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Pankaj Garg,1 Baljit Kaur,2 Vipul D Yagnik,3 Sushil Dawka4 1Indus Super Specialty Hospital, Mohali, India; 2Department of Radiology, SSRD MRI Centre, Chandigarh, India; 3Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India; 4SSR Medical College, Belle Rive, MauritiusCorrespondence: Pankaj GargIndus Super Specialty Hospital, Mohali, 140607, IndiaFax +91-9501011000Email drgargpankaj@yahoo.comBackground: In the anal sphincter complex, the intersphincteric space between the internal and external sphincters is the only conventionally recognized pathway for the spread of sepsis. However, there is another unrecognized space discovered on MRI, the “outer-sphincteric space”, between the external anal sphincter and its lateral fascia along which pus can spread. An abscess in the intersphincteric space is easily drained into the rectum via the transanal route and is more likely to spread into the supralevator space. Conversely, an abscess in the outer-sphincteric space is difficult to drain transanally into the rectum and is more likely to become a transsphincteric abscess/fistula.Methods: The MRIs of anal fistula patients operated over four years on intersphincteric abscesses were analyzed. The pattern of spread into the ischiorectal fossa and/or supralevator space and ease of drainage into the rectum through the transanal route were studied.Results: Thirty-six patients were operated on to drain their intersphincteric abscesses through the anal canal. Two distinct patterns were noted. Twenty patients had abscesses in the intersphincteric space, which were easily drained into the rectum. Of them, 6/20 had supralevator extension, while only 1/20 had spread to the ischiorectal fossa. In 16/36 patients, the abscess was in the outer-sphincteric space and could not be drained into the rectum. In 9/16 of these patients, pus spread into the ischiorectal fossa but supralevator spread did not happen in any patient.Conclusion: Apart from the intersphincteric space, there is perhaps another unrecognized anatomical space – the outer-sphincteric space – discovered on MRI, through which pus can spread in anal fistulas or abscesses.Keywords: anal fistula, intersphincteric, MRI, supralevator, ischiorectal fossa, outer-sphincteric

Safe and effective hernia repair requires a surgeon to have the appropriate knowledge necessary to learn details of the surgical technique. Long-term results of treatment, even with the use of synthetic implants, have shown that recurrences were still a significant clinical problem concerning up to every fourth patient. Therefore, it was pointed out that the mere presence of synthetic material is not a solitary circumstance sufficient for a successful repair. A key finding in recurrence prevention has been to focus surgeons' attention on the relationship between the size of the hernia orifice and the mesh surface. An optimal ratio of these values has not been established yet, however, it is considered that the mesh surface area should be at least sixteen times larger than the area of the abdominal wall defect. In cases of medium and large hernias, in order to place an extensive mesh sheet in the appropriate anatomical space of the abdominal wall, an extensive dissection needs to be performed, including several different compartments. Therefore, a surgeon undertaking a hernia repair needs to know perfectly the anatomy and function of all the myofascial structures involved. Performing an incorrect dissection of a mistaken structure may lead to catastrophic abdominal deformities. Depriving the patient of the natural support of the abdominal wall provided by the muscles may lead to total or partial destabilization of the trunk and lead to disability. In this paper a detailed description of anatomical structures and its practical use has been presented.

Some patients present at an advanced stage of their fingertip infection with an extension of the infection in anatomical spaces or into fragile structures. One hundred and twenty-five patients have been operated on for a finger infection. Forty-one patients (33%) have been treated at the "complication" stage, while 84 cases (67%) were considered "non-complicated". The delay between initial injury and the surgical treatment was 12 days in the "non-complicated" group versus 30 in the "complication" group (p 0.001). Osteitis (39% of the complications), and flexor sheath infection (37%) were the most frequent complications. Prescribing preoperative antibiotics increases the risk of being in the "complicated" group at p = 0.09. One hundred and thirteen patients (90.4%) were cured of their infection after a single operation. Neither the cause of infection, nor the type of germ or associated diabetes increased the risk of complication in our series. A better education of the first interveners (general practitioner or emergency doctor) in hand infection care could reduce the rate of complication allowing a faster access to hand surgeons.

Conventionally, in the pathophysiology of anal fistulas, there is only one space considered significant for the spread of pus in the sphincter complex: the intersphincteric space. However, with increasing experience in the high-resolution MRI, and more focus being given on managing fistulas through the intersphincteric space, two additional pathways of fistula spread have been identified. First is a newly described space labelled as the outer-sphincteric space. Second is a known anatomical space (inner intersphincteric space), but this space was considered as irrelevant from the point of view of fistula spread. The conventional intersphincteric space is present in between these two spaces and is referred as 'middle intersphincteric space' in this paper. These three distinct spaces have significant clinical implications as the pattern of spread of pus is quite different in each space, and the management also differs for fistula tract in each of these spaces.

Upper and lower extremity tunnel neuropathies are classified as the peripheral nervous system disorders and are quite common in clinical practice. The development of tunnel syndrome is associated with compression, entrapment of the nerve in the narrow anatomical spaces (anatomical tunnel). Sensory, motor, and trophic disorders are the main clinical manifestations of the nerve compression syndromes. The article describes the main upper extremity tunnel neuropathies, their names and affected nerves. The main common upper extremity tunnel neuropathies such as carpal tunnel syndrome and cubital tunnel syndrome are considered in depth. The carpal tunnel syndrome is currently recognized as the most common peripheral neuropathy. Risk factors, gender and age characteristics, prevalence, incidence of carpal tunnel syndrome and cubital canal syndrome are presented. A scope of specialized skills comprising certain motions that can contribute to the development of carpal tunnel syndrome is presented. The clinical manifestations of these tunnel syndromes are described. Sensory, motor, and trophic disorders are the main clinical manifestations of nerve compression syndromes. The course and signs of carpal tunnel syndrome that can be divided into three stages are provided. The main diagnostic methods for the syndrome examination are shown. The article provides the main conservative and surgical methods for the treatment of these tunnel syndromes. It was noted that the cubital canal syndrome requires surgical treatment more often. The issue of using thiamine, pyridoxine, cyanocobalamin and their combination for the treatment of tunnel neuropathies is considered in more depth. A clinical case of effective conservative treatment for the carpal tunnel syndrome is discussed.

Background The middle ear is a complex anatomical space which is difficult to interpret from two-dimensional imagery. Appropriate surgical knowledge of the area is required to operate, yet current anatomical teaching methods are costly and hard to access for the trainee. Methods A papercraft 3D design involving anatomical elements added separately to a model was designed, and then peer-validated by medical students and junior doctors. Preliminary quantitative assessment was performed using an anatomical labelling questionnaire, with six students given a lecture to act as a control. Qualitative feedback was also gathered. Results 18 participants were recruited for the study. A total of 12 models were constructed by 6 medical students and 6 junior doctors. 6 medical students received a lecture only. Qualitative feedback was positive and suggested the model improved knowledge and was useful, yet timing and complexity were issues. Students scored, on average, 37% higher after completing the model, with junior doctors also improving anatomical knowledge, though these differences were not significant (p > 0.05). Conclusions In this initial investigation, the model was shown to be an engaging way to learn anatomy, with the tactile and active nature of the process cited as benefits. Construction of the model improved anatomical knowledge to a greater extent than a classical lecture in this study, though this difference was not significant. Further design iterations are required to improve practical utility in the teaching environment, as well as a larger study.

Background Up to now the totally extraperitoneal (TEP) technique is limited to the treatment of inguinal hernias. Applying this anatomical repair concept to the treatment of other abdominal wall hernias, we developed an endoscopic totally extraperitoneal approach (TEA) to treat primary midline ventral hernias, including umbilical and epigastric hernias, in which for mesh placement, an anatomical space is developed between the peritoneum and the posterior rectus sheath in the ventral part of the abdominal wall (preperitoneal space). Methods Between September 2017 and December 2019 according to the selection criterions, 28 consecutive primary midline ventral hernias were repaired using TEA. After extensive endoscopic development of the midline extraperitoneal plane, which was started in the suprasymphysic area, and reduction of the hernia sac, the hernia defect was closed and a large mesh was placed in the preperitoneal position to enforce the anterior abdominal wall. Results All operations were successfully performed without conversion to open surgery. The mean operation time was 103.3 min (range 85–145 min). Patient-reported postoperative pain was qualitatively mild with a mean pain visual analogue scale score of 1.9 on postoperative day 1. The average hospital stay was 1.9 days (range 1–3 days). Three patients developed minor complications and were treated with no long-term adverse effects. Readmissions within 30 days or hernia recurrences were not observed with a mean follow-up period of 18 months (range 10–27 months). Conclusion In selected cases, TEA is a safe and feasible minimally invasive alternative in treating primary ventral hernias. This technique preserves the anatomical and physiological structure of the abdominal wall and may significantly reduce trauma and postoperative complications. Additionally, anti-adhesion-coated meshes and fixation tackers are not required, thus being cost-effective. Further studies are necessary to proof the true clinical efficacy in comparison to well-known alternative techniques.

Background and purpose To investigate the preferred location of intracranial hemangiopericytomas (IHPCs) with voxel-based mapping and 3-dimensional reconstruction from MRI data. Methods Gadolinium-enhanced tumors of 258 primary and single IHPCs were segmented semi-automatically, followed by manual checking and editing of boundaries. The lesions were registered to Montreal Neurological Institute standard anatomical space, and heat-map and 3-dimensional rendered frequency images were generated. All tumors were then superimposed on the Anatomical Automatic Labeling (AAL) template to further investigate the difference in the tumor location based on the voxel-wise frequency of occurrence with respect to laterality, sex, age, and pathologic grade. Results The 3-dimensional rendered images show that the tumors commonly located in the posterior cranial cavity, surrounding the tentorium. The posterior third of the superior sagittal sinus and the confluence of sinuses were commonly affected. According to the analysis of tumor occurrence frequency in the AAL template, IHPCs were mainly observed in the limbic lobe, occipital lobe, and cerebellum. Tumors in younger patients preferentially located in the right occipital region (P = .027), whereas those with higher pathological grade more often located in the left parietal lobe (P = .034). Conclusions This is the first voxel-based study to explore the predilection site of IHPCs. Our study suggests that these tumors commonly affect the posterior cranial cavity, adjoining the tentorium and venous sinus. Further research is needed to investigate the possible factors underlying these topographic preferences.

The paraspinal space is intriguing in nature. There are several needle tip placements described in compact anatomical spaces. This has led to an incertitude regarding the appropriate anatomic locations for needle tip positions. Through our cadaver models we try to resolve the issues surrounding needle tip positions clarifying anatomical spaces and barriers. Further we propose an anatomical classification based on our findings in cadaveric open dissections and cross and sagittal sections.

Background Existing rigid instruments have difficulties in backward inspection and operation. Moreover, the pathway to the maxillary sinus is curved and narrow, resulting in complex and repetitive manual operations. There is a necessity to develop a retro-flexing robot and achieve path-following motion. Methods A continuum robotic system is developed for maxillary sinus surgery (MSS). And the system adopts an anatomical constraint-based optimization of the follow-the-leader strategy to generate a safe control scheme along a given path. Results The accuracy of the system is evaluated, and the task of reaching deep-seated targets is performed in a constrained anatomical space. The simulations and experiments of the path-following motion have validated the feasibility of the proposed method. Furthermore, a preliminary porcine study is performed to assess the capability of instruments. Conclusions The developed continuum robotic system can meet the requirements of MSS.

Background The infratemporal fossa (ITF) represents an area densely packed with neurovascular structures within irregular boundaries. The goal of this study was to classify the ITF into zones corresponding to its anatomical spaces and the order in which they are encountered during an endonasal approach (anteroposterior axis). Methods Six cadaveric specimens (12 sides) with injected colored latex were dissected. Following an endoscopic medial maxillectomy and Denker's approach, a progressive exploration of the masticator space and upper parapharyngeal space was completed. A classification of the ITF based on well-defined spaces was ascertained. Results The ITF was divided into five zones: Zone 1 (retromaxillary space)-space lying between the posterolateral wall of the maxillary sinus and the temporalis and pterygoid muscles. Zone 2 (superior interpterygoid space)-area including the superior head of the lateral pterygoid muscle, V3 , and foramen ovale. Zone 3 (inferior interpterygoid space)-includes the inferior head of lateral pterygoid muscle, medial pterygoid, and temporalis muscles, and the space enclosed by these muscles. Zone 4 (temporo-masseteric space)-space lateral to the temporalis muscle (comprising fat mostly). Zone 5 (tubopharyngeal space)-includes the Eustachian tube, tensor, and levator veli palatini muscles, and structures in upper parapharyngeal space. Conclusion The ITF can be visualized as five zones based on spaces enclosed by the masticator muscles and upper parapharyngeal structures. This novel classification system is useful to guide endoscopic approaches to the ITF, while decreasing the potential for injury of neurovascular structures and pterygoid muscles.

Highlights • Desmoid tumours are rare benign neoplasms with local invasion and recurrence. • A margin-free excision may be challenging for the surgeon. • If necessary, abdominal wall reconstruction can be required for rectus abdominis muscle tumours. • A multidisciplinary approach is necessary approaching this rare disease., Introduction Desmoid tumours are rare benign neoplasms with strong tendency to local invasion and recurrence. They usually rise from muscles and aponeurosis and could be challenging for medical treatment. We here report the case of a patient requiring the excision of part of the abdominal rectus muscle and an abdominal wall reconstruction. Presentation of case A 38 years old women referred to our institution complaining of a painful lump in the anterior abdominal wall. She underwent ultrasonography (US), magnetic resonance imaging (MRI) and a computed tomography (CT) biopsy who showed the presence of a desmoid tumour arising in the right abdominal rectus muscle. She underwent surgical excision of the mass and an abdominal wall reconstruction according to the posterior component separation technique, with a large polypropylene mesh reinforcement. The post-operative period was uneventful and at 6 months she shows no clinical nor radiological recurrence. Discussion Desmoid tumours are rare neoplasms rising in many anatomical spaces and requiring challenging decisions. A radical resection with free margins remains the principal determinant of outcome. Non-surgical approaches and adjuvant therapy may be useful for patients with unresectable lesions. Conclusion The optimal treatment strategy for desmoid tumours still remains unclear. A multidisciplinary approach is always the best strategy to establish the correct treatment.

Structural (also known as anatomical) and diffusion MRI provide complimentary anatomical and microstructural characterization of early brain maturation. However, the existing models of the developing brain in time include only either structural or diffusion MRI channels. Furthermore, there is a lack of tools for combined analysis of structural and diffusion MRI in the same reference space. In this work, we propose a methodology to generate a multi-channel (MC) continuous spatio-temporal parametrized atlas of the brain development that combines multiple MRI-derived parameters in the same anatomical space during 37-44 weeks of postmenstrual age range. We co-align structural and diffusion MRI of 170 normal term subjects from the developing Human Connectomme Project using MC registration driven by both T2-weighted and orientation distribution functions channels and fit the Gompertz model to the signals and spatial transformations in time. The resulting atlas consists of 14 spatio-temporal microstructural indices and two parcellation maps delineating white matter tracts and neonatal transient structures. In order to demonstrate applicability of the atlas for quantitative region-specific studies, a comparison analysis of 140 term and 40 preterm subjects scanned at the term-equivalent age is performed using different MRI-derived microstructural indices in the atlas reference space for multiple white matter regions, including the transient compartments. The atlas and software will be available after publication of the article. ispartof: FRONTIERS IN NEUROSCIENCE vol:15 ispartof: location:Switzerland status: published

Decompression of the spine is defined as removal of bony and soft tissue structures in order to provide space for the spinal cord and/or nerve roots. This definition, however, underscores the dangers and complexity of safely providing anatomical space for these neurologic structures. Complications such as neurologic injury, vascular injury, and durotomy can make these procedures hazardous for the patient and surgeon. Furthermore, inability to fully decompress the neural elements will result in continued symptoms for patients. Intraoperative image guidance can provide important anatomical landmarks to perform these decompressive surgeries safely and efficiently. In particular, performing decompression surgery utilizing minimally invasive techniques with image guidance can allow for the least amount of muscle/soft tissue trauma possible. Within our article we outline research on the forefront of use of intra-operative imaging guidance for spine surgery and implications for decompression surgery. We also outline a case from the senior author to illustrate an example of image-guided spine decompression for cervical radiculopathy. Future technology, such as augmented reality and robotics, is also discussed in the context of image guided decompression. The authors hope this article shows surgeons that use of image guidance in specific clinical situations can allow for better/safer spinal decompression procedures.

Significance: Imaging of the spinal cord is challenging due to the surrounding bony anatomy, physiologic motion, and the small diameter of the spinal cord. This precludes the use of non-invasive imaging techniques in assessing structural changes related to trauma and evaluating residual function. Aim: The purpose of our research was to apply endovascular technology and techniques and construct a preclinical animal model of intrathecal spinal cord imaging using optical coherence tomography (OCT). Approach: Five animals (2 Yorkshire Swine and 3 New Zealand Rabbits) were utilized. Intrathecal access was gained using a 16-guage Tuohy, and an OCT catheter was advanced under roadmap technique into the cervical canal. The OCT catheter has a motorized pullback, and a total length of 54 mm of the spinal canal is imaged. Results: Image acquisition was successful for all animals. There were no instances of difficult catheter navigation, enabling OCT imaging rostrally to C2. The thecal sac provided excellent thoroughfare for the OCT catheter. The clear cerebrospinal fluid also provided an excellent medium for image acquisition, with no detectable artifact from the contents of the cerebrospinal fluid. The anatomical space of the spinal canal could be readily appreciated including: dural lining of the thecal sac, epidural veins, pial lining of the spinal cord, arachnoid bands, dentate ligaments, and nerve rootlets/roots. Conclusion: Minimally invasive intrathecal imaging using endovascular OCT was feasible in this preclinical animal study. The repurposing of an endovascular device for spinal imaging comes with limitations, and a spine-specific device is necessary.

Until now, we have introduced classic example of tumors and elucidated operative strategy depending on each anatomical compartments. As mentioned at the beginning, the best benefit using the concept of anatomical compartments in surgery is that if we can confine our work in one compartment, other compartments will be beyond of our concern. In this chapter, we are going to solely focus on operative strategy for securing specific anatomical space depending on anatomical compartment of each tumor.

The anatomical spaces of the face are defined as loose connective tissues bordered by the mucosa, bone, muscles, and fasciae and which contain the vessels, nerves, salivary glands and ducts, and muscles. Infections and tumors can spread via these spaces to reach the mediastinum, for example. Also, pathology in these spaces can cause dysfunction of adjacent nerves.

The retroperitoneum is the anatomical space in the abdomen located behind the peritoneum. Structures that lie between the parietal peritoneum and the abdominal wall that are not suspended by a mesentery are classified as retroperitoneal in location and include the pancreas, adrenal glands, kidneys, duodenum, portions of the colon, great vessels, lymph nodes, and lymphatics. In this chapter, normal development and anatomy of the pancreas, adrenal glands, and retroperitoneum are discussed, as well as anatomic variants, congenital abnormalities, inflammatory, traumatic and neoplastic disorders.

Many of the surgical devices for minimally invasive surgery have struggled to navigate in tight spaces and to safely address to surgical sites. This research demonstrates a scalable steerable cannula for 360° arthroscopic capsular release (ACR) of the glenohumeral joint. The steerable cannula mainly consists of the pre-curved inner tube of nitinol, the straight outer tube of stainless steel, and the controller part. Using anisotropic patterns and heat treatment, the inner tube has a high degree of curvature. The mechanism controls the distal end with the two degrees of freedom. The inner tube can be translated and rotated relative to the outer tube. The steerable cannula was designed to avoid the axillary nerve under the inferior glenoid to minimize the risk of iatrogenic injury while keeping flexed to match the bony curvature of the glenohumeral joint. The cylindrical cannula can fit various surgical tools and can be sterilized after use. In porcine shoulder test and workspace analysis, the proposed cannula addressed the inferior glenoid that is not reachable by the conventional rigid cannula. Thus, the proposed mechanism can navigate through the narrow and curved anatomical space of the glenoid cavity and reduce the unreachable area for ACR.Clinical Relevance— The propose cannula can be used for 360° arthroscopic capsular release (ACR) in minimally invasive surgery (MIS). This cannula can prevent damage to the axillary nerves which is one of the main complications of ACR. The mechanism has the potentials to reduce the unreachable area in MIS for knee and hip joints.

Parapharyngeal space and infratemporal fossa are 2 overlapping spaces in head and neck which have complex anatomy with vital neurovascular structures passing through them. Tumors of this region are extremely rare but majority of them (80%) are benign. Benign tumors of this region can lead to swellings in facial region, neck and oropharynx. Dysphagia may be a complaint of the patient. Many of these tumors have malignant potential. Removal of these tumors requires a good understanding of the anatomy of this space so that correct surgical approach can be selected. The surgeon needs to be adept in using the most suitable surgical approach for excision of these tumors. There are various approaches which can be used to access these deeply seated tumors but the issue of prime importance is selecting the appropriate approach for the various tumors here based on their size and their exact location in this complex anatomical space. Inappropriate approach can lead to inadequate tumor excision and can lead to injuries to the neurovascular structures in this region which can cause significant disability. The case series reported here describes the various approaches to this region and highlights the importance of correct selection of the surgical approach.

The pterygopalatine fossa (PPF) is a challenging space and pathological processes in this anatomical space are uncommon. This report presents a case of glomus tumor right PPF in a 65 years old female patient who underwent tumor removal by endoscopic transnasal-transmaxillary approach with preoperative selective embolization of the right internal maxillary artery.

Information that is shared across brains is encoded in idiosyncratic fine-scale functional topographies. Hyperalignment captures shared information by projecting pattern vectors for neural responses and connectivities into a common, high-dimensional information space, rather than by aligning topographies in a canonical anatomical space. Individual transformation matrices project information from individual anatomical spaces into the common model information space, preserving the geometry of pairwise dissimilarities between pattern vectors, and model cortical topography as mixtures of overlapping, individual-specific topographic basis functions, rather than as contiguous functional areas. The fundamental property of brain function that is preserved across brains is information content, rather than the functional properties of local features that support that content. In this Perspective, we present the conceptual framework that motivates hyperalignment, its computational underpinnings for joint modeling of a common information space and idiosyncratic cortical topographies, and discuss implications for understanding the structure of cortical functional architecture.

espanolIntroduccion: El receso epitimpanico anterior (REA) es un espacio anatomico definido en 1973 por Wigand y Trillsch. Ha recibido otros muchos nombres, como: compartimento epitimpanico anterior, receso facial anterior, receso atical anterior, epitimpano anterior, receso protimpanico, receso supratubarico y seno geniculado. Se encuentra delimitado entre el tegmen tympani por arriba; la raiz del cigoma hacia delante; el musculo tensor del timpano y su pliegue mucoso por abajo; el nervio facial medialmente y una cresta osea posterior, el “cog” o rueda dentada. Presentamos una descripcion de la anatomia y desarrollo embriologico de este espacio, de los procesos patologicos que con mas frecuencia lo afectan y de las vias de abordaje quirurgico. Material y metodos: Revision sistematica de tipo narrativo. Discusion: La anatomia quirurgica del epitimpano siempre ha resultado dificil de estudiar por la complejidad de los pliegues mucosos, bolsas y ligamentos. La alteracion en la ventilacion desde la trompa hacia la mastoides, favorece el desarrollo del colesteatoma. Conclusion: Hemos considerado de interes realizar esta revision bibliografica sobre el receso epitimpanico anterior, por su complejidad, su variabilidad anatomica, la proximidad de importantes estructuras y la frecuente invasion por el colesteatoma. EnglishIntroduction: The anterior epitympanic recess (AER) is an anatomical space defined in 1973 by Wigand and Trillsch. It has received many other names, such as: anterior epitympanic compartment, anterior facial recess, anterior atical recess, anterior epitympanum, protympanic recess, supratubaric recess, and geniculate sinus. It is delimited between the tegmen tympani above; the root of the zygoma in the anterior area; the tensor tympani muscle and its mucous fold below; the facial nerve medially and inthe posterior part of the space the bony ridge, the "cog" or gear wheel. We present a description of the anatomy and embryological development of this space, of the pathological processes that most frequently affect it and different the surgical approaches. Material and methods: Systematic review of narrative type. Discussion: The surgical anatomy of the epitympanum has always been difficult to study due to the complexity of the mucous folds, bags and ligaments. The alteration in ventilation from the tube to the mastoid favors the development of cholesteatoma. Conclusion: We have considered of interest to carry out this bibliographic review on the anterior epiphympanic recess, due to its complexity, its anatomical variability, the proximity of important structures and the frequent invasion by cholesteatoma.

The transversus abdominis plane (TAP) is the anatomical space between the internal oblique and transversus extends throughout the abdominal wall ending in the aponeurosis of rectus muscles. Anesthetic block of this plane has proven useful in reducing pain and analgesic requirements in abdominal wall surgery. The identification of anatomical structures by ultrasound images simplifies the procedure by correctly and safely blocking innervation of the abdominal wall with the use of local anesthetics. The aim of this study was to highlight the importance of anatomical knowledge, and correlation of anatomical-clinical-surgical and ultrasound information in the interpretation of images obtained by ultrasonography. Further, to evaluate the effects of nerve block of the anterolateral abdominal wall by echo-guided puncture in reference to the need for postoperative analgesia in abdominal surgery. During the period January / 2012 to June / 2013, we conducted training for surgeons through practical observation of normal anatomy on cadavers, ultrasound and observation of the anterolateral abdominal wall with portable ultrasound and 7 MHz linear transducer in patients with, and without known pathology, and then interpreted and compared these for a period of 6 months. Puncture sites for blocking nerve plexus were identified and located by ultrasonography. Following training we considered patients with comorbid conditions that were surgically treated. We included 60 patients underwent surgery for abdominal wall pathology. They were classified considering surgery performed: 14 (23.34) umbilical hernioplasties, 33 (55%) inguinal hernioplasties, 6 (10%), epigastric hernioplasties, 4 (6.66%) femoral hernioplasties and 3 (5%) other hernias. We were able to identify anatomical structures and nerve block in 30 (90.91%) patients underwent surgery for inguinal hernias and 3 (75%) femoral hernioplasties. In the remaining patients block could not be performed due to physical characteristics and when ultrasound equipment was not available: 1 (25%) with femoral hernia and in 3 (9.09%) inguinal hernias. No post-puncture complications were detected. A reduced need for analgesics was observed in all patients during the immediate and midrange post-operative period. Thorough knowledge of anatomical structures and nerve endings, as well as the use of this complementary approach, significantly improve the management of postoperative pain and reduce the need for analgesics. Training in ultrasound and surgical anatomical-clinical correlation to identify these structures should be considered to improve the quality of care in patients with abdominal surgical pathologies.

The mediastinum, the central anatomical space of the thorax, is divided by anatomical landmarks but not by physical boundaries. The mediastinum is a conduit, a space through which cranial nerves, important nerve branches, the sympathetic chain, vascular structures, and visceral structures, the trachea and esophagus pass. This arrangement allows contiguous extension or communication of disease along facial planes and through potential spaces to and from the head and neck or cervical spine, to and from the superior mediastinum, between superior and inferior mediastinal levels, and between inferior mediastinal spaces into the intra- and retroperitoneal spaces. Magnetic resonance imaging (MRI) of the mediastinum in children poses technical challenges, in particular cardiac and respiratory motion, and diagnostic challenges, including a broad range of tissue types and possible diagnoses. In this paper we review mediastinal anatomy, MRI sequences and protocol choices and include a short discussion of features and MRI findings of some of the congenital and acquired pathologies that are most often encountered in the pediatric mediastinum.

Functionally distinct retinal ganglion cells have density and size gradients across the mouse retina, and some degenerative eye diseases follow topographic-specific gradients of cell death. Hence, the anatomical orientation of the retina with respect to the orbit and head is important for understanding the functional anatomy of the retina in both health and disease. However, different research groups use different anatomical landmarks to determine retinal orientation (dorsal, ventral, temporal, nasal poles); variations in the accuracy and reliability in marking these landmarks during dissection may lead to discrepancies in the identification and reporting of retinal topography. The goal of this study was to compare the accuracy and reliability of the canthus, rectus muscle, and choroid fissure landmarks in reporting retinal orientation. The retinal relieving cut angle made from each landmark during dissection was calculated based on its relationship to the opsin transition zone, determined via a custom MATLAB script that aligns retinas from immunostained s-opsin. The choroid fissure and rectus muscle landmarks were the most accurate and reliable, while burn marks using the canthus as a reference were the least. These values were used to build an anatomical map that plots various ocular landmarks in relationship to one another, to the horizontal semicircular canals, to lambda-bregma, and to the earth’s horizon. Surprisingly, during normal locomotion, the mouse’s opsin gradient and the horizontal semicircular canals make equivalent 6° angles aligning the opsin transition zone near the earth’s horizon, a feature which may enhance the mouse’s ability to visually navigate through its environment.

Highlights • Retroperitoneal schwannomas are usually asymptomatic, rare neoplasms. • Diagnosis can only be achieved with surgical removal of mass. • Laparoscopy is the most useful therapeutic approach., Introduction Single pelvic schwannomas are rare tumor arising from the retrorectal, lateral or obturatory space. Laparoscopic approach to schwannoma located in lateral pelvic space has been previously described only in one case report. We present a case of a successful laparoscopic resection of pelvic schwannoma emphasizing the advantages of such a minimal invasive approach. Presentation of case A 54-years-old, obese, male patient was admitted to our hospital referring dysuria and strangury. Abdominal CT scan showed a lateral pelvic well-circumscribed mass with smooth regular margins. A CT-guided fine needle biopsy resulted non-diagnostic. An elective laparoscopic resection was performed. The patient had a short, uneventful post-operative course. Pathological examination revealed a benign schwannoma. Discussion Using PubMed database, we reviewed the English language international literature using the MeSH terms “laparoscopic,” “minimally invasive” and “schwannoma”. We identified quite 20 previous cases of pelvic schwannomas removed by laparoscopy or robotic surgery. We found out that a preoperative diagnosis of these rare neoplasms is difficult to be obtained; in most cases, laparoscopic approach was successfully performed. Conclusion Despite it could not be proven yet, due to the rarity of this tumor, we agree with literature that laparoscopic removal of pelvic benign tumor may offer several advantages. The direct high-definition vision deeply into this narrow anatomical space, especially in obese patients, provides a detailed view that makes easier to isolate and spear the anatomical structures surrounding the tumor. Furthermore, the pneumoperitoneum may create the right plane of dissection, minimizing the risk of tumor rupture and bleeding.

Vertical ridge augmentation in the posterior mandible is a technique-sensitive procedure that requires adequate anatomical knowledge and precise surgical skills to minimize the risk of complications. One of the most important but also challenging aspects of the surgical technique is proper flap management to allow for passive flap closure and reduce the chances of postoperative complications affecting deep anatomical spaces. This article presents a detailed description of a novel lingual flap advancement technique and its validation via a split-mouth, comparative study using a cadaver model. A total of 12 fresh cadaver heads presenting bilateral posterior mandibular edentulism were selected. Sides were randomized to receive a classic lingual flap release technique (control) or the modified technique presented here, which involves the intentional preservation of the mylohyoid muscle attachment to the mandible. Vertical flap release was measured at three different zones using standard forces. The mean difference between the test and control group in zones I (retromolar pad area), II (middle area), and III (premolar area) was 8.273 ± 1.794 mm (standard error of the mean [SEM] = 0.5409 mm), 10.09 ± 2.948 mm (SEM = 0.8889 mm), and 10.273 ± 2.936 mm (SEM = 0.8851 mm), respectively, reaching very strong statistical significance (P < .0001) in all three zones.

Accidental displacement of the third molar tooth or its fragment into the anatomical spaces is a rare but potentially serious complication. The most common sites of mandibular third molar displacement are the sublingual, submandibular, and pterygomandibular spaces. Removal of a displaced tooth or its fragments from these spaces may be difficult due to poor access and the vital structures involved in these spaces; therefore, removal may result in permanent damage. This article is intended to provide a concise update of the reported cases of submandibular displacement and to present a case of intraoral management of mandibular third molar root fragments that were displaced into the submandibular space.

There has been an overall increase in pelvic organ prolapse due to demographic changes (increased life expectancy). Increasing sociocultural demands of women require treatments that are more effective with methods that are more successful. In the treatment of pelvic floor insufficiency and uterovaginal prolapse, pelvic floor reconstructions with mesh implants have proven to be superior to conventional methods such as the classic colporrhaphy, reconstructions with biomaterial, and native tissue repair in appropriately selected patients and when applying exact operation techniques, especially because of good long-term results and low recurrence rates. When making a systematic therapy plan, one should adhere to certain steps, for example, a pelvic floor reconstruction should be undertaken before performing the corrective procedure for incontinence. The approach, if vaginal, laparoscopic, or abdominal should be chosen wisely, taking into consideration the required space of action, in such a way that none or only minimal collateral damage related to the operation occurs. The use of instrumental suturing techniques and operation robots are advantageous in the case of difficult approaches and limited anatomical spaces. In principle, the surgeon who implants meshes should be able to explant them! The surgical concept of mesh-related interventions in the pelvis must meet established rules. "Implant as little mesh as possible and only as much suitable (!) mesh as absolutely necessary!" In the case of apical direct fixations, a therapeutically relevant target variable is the elevation angle of vagina (EAV). Established anatomical fixation points are preferable. A safe distance between implants and vulnerable tissue is to be maintained. Mesh-based prolapse repairs are indicated in recurrences, in primary situations, in combined defects of the anterior compartment, in central defects of multimorbid and elderly patients, and above all, when organ preservation is wanted. Native connective tissue structures are to be preserved, strengthened and reconstructed to restore altered functions. Practical skills for highly specialized mesh-based operations as well as effective techniques for complication management should be taught in interdisciplinary specialist courses.

Ventral sulcus spinal cord arteriovenous shunts (SCAVS) are rare vascular lesions that are located outside the spinal cord, are exclusively vascularized by the anterior spinal axis, and drain exclusively through the anterior spinal vein. We report the anatomical, clinical, and neuro-radiological features of SCAVS managed by our team. We conducted a retrospective study of patients with SCAVSs evaluated by the senior author of this report (GR) between 1981 and 2014. Data were collected by reviewing clinical notes and by a systematic analysis of spinal angiograms and MRI. Among 358 patients, we identified 8 patients (3 women) with ventral sulcus spinal cord arteriovenous shunts. Mean age was 30.5 years. Six patients presented with progressive neurological symptoms, and two with acute neurological symptoms related to hematomyelia. Three shunts were located in the cervical cord, four in the thoracic cord, and one at the conus medullaris; there were two nidus type A-V shunts (AVMs) and six fistula type A-V shunts (AVFs). Seven patients were treated by endovascular therapy with glue embolization. Embolization led to anatomical cure in 5 cases, and a significant reduction of shunt volume and flow of more than 75% in 2 cases. In none of the cases we observed permanent morbidity. AVS of the ventral sulcus of the spinal cord are rare. Recognition of these lesions and precise localization of the anatomical space in which they are located, may allow a better understanding of their pathophysiology and clinical manifestations and guide proper therapeutic decisions.

Object Endoscopic third ventriculostomy (ETV) uses anatomical spaces of the ventricular system to reach the third ventricle floor and create an alternative pathway for cerebrospinal fluid flow. Optimal ETV trajectories have been previously proposed in the literature, designed to grant access to the third ventricle floor without a displacement of eloquent periventricular structures. However, in hydrocephalus, there is a significant variability to the configuration of the ventricular system, implying that the optimal ETV trajectory and cranial entry point needs to be planned on a case-by-case basis. In the current study, we created a mathematical model, which tailors the optimal ETV entry point to the individual case by incorporating the ventricle dimensions. Methods We retrospectively reviewed the imaging of 30 consecutive pediatric patients with varying degrees of ventriculomegaly. Three dimensional radioanatomical models were created using preoperative MRI scans to simulate the optimal ETV trajectory and entry point for each case. The surface location of cranial entry points for individual ETV trajectories was recorded as Cartesian coordinates centered at Bregma. The distance from the Bregma in the coronal plane represented as “x”, and the distance from the coronal suture in the sagittal plane represented as “y”. The correlation between the ventricle dimensions and the x, y coordinates were tested using linear regression models. Results The distance of the optimal ETV entry point from the Bregma in the coronal plane (“x”) and from the coronal suture in the sagittal plane (“y”) correlated well with the frontal horn ratio (FHR). The coordinates for x and y were fitted along the following linear equations: x = 85.8 FHR−13.3 (r 2 = 0.84, p

International audience; We introduce a framework for the statistical characterization of heart remodeling from both shape and dynamics of the left ventricle. Shape was characterized by thickness and radius maps, unfolded in a two-dimensional dense Bull's eye. Motion was represented as a mixture of affine transformations in an anatomical space of coordinates. Using this representation, a population can be projected (after defining spa-tiotemporal correspondences) to an atlas space built for a given reference population-here, healthy subjects using a classic PCA approach-yielding a joint model of healthy shape and motion statistics. The reconstruction error on shape and motion can then be exploited to quantify remodeling abnormalities. We demonstrate these concepts on 48 healthy subjects and 62 patients with infarct (29 with one year follow-up) imaged with 3D echocardiography, analyzing a total of 139 sequences.

Ovarian cancer is characteristic of superficial implantation and peritoneal carcinomatosis. Hudson introduced a novel technique 50 years ago, which removed the entire Douglas pouch as a false capsule of the tumor (Hudson, 1968 [1]). Angeles et al. standardized the procedure in 10 steps in a previous publication (Angeles et al., 2019 [2]). We made small modifications of the Hudson procedure in this video. Ovarian cancer is characteristic of superficial implantation and peritoneal carcinomatosis. Hudson introduced a novel technique 50 years ago, which removed the entire Douglas pouch as a false capsule of the tumor (Hudson, 1968 [1]). Angeles et al. standardized the procedure in 10 steps in a previous publication (Angeles et al., 2019 [2]). We made small modifications of the Hudson procedure in this video.The key points of the procedure were summarized as follows. Firstly, dissecting off the pelvic parietal peritoneum very superficially. Secondly, the round ligament, infundibulo-pelvic ligament, medial umbilical ligament, and umbilical artery are divided and ligated in the extraperitoneal space. Thirdly, the bladder is mobilized caudally and the vesico-vaginal space is exposed after completely dissecting off the vesical peritoneum. Fourthly, the ureter is isolated and mobilized laterally. Then, uterine vessels and parametria are divided and ligated, which is followed by colpotomy to access the recto-vaginal septum. By retracting the total specimen cranially, the Douglas pouch is dissected retrogradely according to Hudson procedure. Lastly, the peritoneum of the mesorectum and mesosigmoid is shaved at the pelvic brim. Therefore, using this method, almost all the pelvic visceral peritoneum was dissected (). In addition, we didn't intentionally expose the anatomical spaces (pre-vesical, para-vesical, para-rectal, and pre-sacral) completely, which was effective and time-saving.Complete removal of the disseminated tumors in both parietal and visceral peritoneum was achieved by the method introduced in our video.Our method, modified from Hudson procedure, is effective for complete cytoreduction in selected ovarian cancer patients with extensive peritoneal carcinomatosis sparing rectosigmoid resection.

Navigation engages many cortical areas, including visual, parietal, and retrosplenial cortices. These regions have been mapped anatomically and with sensory stimuli and studied individually during behavior. Here, we investigated how behaviorally driven neural activity is distributed and combined across these regions. We performed dense sampling of single-neuron activity across the mouse posterior cortex and developed unbiased methods to relate neural activity to behavior and anatomical space. Most parts of the posterior cortex encoded most behavior-related features. However, the relative strength with which features were encoded varied across space. Therefore, the posterior cortex could be divided into discriminable areas based solely on behaviorally relevant neural activity, revealing functional structure in association regions. Multimodal representations combining sensory and movement signals were strongest in posterior parietal cortex, where gradients of single-feature representations spatially overlapped. We propose that encoding of behavioral features is not constrained by retinotopic borders and instead varies smoothly over space within association regions.

Objective: Contralateral C7 nerve root transfer surgery has been successfully applied to rescue motor function of a hemiplegic upper extremity in patients with central neurological injury. This surgical technique is challenging, and limited anatomical space makes it difficult to manipulate tissues and may lead to higher complication rates. The authors hypothesis a new surgical route in which cervical nerve roots of both donor and recipient sides are exposed from a posterior intradural approach and neurorrhaphy is performed easily and clearly. The feasibility of this operation is tested in a cadaver model. Methods: A fresh cadaver was placed prone. After a standard midline incision and extensive cervical laminectomy, the dura and arachnoid were widely opened, and the spinal nerve roots of C6, C7, and C8 were exposed bilaterally. Nerve grafting was attempted between pairs of donor and recipient nerve roots on contralateral sides of the spinal cord. After completion of neurorrhaphy, the dura was closed. Results: Precise neurorrhaphy could be performed intradurally between posterior and anterior nerve roots of C7 on both sides. Multiple anastomoses of C7 to various nerve roots on the contralateral side could also be performed within the same surgical field with an interposition nerve graft. Conclusion: The posterior intradural repair idea affords many advantages, the pathway is shorter and more straightforward, which provides more access to multiple nerve roots repair in one surgical field, and is more familiar to many neurosurgeons and spine surgeons. It may potentially be adapted for clinical use.

Hernia and Abdominal wall repair represents one of the surgical environments where knowledge is the real key to success, not the dissection of anatomic plane as happens in general surgery but the correct and effective use of anatomic structures represents the true ability of hernia surgeons. During the past years, several authors have left their names attached to anatomical structure and their variants testifying a great interest in the understanding of the pathological processes and modifications responsible of an abdominal wall defect. Today the interest in this field has raised more and more, thanks to the availability of new technologies, new approaches, and actually new procedures that push further the research in this area. It’s interesting to note that, on one hand, the need for a detailed knowledge of inguinal region has been flattened by the use of meshes, because of the reduced dissection in comparison to traditional tissue repairs. On the opposite side, the rise of Abdominal Wall Reconstruction concepts has been taken to the extreme of the concept of tenotomy and invented new anatomical routes and spaces for the surgeons. The aim of the present chapter is to easily describe these anatomical spaces and offer to the readers some tips and new insights to begin the route of abdominal wall anatomy.

Pediatric sonography of the neck should take place in a calm environment. Communication should be adapted to the particular needs of children and parents. It is useful to analyze pathologies in children on the basis of anatomical spaces and morphological (cystic, solid, vascular) components, including lymph node involvement. In particular, although some may also occur in adulthood, pediatric age-related pathologies such as embryological remnants and malformations should be considered, and individual findings may indicate a syndromic disease that may require further investigation.

Purpose of Review Treating malignant tumors of the anterior skull base (ASB) is a challenging task, involving complex surgery in an intricate anatomical space. The effective treatment of ASB tumors requires careful pretreatment evaluation and preoperative surgical planning by the skull base surgical team.

Objective To investigate the practicality of a new method using anatomical spaces for performing standard laparoscopic radical hysterectomy (LRH) without ureteral injury in patients with cervical cancer. Methods Clinicopathological characteristics and perioperative complications were retrospectively analysed in 440 patients with stages IB1 to IIB cervical cancer. The patients were assigned to two of the following groups: LRH by our method of using anatomical landmarks (anatomical space group, n = 217) and the traditional method (traditional group, n = 223). Results The mean operative duration and time of vesicouterine ligament (VUL) dissection were significantly shorter (173.87 ± 30.39 vs. 210.83 ± 44.55 minutes; 32.75 ± 7.23 vs. 43.48 ± 11.22 minutes), and blood loss was less in the anatomical space group compared with the traditional group. The rate of the intraoperative complication of ureteral injury was also significantly lower in the anatomical space group compared with the traditional group (0 vs. 5). Conclusions LRH by the anatomical method, using the axillary space and other potential spaces as anatomical landmarks, results in less blood loss and reduced ureteral injury compared with the traditional method. This method is safe and practical for separating the ureter from the VUL in patients with cervical cancer.

The suprachoroidal space (SCS), a potential anatomical space between the sclera and choroid, is a novel route for drug delivery targeting the chorioretinal layers of the eye. The safety and efficacy of SCS drug delivery have been shown in multiple clinical trials. Recent studies have developed methods for more precise targeting within the SCS at sites of action at the posterior pole (e.g., macula), near the limbus (e.g., ciliary body), and throughout the SCS using iontophoresis, swollen hydrogels, high-density particle emulsions, highly viscous and non-Newtonian fluids, and microstents. Here, we review novel technologies targeting the posterior, anterior, or entire SCS.

Encoding models for mapping voxelwise semantic tuning are typically estimated separately for each individual, limiting their generalizability. In the current report, we develop a method for estimating semantic encoding models that generalize across individuals. Functional MRI was used to measure brain responses while participants freely viewed a naturalistic audiovisual movie. Word embeddings capturing agent-, action-, object-, and scene-related semantic content were assigned to each imaging volume based on an annotation of the film. We constructed both conventional within-subject semantic encoding models and between-subject models where the model was trained on a subset of participants and validated on a left-out participant. Between-subject models were trained using cortical surface-based anatomical normalization or surface-based whole-cortex hyperalignment. We used hyperalignment to project group data into an individual's unique anatomical space via a common representational space, thus leveraging a larger volume of data for out-of-sample prediction while preserving the individual's fine-grained functional–anatomical idiosyncrasies. Our findings demonstrate that anatomical normalization degrades the spatial specificity of between-subject encoding models relative to within-subject models. Hyperalignment, on the other hand, recovers the spatial specificity of semantic tuning lost during anatomical normalization, and yields model performance exceeding that of within-subject models.

Made available in DSpace on 2018-12-11T17:17:59Z (GMT). No. of bitstreams: 0 Previous issue date: 2018-06-01 The removal of displaced dental elements from deep anatomical spaces is a condition that requires the knowledge of the region and skills to perform the procedure. The lateral pharyngeal space contains important structures such as the internal carotid artery and close proximity with the cranium basis. The aim of this paper is to report a clinical case of a lower third molar displaced to the lateral pharyngeal space after a mandibular angle fracture and its treatment by surgical intervention. The tooth was removed under general anesthesia by direct approach and the fracture was reduced and fixed with a plate and screws. This case report illustrates the importance of an immediate procedure to avoiding severe complications and further damage to important anatomical structures. Department of Surgery and Clinic Integrated Araçatuba Dental School UNESP, José Bonifácio Street, number 1193 Department of Surgery and Clinic Integrated Araçatuba Dental School UNESP, José Bonifácio Street, number 1193

Descending necrotising mediastinitis (DNM) is an uncommon clinical entity which may arise secondary to primary odontogenic or neck infection in susceptible patients. Infection may spread contiguously via the alar or ’danger' space, a potential anatomical space posterior to the true retropharyngeal space.(1) Spread of infection to the mediastinum almost always necessitates urgent cardiothoracic surgical intervention.(2–4) This case report describes a male patient whose clinical deterioration following the diagnosis of submandibular abscess was investigated with CT imaging of the chest, where a diagnosis of DNM was made. Diagnosis was confirmed following surgical intervention and aspiration of pus from the mediastinum.