. Patient positioning in left lateral decubitus position with kidney rest and table break at iliac crest. (From Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 23(4):389-396, 1999, with permission.)

Figure 16.21. Operating room set-up. (From Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 23(4):389- 396, 1999, with permission.)

Figure 16.22. Cannula sites and uses. (From Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 23(4):389- 396, 1999, with permission.)

Laparoscopic Adrenalectomy 623 Figure 16.23. Initial incision along splenorenal and splenocolic ligaments. (From Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 23(4):389-396, 1999, with permission.)

Figure 16.24. “Opening the Book.” Mobilized spleen and tail of pancreas rotated off of the kidney and adrenal. (From Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 23(4): 389-396, 1999, with permission.)

Figure 16.25. Isolation and control of left adrenal vein. (From Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 23(4):389-396, 1999, with permission.)

Figure 16.27. Specimen retrieval sac is extracted from abdomen through 10 mm cannula site. (From Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 23(4):389-396, 1999, with permission.)

Figure 16.28. Cannula sites and uses for laparoscopic right adrenalectomy. (From Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 23(4):389-396, 1999, with permission.)

Figure 16.29. Hockey-stick incision for initial dissection of right adrenal. (From Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold stan- dard. World J Surg 23(4):389-396, 1999, with permission.)

Figure 16.30. Exposure and isolation of vena cava and right adrenal vein using blunt-tipped right-angle dissector. (From Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 23(4):389- 396, 1999, with permission.)

Figure 16.31. Ligation of right adrenal vein with Ligaclips. (From Smith CD, Weber Cu, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 23(4):389-396, 1999, with permission.)

Figure 17.1. The abdominal aorta as it extends from the diaphragmatic hiatus to the common iliac bifurcation.

Figure 17.3. Infiltration of local anesthesia along the planned line of incision.

gure 17.4. Exposure of the carotid bifurcation and adjacent nerves.

Figure 17.5. Arterial control of common carotid, internal carotid, and external carotid arteries with umbilical tape. Arterial control of superior thyroid artery with 3-0 silk tie.

Figure 17.6. An arteriotomy is made with a scalpel and extended with Potts scissors.

Figure 17.7. Placement of an indwelling shunt from the internal carotid artery to the common carotid artery.

Figure 17.8. An endarterectomy spatula is used to lift plaque off the adventitia.

Figure 17.10. Placement of a Jackson-Pratt drain through a separate incision, and skin closure.

Figure 17.9. Closure of arteriotomy with a polyester patch using 6-0 monofila- ment suture.

Figure 17.11. A vertical incision is made in the posterior parietal peritoneum to provide exposure from the infrarenal aorta to the common iliac arteries.

igure 17.12. Doppler ultrasound interrogation of the inferior mesenteric artery.

Figure 17.13. Incision of the aortic wall and common iliac arteries, facilitating removal of thrombus.

Figure 17.14. Ligation of back-bleeding lumbar arteries with figure-of-eight sutures.

Femoropopliteal Bypass, Below Knee 645 Figure 17.15. The proximal suture line is started on the back wall and brought anteriorly from each side with a continuous running suture.

Figure 17.16. End-to-side anastomosis is fashioned to each iliac artery using a continuous running suture.

Figure 17.17. Reimplantation of the inferior mesenteric artery onto the aortic graft.

Figure 17.19. Incisions along the medial aspect of the leg facilitating dissec- tion of the femoral and popliteal arteries, as well as harvest of the saphenous vein.

Figure 17.21. The below-knee popliteal artery exposure showing branching of the anterior tibial artery.

Figure 17.20. Venous tributaries are ligated with 4-0 silk flush with the main trunk. Their distal aspect may be clipped or tied off in a similar manner. Femoropopliteal Bypass, Below Knee 64S

Figure 17.22. End-to-side anastomosis of spatulated vein to below-knee popliteal artery.

Figure 17.23. Completed distal anastomosis and reversed greater saphenous vein situated in anatomic tunnel.

Figure 17.24. End-to-side femoral anastomosis. Femoropopliteal Bypass, Below Knee _ 657

Figure 18.1. (From HW Jones III. Hysterectomy. In: JA Rock and HW Jones III, eds. TeLinde’s Operative Gynecology, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, p. 810, with permission.)

Abdominal Hysterectomy 657 Figure 18.2. (From JD Thompson and J Warshaw. Hysterectomy. In: Rock JA and JD Thompson, eds. TeLinde’s Operative Gynecology, 8th ed. Philadelphia: Lippincott-Raven, 1997, p. 802, with permission.)

Figure 18.3. (From JD Thompson and J Warshaw. Hysterectomy. In: JA Rock and JD Thompson, eds. TeLinde’s Operative Gynecology, 8th ed. Philadelphia: Lippincott-Raven, 1997, p. 804, with permission.)

Figure 18.4. (From HW Jones III. Hysterectomy. In: JA Rock and HW Jones III, eds. TeLinde’s Operative Gynecology, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, p. 812, with permission.)

Figure 18.5. (From HW Jones III. Hysterectomy. In: JA Rock and HW Jones III, eds. TeLinde’s Operative Gynecology, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, p. 814, with permission.)

Figure 18.6. (From HW Jones III. Hysterectomy. In: JA Rock and HW Jones III, eds. TeLinde’s Operative Gynecology, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, p. 814, with permission.)

Figure 18.7. (From EH Richardson. A Simplified Technique for Abdominal Pan- hysterectomy. Surg Gynecol Obstet (now J Am Coll Surg) 48:248-256, 1929; with permission.)

Figure 18.8. (From JD Thompson and J Warshaw. Hysterectomy. In: JA Rock and JD Thompson, eds. TeLinde’s Operative Gynecology, 8th ed. Philadelphia: Lippincott-Raven, 1997, p. 813, with permission.) 562 18. Uterus, Tubes, and Ovaries

Figure 19.2. The superficial and deep palmar arches and the topography of the motor branches of the median nerve. (By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(1):72-76, 1992.)

Figure 19.3. The “postage stamp” size of the flexor retinaculum. (By permis- sion of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(2):77- 81, 1992.)

Figure 19.4. Superficial relations of the flexor retinaculum. (By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(2):77-81, 1992.)

Figure 19.5. The canals within the carpal tunnel (the middle surgical zone). (By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(2):77-81, 1992.)

Figure 19.6. The proximal surgical zone. (From EW Lampe. Clin Symp 21(3):66—-109, 1969. Copyright by Ciba-Geigy.)

Figure 19.7. The distal surgical zone. (By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(3):158-166, 1992.)

Figure 19.8. A. Palmar cutaneous branches of the ulnar, musculocutaneous, radial, and median nerves. B. Palmar cutaneous branch of the median nerve. (By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(3):158-166, 1992.)

Figure 19.10. Skin incision. This incision follows the natural crease and not the axis of the fourth finger. (By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(3):158-166, 1992.)

Figure 19.11. A. Three possible sites of penetration of the palmar cutaneous nerve. B. Note the palmar cutaneous branch of the median nerve that parallels the palmaris longus tendon. (By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(3):158-166, 1992.)

Figure 19.12. Division of the volar carpal ligament. (By permission of JE Skan- dalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(3):158-166, 1992.)

Figure 19.13. Division of the flexor retinaculum. (By permission of JE Skanda- lakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(3):158-166, 1992.)

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Single artery replantation of totally avulsed scalp

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Variations in the Location of Basilar Artery on Ventral Surface of Pons

Kanij Fatema

Bangladesh Journal of Anatomy, 2014

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Anatomic study of the arterial territories of the face depending on the external carotid artery branches

Sandrine Touzet-roumazeille

Morphologie, 2019

Étude anatomique des territoires artériels de la face dépendants des branches de l'artère carotide externe

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Lee J. Skandalakis Surgical Anatomy and Technique

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