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The Deep Inferior Epigastric Perforator (DIEP) flap is an excellent superior option for autologous breast reconstruction, and considered the gold standard by many following mastectomy, associated with high patient satisfaction and low donor-site morbidity. The traditional single pedicle arrangement may not always provide enough tissue, particularly if trying to match the contralateral breast and this may be a pertinent feature in patients who are slim, post massive weight-loss, had previous liposuction or have a midline abdominal scar. Bipedicled (double pedicle) or stacked configurations of the DIEP flap provide new concepts in flap design, which may overcome some of these precluding features. The use of a double pedicle for unilateral reconstruction can maximize the amount of lower abdominal tissue harvested by recruitment of zone IV territories, and augmenting the overall vascular supply to the flap. This chapter discusses the indications for bipedicled DIEP reconstructions and includes case studies for intra-flap vascular constructs combining DIEA “continuities” with a contralateral SIEA hemi-abdominal flap.

Background Paramedian forehead flap represents a workhorse in facial soft tissue reconstruction but always requires a second step in order to interrupt the skin bridge. Direct visualization and dissection of vascular pedicle may avoid this drawback. Methods Twenty one patients were treated between January 2012 and January 2014: 6 underwent nasal reconstruction and 15 full thickness defect of medial canthus of an orbital region. The follow-up ranges between 6 months and 2 years. All procedures were carried out in a single stage. Result All flaps were performed in a single-stage procedure, survived and healed uneventfully. Conclusion The authors describe a refinement of the original technique to be reserved for cases where vessels could be identified by Doppler, consisting in the direct visualization and dissection of the initial tract of the vascular pedicle, thus providing an extremely mobile pedicle whose size allows to locate the first part of the pedicle in the nasion, tunneling under a skin bridge between the emergence of the vessels and the defect.

The knowledge of variations of blood vessels of kidney is important during operative and diagnostic procedures. The present study contributes in making the clinicians aware of possible variations in renal vascular pedicle. 48 kidney specimens were studied for renal vessels in the Department of Anatomy, Pt. B. D. Sharma PGIMS, Rohtak. Out of 48 specimens, two kidneys were found to have anomalous vasculature. One kidney (Right Side) was observed to have triple renal veins along with an accessory renal artery. One other kidney (Left Side) exhibited triple renal artery. The study is being carried out till date and is planned for an extensive research for another few years to review and to collect more data in this perspective.

In reconstructive surgery, there is a clinical need for an alternative to the current methods of autologous reconstruction which are complex, costly and trade one defect for another. Tissue engineering holds the promise to address this increasing demand. However, most tissue engineering strategies fail to generate stable and functional tissue substitutes because of poor vascularization. This paper focuses on an in vivo tissue engineering chamber model of intrinsic vascularization where a perfused artery and a vein either as an arteriovenous loop or a flow-through pedicle configuration is directed inside a protected hollow chamber. In this chamber-based system angiogenic sprouting occurs from the arteriovenous vessels and this system attracts ischemic and inflammatory driven endogenous cell migration which gradually fills the chamber space with fibro-vascular tissue. Exogenous cell/matrix implantation at the time of chamber construction enhances cell survival and determines specificity of the engineered tissues which develop. Our studies have shown that this chamber model can successfully generate different tissues such as fat, cardiac muscle, liver and others. However, modifications and refinements are required to ensure target tissue formation is consistent and reproducible. This article describes a standardized protocol for the fabrication of two different vascularized tissue engineering chamber models in vivo.

Primary malignant peripheral nerve sheath tumour (MPNST) is an uncommon malignant tumour that arises from the peripheral nerves. Most of these tumours arise in the regions of the trunk, head and neck, or extremities and are rarely seen in the abdomen. In this report, we describe a case of MPNST of the greater omentum, which, to the best of our knowledge, is only the second case reported in the literature. MPNST is an uncommon tumour that can show local invasion and has a high risk of recurrence. We also discuss the utility of “omental vascular pedicle sign” to help establish the omental origin of intra-abdominal masses.

Introduction My new concepts on abdominoplasty have been an important knowledge to improve ear reconstruction on congenital and acquired deformities. In my anatomical research performing dissections on cadaver looking for new surgical operations to perform safe abdominoplasty, it was evident to me that those surgical principles were also correlated with ear reconstruction procedures. As far as normal auricles present important anatomical structures for their support on the lateral sides of the head, when ear reconstruction is done, I was deeply concerned that it is mandatory to create a main pedicle for the new auricle. Meantime, I identified narrow technical knowledge to create a new auricle which stimulated me to devote much effort to find new procedures to improve surgical results in order to achieve well balance to facial contour. Even creation of the temporoparietal fascial flaps is a useful step forward to identify a vascular pedicle to provide adequate blood supply to the reconstructed ear which is similar to the preservation of perforator vessels on new concepts on abdominolipoplasty. When a person presents normal auricles, another one may not see them on each side of the head. However, any alterations on size, shape, position, and location of one or two pinnas will be noticed by most people even from a distance.

The use of autologous abdominal tissue for breast reconstruction has become the gold standard. The highly variable anatomy of the inferior epigastric system has caused an increase in pre-operative computed tomographic angiography (CTA) studies to determine the dominant vascular pedicle of which to base the DIEP or SIEA flap. The use of a coding system based on the dominant perforators increases the utility of the CTA by improving communication between the radiologist and the surgeon, and also enhancing documentation of these perforators for research purposes. The authors describe their coordinate system of identifying perforators so that preoperatively the unique anatomy of the patient can be understood in order to shorten operating time and improve patient outcomes.

The lateral arm flap is a versatile fasciocutaneous flap that may be used locally on the upper extremity or as a microvascular free flap. Since the flap’s description by Song et al. in 1982 [1], its ease of harvesting and the constancy of its vascular pedicle have made the lateral arm free flap an important component in the armamentarium of hand and reconstructive surgeons. The ability to harvest this flap in the same operative field as the recipient defect on the same upper extremity is a major asset in hand surgery.

The present article is an update on progress in the two available techniques of oocyte and ovarian cryopreservation: slow cooling/rapid thawing and vitrification. A new line of research has opened in recent years: freezing the whole ovary with its vascular pedicle, so as to enable vascular grafts limiting ischemia-related follicle reserve loss.The technique of mature oocyte vitrification has advanced significantly, with improved oocyte physiology, increased safety, and higher clinical pregnancy rates. The number of studies on whole ovary freezing has grown, and there has been a large-mammal (sheep) live birth by orthotopic graft with vascular anastomosis of a cryopreserved ovary.Ovarian and oocyte cryopreservation is essential to conserving the fertility of young women. Results of mature oocyte freezing techniques have improved significantly over the past few years, but remain poorer than those with embryo freezing. Mature oocyte vitrification is progressing well, but requires safety validation in view of the high cryoprotectant concentrations used. Ovarian cortex fragment freezing is widely used in patients, with two live births after orthotopic graft, worldwide. The problem of rapid graft exhaustion has led to a focus on whole ovary cryopreservation which has resulted in one live birth in a ewe.

Objective— To evaluate the clinical use and outcome of a rectus abdominis microvascular free flap for wound closure in dogs. Study Design— Retrospective case series. Animals— Dogs (n=9) with complex extremity or oral wounds. Methods— Medical records (2002–2006) of dogs that had a rectus abdominis free tissue transfer to close an extremity or oral wound were reviewed. Results— Nine dogs were identified: 5 had distal extremity wounds, 3 had oral palatal defects, and 1 had a large hygroma excised. A rectus abdominis free tissue transfer with a caudal epigastric vascular pedicle was successfully used for management of these wounds. No major complications occurred with the donor site and a good cosmetic and functional outcome occurred in all dogs. Conclusion— The rectus abdominis is a versatile muscle that can be used for reconstructing cutaneous and oral defects with repeatable success. Clinical Relevance— Free tissue transfer of the rectus abdominis muscle is a clinically useful technique for closure of a variety of difficult soft tissue wounds.

Objetivo: cuantificar las medidas del mediastino, índice cardiotorácico y pedículo vascular en las radiografías tomadas con el paciente en decúbito supino y en espiración, comparadas con las tomadas en vertical y en inspiración, y así proponer una estandarización del proceso de evaluación del mediastino.Materiales y métodos: estudio prospectivo de correlación inter-observadores, realizado en el servicio de imágenes diagnósticas del Hospital de San José, en el período comprendido entre enero y diciembre de 2.003. A los pacientes seleccionados dentro de los criterios de inclusión, se les realizaron cuatro radiografías en vertical y en decúbito, en inspiración y espiración, y se determinó el IC y el PV, medidas realizadas en forma independiente por dos radiólogos expertos. Se evaluó el grado de correlación entre los dos observadores utilizando el coeficiente de Pearson (p 0.05).Conclusión: la variabilidad en hombres con el cambio de posición a decúbito en espiración es de 0.06 para el IC y de 1.35 cm para el PV. En las mujeres la variabilidad es de 0.09 para el IC y de 1.18 cm para el PV independiente de la edad. Se encontró que los hallazgos se correlacionan con las escasas publicaciones, pero los datos obtenidos en nuestra muestra poblacional son menores que los referidos en la literatura internacional.Abreviaturas: MM, medidas del mediastino; IC, índice cardiotoráxico; PV, pedículo vascular; DS, desviación estándar; VI, vertical inspiración; VE, vertical espiración; DI, decúbito inspiración; DE, decúbito espiración.

The serratus anterior flap is commonly used without its cutaneous component and is covered with a skin graft. We have successfully used the free serratus anterior flap along with its skin paddle and have found it to be valuable for reconstruction of the face. We have done fresh cadaveric dissections and arteriography to identify perforator vessels to the skin overlying the muscle. Clinically, free transfer of the musculocutaneous flap to the face was carried out in 27 patients, mostly for severe noma (infection) sequellae. Anatomical dissection and arteriography revealed no cutaneous perforator vessels directly communicating with the vascular pedicle of the muscle. However, large perforators from the intercostal vessels were found passing through the muscle to reach the skin. In the clinical cases, flap survival was 100% in 24 patients. The serratus anterior musculocutaneous flap is reliable and particularly well-suited for reconstruction of the face with many advantages. We speculate that the skin paddle may be vascularised by perforators from the intercostal vessels communicating with the thoracodorsal pedicle through intramuscular choke vessels.

Background: To assess the natural pregnancy of rabbits submitted to bilateral oophorectomy and orthotopic allogeneic or autologous intact and sliced ovarian transplantation without a vascular pedicle, and to determine the morpho-functional aspects of the transplanted ovaries. Methods: Fifty-six female rabbits were studied. The ovaries were removed and orthotopically transplanted or replaced without vascular anastomoses: Group 1 (n = 8), only laparotomy and laparorrhaphy; Group 2A (n = 8), intact ovaries were transplanted on both sides; Group 2B (n = 8), both ovaries were sliced and orthotopically transplanted; Group 2C (n = 8), an intact ovary was transplanted on one side and a sliced ovary on the other side; Groups 3A–C, the ovaries were reimplanted according to the procedure and subgroups described for Group 2. Three months later, the animals were paired with males for copulation. Estradiol, progesterone, FSH and LH hormone levels were assessed. A histological study was carried out, and the number of pregnancies and litters were also determined. Chi-squared test compared the number of pregnancies and litters. One-way anova and the Tukey-Kramer tests compared the hormonal dosages. Results: Pregnancies occurred in seven rabbits of Group 1, in 37.5% of rabbits in Groups 2A and 3A, in 50% of groups 2B, 3B and 3C, and in 62.5% of group 2C. Hormone levels and histology confirmed the vitality of all ovaries. Conclusions: Intact or sliced orthotopic allogeneic and autologous ovarian transplantation without a vascular pedicle is viable in rabbits, and preserves their hormonal and fertile functions.

Since the introduction of microsurgery and free flap transfers, the techniques of dissection and harvesting of flaps and their vascular pedicles have continuously advanced. As the vascular pedicles of free and pedicled flaps should be protected during their harvest or dissection, the usual trials to protect pedicle vessels depend ultimately on the surgeon and clinical experience. A new microsurgical instrument, the vessel protector, facilitating protection and holding of the vascular pedicle has been developed. Through experimental and clinical trials, the instrument has been demonstrated to protect the structures inside a distal coiled end while also holding them. This has several advantages over conventional dissection by jeweler's forceps and scissors.

Purpose To evaluate the application of the medial sural artery perforator flap (MSAPF) aided by preoperative ultrasonic perforator localization for postsurgical reconstruction of oral carcinoma. Materials and Methods From November 2013 to August 2014, 25 patients with oral carcinoma underwent postsurgical reconstruction after oral carcinoma resection using MSAPFs. To explore and locate the perforators, preoperative vascular ultrasound localization was used to find the MSAPs. The number and location of the perforators, length of the vascular pedicle, and thickness of the MSAPF were measured. Thirty-eight patients who underwent reconstruction with a radial forearm flap (RFF) and 21 patients who underwent reconstruction with an anterolateral thigh flap (ALTF) were selected for comparison. Results The number of MSAPs ranged from 1 to 4, and 52 perforators were found accurately using preoperative ultrasonic localization (92.86%). The distance from the perforator to the popliteal crease ranged from 6.2 to 17.1 cm (10.70 ± 2.31 cm); the distance from the perforator to the midline of the back of the calf ranged from 0.1 to 3.5 cm (1.83 ± 0.81 cm); and the pedicle length ranged from 6.8 to 12.5 cm (10.14 ± 1.51 cm). Compared with the RFF, and ALTF, the thickness, postoperative oral sensation, and function of the MSAPF were similar to those of the RFF but better than those of the ALTF. In appearance and function of the donor site, the MSAPF was similar to the ALTF, but better than the RFF. Conclusion The MSAPF is a good alternative for postsurgical reconstruction of oral carcinoma because of its anatomic structural stability, suitable thickness, minimal donor-site scar, and ideal functional recovery after surgery. Preoperative vascular ultrasonic localization is a feasible and advantageous method for preoperative mapping of the MSAP because of its high accuracy.

Torsion of a wandering spleen is a rare cause of acute abdomen in children, usually diagnosed with color-Doppler ultrasonography and enhanced computed tomography. We report a pediatric case of torsion of wandering spleen.

Complete ectopia cordis in the newborn represents a significant management challenge. There are minimal data available to inform optimal clinical care for those infants with coexisting complex congenital heart disease who are therefore not candidates for surgical intervention. The exteriorisation of the heart and absence of the pericardial sac requires meticulous wound care to prevent desiccation of the myocardium and to minimise infection risk. Additionally, the technique selected must address the risk of occlusion of the cardiac vascular pedicle and abrasion between the mobile myocardium and dressing surface. We report a novel approach to wound management and integrated palliative care that enabled community-based care. Our patient, a full-term male infant with complete ectopia cordis was born in good condition by assisted vaginal delivery. He was discharged from hospital on day 8 and was cared for in the community until his demise from cardiac failure on day 15.

In this article, we describe a case of maxillary carcinoma requiring reconstruction in which we used a free deep inferior epigastric perforator (DIEP) flap combined with vascularised costal cartilages. The DIEP flap was harvested with a rectus abdominis muscle in its cranial side. Eighth and ninth costal cartilages were harvested and connected with the muscle. The Zygomaticomaxillary buttress was reconstructed using vascularised costal cartilages. Nasal and oral lining were reconstructed with a DIEP flap. The viability of grafted bone was proved in bone scintigraphy and three-dimensional computed tomography after six months. Cosmetically the result was good. Compared with other methods, this flap can be thinned easily to match a defect and vascularised cartilages connected with rectus muscle can be nourished by the same vascular pedicle. This is a first report of perforator flap combined with vascularised cartilage. This flap has a possibility to be used for a lot of reconstruction that needs bone reconstruction with perforator flap.

A valid, low-cost, high-yield instrument to assess intravascular volume status in critically ill patients does not exist. The portable chest X-ray is a common part of any intensivist's or chest clinician's daily rounds.A simple, objective, valid measure of intravascular volume status, the vascular pedicle width, remains underappreciated in the medical literature. While more invasive, more expensive, and less common technologies are looked upon to assist in the clinical evaluation of volume status among critically ill patients, the vascular pedicle width stands alone in its low-cost, nearly risk-free potential to impact clinical practice. Even as the daily chest X-ray has become less common in practice, the role of measuring vascular pedicle width is potentially significant, particularly among mechanically ventilated patients. A standardized approach to reading the portable chest X-ray (supine or erect) is needed to facilitate interpretation of complex medical problems among the critically ill. Prospective evaluation of its appropriate use, particularly as compared with other, typically more invasive measures of intravascular volume, is warranted.Vascular pedicle width measurement using a standardized approach to daily chest X-ray interpretation represents untapped potential for improving the non-invasive assessment of volume status in critically ill patients.

In the quixotic quest for the “ideal” flap, the major attribute of the medial circumflex femoral artery perforator flap is its minimal donor-site deformity even if primary closure is not possible and a skin graft must be used. This source vessel captures the medial groin skin territory, and therefore sometimes has been referred to as the “medial groin” flap. This flap can be moderately large, the donor site easily hidden by clothing, the flap almost always has at least a single relatively large musculocutaneous perforator, and the location of the vascular pedicle has a consistent location already familiar to most microsurgeons. The history and approach specifically in the development of the medial circumflex femoral artery perforator flap is presented here to explain the rationale as to why this donor site deserves consideration in the hierarchy of cutaneous flap selection.

Programmable pump for continuous infusion of intrathecal baclofen, an agonist of the inhibitory neurotransmitter gamma-aminobutyric acid, is nowadays being widely used to control spasticity. The most common complications leading to explantation of the pumps are skin breakdown and infection at the pump implantation site which cannot be effectively treated without pump removal. We report a 37-year-old man who developed a baclofen pump pocket infection that did not respond to antibiotic therapy. Because the continuation of intrathecal baclofen administration was critical to the patient, and because the high cost of the pump precluded its prompt replacement, the pump was salvaged using the ipsilateral rectus abdominis muscle that was elevated on its inferior vascular pedicle and wrapped around the pump. Abdominal skin was then approximated, leaving a small portion of exposed muscle overlying the refill site that was covered by a split-thickness skin graft. Continuous intrathecal baclofen administration was never discontinued. Three months later, the pump's refill site could be easily identified manually for pump refill. There were no signs of recurrent infection during the 2-year follow-up period.

The main aim of the treatment of fingertip amputations with no indication of replantation was to establish the functional and esthetic construction. The critical point in the utilization of the bone and nail tissue as a graft for reconstruction was to choose a flap that is sufficiently vascular to nourish these grafts. We have performed homodigital artery flaps to cover the bone and nailbed grafts taken from the amputation to restore fingertip function with an acceptable result. The venous insufficiency with the increased probability in flap failure should be taken into consideration. We proposed the preservation of some amount of soft tissue around the vascular pedicle to overcome the venous insufficiency and in our point of view, digital artery sacrifice was worth it to preserve the length of the finger and the esthetic nail appearance.

High-energy trauma resulting in a composite defect of the lower extremity confronts the microvascular surgeon with more difficulties than do free flap reconstruction elsewhere in the body, since the choice of distant recipient vessels is particularly difficult. Combining principles of perforator flap surgery with those of composite tissue transfer, we designed a thoracodorsal artery perforator flap with a vascularized bone segment from the scapula for reconstruction of a composite lower extremity defect in a patient following a paragliding accident. This is the first report on the application of a composite thoracodorsal artery perforator flap with vascularized scapula in lower extremity reconstruction. Among its multiple advantages, such as preservation of latissimus dorsi function, it is a good tool for one-stage reconstruction of traumatic composite lower extremity defects because its low donor site morbidity and long vascular pedicle enables anastomosis placement outside the zone of injury.

An anatomic study was performed to analyse the proximal perforator vessels of the gracilis musculocutaneous flap. Twenty-three cadaver legs preserved by the method of Thiel were carefully dissected 24h after the proximal vascular pedicle was injected with a red silicone mass. Nine additional cadaver legs were injected with ink, to visualise the skin area supplied by the proximal perforators, respectively, clarified by a modified Spalteholz technique to demonstrate the anatomic course of the perforators. A considerable variation in numbers and localisation of proximal cutaneous perforators was found. One to four perforators were seen within an area of 6 x 6 cm(2) at the entrance of the main pedicle into the proximal gracilis muscle. Their external diameter ranged from 0.5 to 1.0 mm. The ink-injections showed an oval shaped angiosome with a mean surface of 88 cm(2) at the level of the proximal gracilis pedicle. We conclude from this anatomic study, that a cutaneous flap based on the medial circumflex femoral gracilis perforators can be harvested by experienced hands bearing in mind the unpredictable perforator-anatomy.

When it is necessary to apply free flaps for foot reconstruction, the choices are limited. Conventionally, split-thickness skin-grafted muscle flaps and fasciocutaneous flaps from the back or thigh have been two major options, but these methods take substantial time to wearing normal shoes. As an alternative, the authors use the deep inferior epigastric perforator (DIEP) flap with an external pedicle. After elevation and thinning of the flap, the vascular pedicle is anastomosed at a site distant from the skin defect of the foot. About 20 days after that, the pedicle is severed, and the skin island is trimmed and sutured. This method provides thin and wide coverage within a limited time, and donor-site morbidity is minimal both functionally and aesthetically.

Alternative techniques for pedicle transfer of a reverse radial forearm flap for hand coverage, and a latissimus dorsi myocutaneous free flap for pelvic wound coverage, are illustrated. Exteriorization of the vascular pedicle of a reverse radial forearm flap allows a greater arc of movement of the flap for more distal coverage, and avoids the potential vascular compromise of tunnelling under a tight skin bridge. Two-stage transfer of a latissimus dorsi myocutaneous free flap on a wrist carrier pedicle may be useful in circumstances when local recipient vessels are inadequate for free flap transfer. Although both of these vascular pedicle modifications have drawbacks, they may be of value in limited circumstances. Their advantages and limitations are discussed.Les techniques alternatives de transfert de pédicule dans un lambeau radial inverse à l’avant-bras pour couverture de la main et d’un lambeau libre myocutané du grand dorsal pour couverture d’une plaie pelvienne sont illustrées ici. L’extériorisation du pédicule vasculaire pour un lambeau radial inverse à l’avant-bras permet un plus grand arc de mouvement du lambeau pour une couverture plus distale et évite le compromis vasculaire potentiel d’un tunnel sous un pont cutané resserré. Un transfert en deux étapes du lambeau libre myocutané du grand dorsal sur un pédicule porteur au niveau du poignet peut être utile lorsque les vaisseaux receveurs locaux ne sont pas adéquats pour un transfert de lambeau libre. Bien que ces deux modifications du pédicule vasculaire aient leurs inconvénients, elles peuvent être utiles dans certaines circonstances. Leurs avantages et leurs limites sont présentés ici.

Between June 1992 and November 2002, 17 patients underwent secondary reconstruction of circumferential esophageal defects due to the failure of immediate reconstruction following ablation of thoracic esophageal cancer. Salvage reconstruction was achieved using free jejunal transfer in 13 patients (including long segment with double vascular pedicle in 2 cases), skin and/or musculocutaneous flap in 2 cases, and jejunal pull-up in 2 cases. In 5 patients, the second salvage surgery was required because of the failed first salvage. However, successful restoration of the esophagus and peroral alimentation was finally achieved in 16 of 17 patients, except 1 patient with several salvage operations using skin and musculocutaneous flap because the gut was unusable. We concluded that the preferred first choice for salvage restoration is free jejunal transfer. If the length of the esophageal defect is extensive, colonic interposition or jejunal pedicle with microvascular anastomosis for supercharging is the next option. If these procedures cannot be used, the transfer of a long jejunal segment with double vascular pedicles is recommended. Reconstruction using skin and/or musculocutaneous flap is the final option. As primary wound closure is often difficult in secondary reconstruction of the esophagus, a pectoralis major musculocutaneous flap is reliable to cover the reconstructed esophagus because skin flaps located in the neck region may be damaged by neck dissection or irradiation, and coverage of the anastomosis with muscle between the digestive tracts is effective to prevent leakage.

Dog and rat animal models have been developed for repeated intravascular administrations to the liver. However, mice have generally been considered too small to use for these models. This study describes the development of mouse models that permit the establishment of liver metastases that can be subsequently treated by repeated injections into the portal venous system. A mini-laparotomy is done to mobilize the spleen and transpose it to a s.c. pocket with its vascular pedicle intact. A suspension of single tumor cells is then inoculated into the portal vein to establish diffuse liver metastases. These tumors may be treated by simple percutaneous injections directly into the s.c. whole spleen reservoir. The ease of injection into the s.c. spleen permits repeated injections into the portal venous system. The usefulness of this model was shown in experiments revealing that multiple portal venous administrations of a replication-conditional, oncolytic herpes simplex virus mutant are more effective than a single portal venous administration. In a modification of this model, the spleen is first split into two, leaving intact the vascular pedicle for each half of the spleen. Tumor cells are inoculated into one hemi-spleen, which is then resected 10 minutes later. The other hemi-spleen is transposed to the s.c. position, thereby permitting subsequent repetitive portal venous injections via percutaneous injections into the s.c. hemi-spleen. These mouse models are useful for a wide range of studies.

Guneren, Ethem/0000-0002-5981-7010; Demir, Ahmet/0000-0002-8820-3122 WOS: 000228608300005 PubMed: 15880296 This article describes a pedicle-lengthening procedure (the Y-V-I principle) that reverts a Y-shaped vascular structure into an I-shaped vascular structure, and its application to the latissimus dorsi muscle. If the Y-shaped vascular structure is divided proximal to the branching point and ligated, it becomes a V-shaped vascular structure. To obtain a linear I-shaped vascular structure, the V is opened, and the length of the vascular pedicle will become equal to the combined length of both limbs of the V. This report indicates that the latissimus dorsi flap may be transferred based on the circumflex scapular artery or the serratus branch.

Biliary conduits are constructed in operations for choledochal cysts. A wide variety of options are available for biliary tract reconstruction. We present our experience of treating six children with choledochal cysts by using the appendix as a biliary conduit. After mobilizing the appendix on its vascular pedicle, nonrefluxing, tunneled anastomosis was made with the 2nd part of the duodenum and the appendix. The operative procedure was simple and less time-consuming. Postoperative evaluation was done with the help of HIDA scan and ultrasound examination. Postoperative cholangitis was conspicuously absent in the two years of follow-up. One child has been lost to follow-up. From our preliminary experience, the operation seems simple and satisfying. Though the long-term efficacy still remains to be proven, the appendix should prove durable as a functional conduit.

Clinical applications of two free lateral leg perforator flaps are described: a free soleus perforator flap that is based on the musculocutaneous perforator vessels from one of the three main arteries in the proximal lateral lower leg, and a free peroneal perforator flap that is based on the septocutaneous or direct skin perforator vessels from the peroneal artery in the distal and middle thirds of the lateral lower leg. The authors applied free soleus perforator flaps to 18 patients and free peroneal perforator flaps to five patients with soft-tissue defects. The recipient site was the great toe in 14 patients, the hand and fingers in five patients, the leg in two patients, and the upper arm and the jaw in one patient each. The largest soleus perforator flap was 15 x 9 cm, and the largest peroneal perforator flap was 9 x 4 cm. Vascular pedicle lengths ranged from 6.5 to 10 cm in soleus perforator flaps and from 4 to 6 cm in peroneal perforator flaps. All flaps, except for the flap in one patient in the peroneal perforator flap series, survived completely. Advantages of these flaps are that there is no need to sacrifice any main artery in the lower leg, and there is minimal morbidity at the donor site. For patients with a small to medium soft-tissue defect, these free perforator flaps are useful.

Die drei häufigsten Ursachen des Lungenödems sind die Herzinsuffizienz, die Niereninsuffizienz und der diffuse Alveolarschaden (Permeabilitätsödem). Das Permeabilitätsödem lässt sich von dem kardialen und renalen Lungenödem relativ leicht abgrenzen durch die typisch periphere fleckförmige alveoläre Transparenzminderung mit Bronchopneumogramm, ohne interstitielle Transsudation und nur selten mit Pleuraergüssen. Sowohl das kardiale als auch das renale Lungenödem sind meistens von einer Herzvergrößerung, einer Verbreiterung des sogenannten Vascular Pedicles und einer Umverteilung der Lungenzirkulation begleitet. Beide beginnen interstitiell und gehen dann oft in ein alveoläres Stadium über. Pleuraergüsse kommen oft vor. Das Verteilungsmuster hilft oft bei der Unterscheidung: das kardiale Lungenödem folgt der Gravitation (basal betont) und das renale Lungenödem liegt oft zentrobasal.

Objective To describe the clinical use of a semitendinosus myocutaneous flap for soft-tissue reconstruction of a grade IIIB open tibial fracture. Study Design Case report. Animals A 5-year-old castrated male Labrador retriever with a grade IIIB open tibial fracture. Methods A myocutaneous flap was created by elevating the origin of the semitendinosus muscle and the associated overlying skin. The flap was rotated distally based on the distal vascular pedicle into a soft-tissue defect overlying the central and distal third of the tibia. Results The flap allowed one-stage reconstruction of a severe soft-tissue defect overlying denuded bone in a grade IIIB open tibial fracture. The muscular portion of the flap survived; however, there was necrosis of 3 cm of skin extending distally beyond the muscular portion of the flap. Conclusion Distal rotation of the semitendinosus muscle and overlying skin can be used in the treatment of severe soft-tissue defects of the canine crus. Clinical Relevance Complex soft-tissue injuries to the canine crus can be treated with a myocutaneous flap as a reasonable alternative to other reconstructive techniques.

Torsion of the greater omentum is a rare condition of acute abdomen. We, herein, report a 37-year-old man, who presented to the emergency department with right lower abdominal pain, nausea, and fever. The initial clinical impression was acute appendicitis. Preoperative computed tomographic study showed a well-defined, fat-containing mass interspersed with soft-tissue strands in the right lower abdomen and pelvis, and it also induced partial obstruction of the small intestine. This mass was found in connection with a vertical rod of the omental vessels. Surgical exploration revealed torsion of the greater omentum with hemorrhagic infarction. Computed tomography (CT) is a useful imaging modality for making a specific diagnosis. An inflamed fat-containing mass with a vascular pedicle is characteristic for the torsion of the greater omentum.

Laparoscopic hepatectomy has been recently proposed for the treatment of liver tumors, however there is a lack of experimental models to study surgical technique and the metabolic reactions after this procedure. The dog is an important animal for research but the laparoscopic hepatectomy model is not well established in this animal. We describe the surgical laparoscopic technique of left liver segmentectomy in the dog and the preliminary results of this procedure. Female dogs weighting more then 15 kg were used. Four transversal abdominal incisions (two of 1 cm and two of 0.5 cm) were made for the introduction of the video camera and the other laparoscopic instruments. The liver was inspected and the left lobe was mobilized through incision of the left triangular hepatic ligament. The vascular pedicle corresponding to the left medial lobe (corresponding to segment II) was identified, dissected, and clamped, delimiting a correspondent ischemic area. The hepatic parenchyma was divided according to the previous delimitation with minimum bleeding. The segment of the liver was then removed through an enlarged abdominal incision. The incisions were closed by continuous suture. The mean time of the procedure was forty minutes. We observed normal clinical evolution without any sign of complications due to the hepatic resection, and normal augmentation of body weight on follow-up of more than 3 months. Left hepatectomy in the dog is a viable procedure and may serve for surgical training and development of research projects in this field.

Free-tissue transfer has become the accepted standard for reconstruction of complex defects. With the growth of this field, anatomic studies and clinical work have added many flaps to the armamentarium of the microvascular surgeon. Further advancements and experience with techniques of perforator flap surgery have allowed for the harvest of flaps in a free-style manner, where a flap is harvested based only on the preoperative knowledge of Doppler signals present in a specific region. Between June of 2002 and September of 2003, 13 free-style free flaps were harvested from the region of the thigh. All patients presented with an oral or pharyngeal cancer and underwent resection and immediate reconstruction of these flaps. All flaps were cutaneous and were harvested in a suprafascial plane. The average size of the flaps was 108 cm2 (range, 36 to 187 cm2), and the average length of the vascular pedicle was 10 cm (range, 9 to 12 cm). All flaps were successful in achieving wound coverage and functional outcomes without any vascular compromise necessitating re-exploration. Free-style free flaps have become a clinical reality. The concepts and techniques used to harvest a free-style free flap will aid in dealing with anatomic variations that are encountered during conventional flap harvest. Future trends in flap selection will focus mainly on choosing tissue with appropriate texture, thickness, and pliability to match requirements at the recipient site while minimizing donor-site morbidity.

The principle of prefabricated flaps is based on the transformation of a formerly random-pattern vascularized flap, through implantation of a vascular pedicle, into a newly neovascularized axial flap, which can be transferred after a period of neovascularisation from the prepared donor site to the recipient site by using microvascular techniques. In 30 Chinchilla Bastard rabbits weighing from 3700 to 4200 g, a skeletonized arteriovenous pedicle with distal ligation harvested from the femoral and saphena magna artery and vein was implanted beneath an 8 x 15 cm abdominal skin flap to investigate the neovascularisation process in the flap over the course of time. In order to prevent neovascularisation occurring from the underlying vascular bed into the flap, a silicon sheet measuring 8 x 15 cm x 0.25 mm was placed and fixed on the abdominal wall. Flap vitality and neovascularisation process in prefabricated flaps were evaluated by macroscopic observation, blood analysis, selective microangiography, histology and scintigraphy at the various time intervals of 4, 8, 12, 16 and 20 days. The study results showed that newly formed vessels sprouting from the implanted pedicle were seen four days after pedicle implantation. With the retention time of pedicle in the flaps, they continued to grow, became meander and more dense. Respective connections between newly formed vessels and the originally available vasculature of the abdominal flap were markedly observed in the 12- and 16-day groups. Twenty days after prefabrication, the abdominal flap was completely perfused by the blood flow supplied from the newly implanted arteriovenous pedicle through newly formed vessels arising from the implanted pedicle and their rich vascular communications. The neovascularisation in the prefabricated flap consisted of the implanted pedicle, newly formed vessels, the originally available vasculature and their vascular connections. In comparison to the control group (the quantification was determined of 100 %), the vessel quantity in the prefabricated flap of the 20-day group had increased to 98.7 %. As a pre-clinical test, prefabricated flaps through arteriovenous pedicle implantation with special advantages can be a new useful method in plastic and reconstructive surgery.

Covering of soft tissue injuries on the lower leg is frequently a difficult challenge. In this article the sural artery flap is presented as a valuable therapeutic plastical surgery method for covering of these defects. Within the middle dorsal area of the lower leg, and centered above the sural nerve, an island of skin is cut out and the subcutane vascular pedicle is prepared along the nerve. The won skin flap is rotated into the defect and fixed without tension. The flap pedicle is covered with meshcraft, the wound closing of the donor-site defect is usually done primarily. This article reports on 25 men and 10 women, who were treated between May 1997 and December 2003 using the neuro vascular sural flap. With 30 of the 35 patients the flap healed without functional impairment, only one patient experienced a necrosis leading to the loss of the flap, while in 4 cases a partial loss of the skin island was registered. By means of meshcraft transplantation a complete healing was achieved. The superficial sural artery flap usually results in a reliable and complete healing of soft tissue defects within the area of the lower legs with justifiable operational expenditures also with old and vascular-ill patients.

This study was designed to determine the entering sites of vascular pedicles of the infrahyoid muscles. The neck regions of 12 cadavers were investigated bilaterally. The vascular pedicles of the infrahyoid muscles (except the thyrohyoid and inferior belly of the omohyoid muscle) were dissected and measurements taken with a caliper in reference to the attachments of the muscles. For the sternothyroid muscle, two vascular pedicles were found bilaterally in all cadavers. Two vascular pedicles were found bilaterally for the sternohyoid muscle in 11 cadavers; in one cadaver the inferior vascular pedicle was absent bilaterally. One vascular pedicle was found bilaterally for the superior belly of the omohyoid muscle in all cadavers. These data regarding the vascular pedicles of the infrahyoid muscles might be useful for preserving the vascular supply of the infrahyoid muscles during flap preparation.

The superior medial thigh skin territory has previously been successfully transferred as a free flap as part of a gracilis musculocutaneous flap. However, muscle bulk can be avoided and its function preserved by instead retaining only the musculocutaneous perforators arising from the gracilis pedicle like in a true perforator flap. A clinical example of this new perforator flap is described as the gracilis (medial circumflex femoral) perforator flap. This could become an ideal skin flap because no muscle is included, a well-defined segment of skin can be reliably harvested, closure of the donor site leaves a scar in the groin that can be readily concealed, and its dominant vascular pedicle is consistent in location and already familiar to most reconstructive surgeons.

Microsurgical reconstruction has evolved to a stage where a nearly 100% success rate has been achieved. Therefore, refinement of the functional and aesthetic result, as well as a decrease in donor site morbidity have become the major concerns. The anterolateral thigh flap meets these requirements; its wide application to various fields is based on the following charateristics. Its reliable vascularity. Its vascular pedicle is long and large, at least 8 cm (can be 20 cm). Flap territory is large and easy to design. The pedicle can be at the periphery of the flap. Its length can be 40 cm and its width can be half of the thigh, with the maximal dimension as large as 40 x 20 cm (800 cm2). Primary trimming of the flap to 3 mm to 5 mm in thickness does not compromise its vascularity. The subcutaneous fat can be included to facilitate gliding of the underlying tendons. To harvest chimeric flaps, the following components can be included: muscles, fascia and bone (an osseous flap can be joined to the flap with microvascular anastomoses). A two-team approach is possible, because the recipient site is usually far away from the donor site. Usually it does not require that the patient change position. It can be closed primarily without skin graft if its width is less than 8 cm. The donor site is easily covered with clothes, and the motor function is least affected. Care should be taken in flap dissection, inset, and postoperative care, as well as strategies for re-exploration.

PURPOSE OF REVIEW Open partial nephrectomy is now recognized as the standard of care for small renal parenchymal tumors. Significant technical problems remain with regard to performing this procedure laparoscopically, namely warm renal ischemia during occlusion of the renal vascular pedicle and renal parenchymal bleeding following tumor excision and release of pedicle control. This article reviews the recent literature in the field of renal parenchymal hemostasis and its role in improving outcomes and increasing applicability for laparoscopic nephron-sparing surgery. RECENT FINDINGS Two themes emerge in reviewing the recent literature on renal hemostasis: the use of increasingly advanced tissue sealants and the use of physical methods. Advances in both areas are covered in this article. SUMMARY Laparoscopic partial nephrectomy has been developed in an attempt to reduce the morbidity of the open technique. We believe that advances in secure renal parenchymal hemostasis will increase the applicability of the laparoscopic procedure and bring it within the grasp of ordinary urologists.

Microvascular transfer of the omentum has several unique advantages for the reconstruction and revascularization of extremity wounds. The omentum provides well-vascularized, malleable tissue for reconstruction of extensive soft-tissue defects and has a long vascular pedicle (35 to 40 cm) with sizable vessels, which reduces some of the potential technical challenges of microsurgery. It can also be used for flow-through revascularization of ischemic distal extremities. The unique properties of the omentum make it an ideal tissue for the reconstruction of difficult extremity defects, allowing simultaneous reconstruction and revascularization. Experience with six free omental tissue transfers for upper-extremity and lower-extremity reconstruction is described. Three of the cases involved distal anastomoses to take advantage of the flow-through characteristics of the flap, providing distal arterial augmentation. All flaps accomplished the reconstructive goals of wound coverage and extremity revascularization. The omentum is a valuable, often overlooked tissue for the treatment of difficult extremity wounds.

OBJECTIVE: In gracilis functioning free muscle transplantation, the limited caliber of the dominant vascular pedicle increases the complexity of the anastomosis and the risk of vascular compromise. The purpose of this study was to characterize the results of using a T-shaped vascular pedicle for flow-through anastomosis in gracilis functioning free muscle transplantation for brachial plexus injury. METHODS: The outcomes of patients with brachial plexus injury who received gracilis functioning free muscle transplantation with either conventional end-to-end anastomosis or flow-through anastomosis from 2005 to 2013 were retrospectively compared. In the flow-through group, the pedicle comprised a segment of the profunda femoris and the nutrient artery of the gracilis. The recipient artery was interposed by the T-shaped pedicle. RESULTS: A total of 46 patients received flow-through anastomosis, and 25 patients received conventional end-to-end anastomosis. The surgical time was similar between the groups. The diameter of the arterial anastomosis in the flow-through group was significantly larger than that in the end-to-end group (3.87 mm vs. 2.06 mm, respectively, p

Among the various techniques proposed to protect the median nerve from scarring and to provide it with a vascular supply, the synovial flap represents a simple and effective method. The flap is taken from the flexor tendons sheath and results in a thin and richly vascularized tissue that will act as a barrier to scarring and provide neovascularization to improve nerve regeneration and gliding. The aim of this study was to evaluate the arterial vascularization of this flap to assess its reliability. An anatomic study was carried out on 24 fresh upper limbs infused with colored and radiopaque solutions before or after flap elevation. Anatomical findings showed the synovial flap to be supplied by a consistent vascular pedicle arising from the ulnar artery 2 to 5 centimeters proximal to the pisiform bone and running between the flexor tendons of the ring and little fingers. The synovial flap is known to be a simple and effective method for protecting the median nerve. The present study shows that its consistent vascularization makes it a reliable technique. We believe this procedure is relevant for the treatment of recurring carpal tunnel syndrome.

Background Following colon resection, the construction of a well-perfused, tension-free isoperistaltic anastomosis can be made difficult by multiple factors including prior abdominal surgery or compromised vascular supply. Here, we describe the technique of antiperistaltic cecorectal anastomosis as a method for preserving viable colon without compromising functional outcome. Technique Following extensive colorectal resection, different techniques for isoperistaltic reconstruction using the cecum and ascending colon have been described, including the Deloyers procedure and limited isoperistaltic cecorectal anastomosis. However, these isoperistaltic reconstructions often require ligation of the middle colic and right colic arteries and/or sacrifice of viable distal colon to aid reconstruction. In complex situations that require preservation of normal vascular anatomy, an antiperistaltic cecorectal anastomosis can be constructed that maintains the orientation of the vascular pedicle. In addition to the preservation of the colonic arterial supply, a distinguishing feature of this technique is the substantial portion of antiperistaltic colon that is preserved and interposed to reestablish continuity. Results In a case where it was used, construction of an antiperistaltic cecorectal anastomosis was technically successful and led to a good functional outcome. Conclusion Antiperistaltic cecorectal anastomosis should be considered as an option in colonic reconstruction for patients with extensive prior abdominal surgery or when complex anatomic issues require preservation of native vascular anatomy. In these situations, this technique offers several advantages over isoperistaltic reconstruction and may be the only option for reconstruction that uses the remaining cecum and colon.

Implantation of a penile prosthesis is necessary to guarantee the rigidity necessary for penetrative sex. Inflatable device guarantees superior results than malleable implant. The procedure is challenging due to the lack of the protective tunica albuginea in the phallus, and complication rates are higher than in the case of virgin implants in the male.